oral vs. iv. steroids

    
      Re: oral vs. iv. steroids
    


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Posted by CCF Neuro MD on September 04, 1997 at 09:59:17:

In Reply to: oral vs. iv. steroids posted by sharon brown on August 27, 1997 at 14:55:46:

: The following article from the lancet goes against everything my ms specialist (who is the head of the ms clinic at washington university) says about steroids.
  He has told me that the order of preference in treatment is i.v., then placebos, then oral steroids - in light of that, and given your own knowledge, what is your take on this article?
   the lancet, march 29,  
  1997                                                        
  "summary- background - an intravenous rather than oral      
  course of methylprednisolone is often prescribed for        
  treating acute relapses in m.s. despite the lack of evidence
  to support this route of administration. Our double-blind  
  placebo-controlled randomisedtrial was designed to compare  
  the efficacy of commonly used intravenous and oral steroid  
  regimens in promoting recovery from acute relapses in ms.  
  
  methods - 42 patients with clinically definite relapse in ms
  received oral, and 38 intravenous, methylpredisolone.      
  Clinical measurements at entry and at 1 week,4 weeks, 12 wks
  and 24 wks included kurtzke's expanded disability status    
  scale. the primary outcome citerion was a difference between
  the two treatment groups of one or more edss grades at 4    
  weeks.                                                      
  findings - there were no significant differences between the
  twogroups at any stage of the study in any measurement      
  taken: the mean difference in edss at 4 weeks (adjusted for
  baseline level) was 0.07 grades more in those taking oral    
  steroids. The most optimistic outcome for intravenous      
  therapy is an average benefit of less than half a grade    
  improvement on edss over oral treatment."                    
  there's a group of us on prodigy's ms bulletin board who are puzzling through this question as well.
  thanks for your help - sharon brown
  interpretation - since our study did not show any clear  
  advantage of the intravenous regime we conclude that it is  
  preferable to prescribe oral rather than intravenous        
  steroids for acute relapses in ms for reasons of patient    
  convenience,safety and cost.                                
                                                              
  introduction: m.s. is the second commonest cause of        
  neurological disability in young adults in the UK with an  
  estimated prevelence of 70,000 to 80,000. Steroids are an  
  accepted treatment for acute relapses in ms with both      
  clinical and mri evidence for their efficacy in accelerating
  recovery. itis usual to administer eitherintravenous        
  methylprednisolone 1,000 mg a day for three days or 500 mg
  a day for five days or to prescripe oral prednisolone course
  taken over about 3 weeks inreducing doses. there have been  
  no reports that intravenous therapy is any more effective  
  than oral therapy in conventional doses for the treatment of
  ms relapses. a small trial comparing identical doses of    
  intravenous and oral methylpredisolone followed up for 4    
  weeks did not show any differences between the two routes of
  treatment.
===================================================================
Dear Sharon:
We are aware of the publication by Barnes et al. in Lancet this year comparing IV methylprednisolone (1g every day for 3 days) and oral methylprednisolone (a total of 588g given over 3 weeks in tapered dose schedule). They failed to find a significant difference in the efficacy of these medications as assessed in 80 MS patients followed for 24 weeks using the EDSS and other measures of  MS deficit. The study, however, can be criticised on several grounds. Firstly, the number of patients is small and hence the study might not have sufficient power statistically to demonstrate a small but significant difference in efficacy. Secondly, the severity of MS varied widely in the patients enrolled. Thirdly, the subjective definition of a relapse, and also the wide timeframe allowed for treatment may be confounding factors.
The current recommendations of IV steroids are based upon a large and well-conducted study called the ONTT (Optic Neuritis Treatment Trial) which was published in 1992. These recommendations still hold. Also, follow-up of patients enrolled on this latter study may seem to indicate that IV steroids may have a beneficial effect on the disease course for as long as two years.
I hope this answers your question.
This information is provided for general medical education purposes only. Please your physician for diagnostic and treatment options of your specific medical condition