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Abstract & Commentary
Source: Zivadinov R, et al. Effects of IV methylprednisolone on brain atrophy in relapsing-remitting MS. Neurology. 2001; 57:1239-1247.
In this randomized 5-year study, 88 patients with relapsing-remitting multiple sclerosis (MS) were assigned to either regular pulses of IV methylprednisolone (IVMP) 1000 mg/d for 5 d every 4 months for 3 years, and then every 6 months for 2 years, vs. the same dose schedule only for relapses. MRI and clinical disability measures were performed in a blinded fashion. Patients on the regular pulse treatment received approximately 3 times the total amount of steroids than the relapse group over 5 years. The regular pulse IVMP group had less progression of disability than the relapse treated group (EDSS 1.7 vs 3.4, or a 32% reduction, P < 0.0001). Similarly, on brain MRI there was significantly less T1 black hole volume formation and less brain atrophy in the regular pulse IVMP group. There was no significant difference between treatment arms at 5 years, however, in the annualized relapse rate (0.6 vs 0.6) or T2 lesion volume on brain MRI (21.4 vs 27.8).
While corticosteroid therapy has been a mainstay in the treatment of acute relapses of MS to reduce the severity and duration of an attack, the benefits in changing the ultimate outcome of disease have been somewhat unclear. Also controversial is the use of regular pulses of IVMP in a "preventative" fashion to modify disease progression. This prospective study that combined standardized clinical assessments with highly quantitative brain MRI measures demonstrates a benefit of prophylactic pulse IVMP in slowing disease progression above that achieved by random treatment of relapses only. A larger multicenter trial, probably in combination with the interferon-beta or glatiramer acetate, will be required to more definitively establish a role of pulse IVMP therapy. —Brian R. Apatoff
Dr. Apatoff, Associate Professor of Neurology, New York Presbyterian Hospital-Cornell Campus, is Assistant Editor of Neurology Alert.