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Corticosteroids and Plasma Exchange Treatments for MS Acute Attacks

James Bowen, MD

Medical Director, Multiple Sclerosis Center

Swedish Neuroscience Institute, Seattle, WA

 

Types of Treatment

Corticosteroids

Side Effects of Corticosteroids

Plasma Exchange

Side Effects of Plasma Exchange

For More Information


Types of Treatment

There are currently two treatments for acute MS attacks: corticosteroids or plasma exchange.

  • Minor attacks may not need treatment.
  • Attacks causing bothersome symptoms require corticosteroids. The decision to treat with corticosteroids often depends on how bothersome the symptoms are to the patient.
  • Attacks that fail to respond to corticosteroids may be treated with plasma exchange. The side effects of plasma exchange must be balanced against the severity of the symptoms.

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Corticosteroids

Intravenous corticosteroids are preferred because of the results of the optic neuritis treatment trial, suggesting that oral corticosteroids alone might cause an increase in future attacks. This treatment is generally given in an outpatient infusion center or emergency room. Rarely, patients require hospital admission due to the severity of their symptoms.

  • The standard dose is: methylprednisolone 1000mg (1 gram) in 100cc normal saline IV over 1 hour each day for 3 days. This is followed by prednisone 60mg per day for 11 day. Tapering the dose is not needed after this short course.
  • This regimen may be altered to fit an individual patient’s needs. For example, five days of intravenous treatment may be given, or the oral prednisone may be deleted.
  • Some patients may need a second course of corticosteroids if they deteriorate shortly after the first course of treatment.
  • If methylprednisolone is unavailable, dexamethasone may be substituted with a conversion of 185mg dexamethasone = 1000mg methylprednisolone.
  • Patients may need assistance with sleep while taking corticosteroids. Non-addicting, long-lasting medications like doxepin 25-100mg qhs prn, or amitriptyline 25-100mg qhs prn have the added advantage of decreasing anxiety or mood change throughout the day.
  • Rarely, patients get palpitations. This may be treated with beta blockers.

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 Side Effects of Corticosteroids

  • Metallic taste in the mouth during the infusion
  • Stomach irritation. Antacids and H2 blockers are not usually prescribed unless patients become symptomatic.
  • Difficulty sleeping, restlessness, anxiety, or mood change
  • Increased appetite resulting in weight gain
  • Fluid retention
  • Moon face or swelling between the shoulder blades
  • Excessive sweating
  • Acne
  • Aseptic necrosis of the hips is extremely rare with short courses of corticosteroids. Osteoporosis is not usually an issue with short courses of corticosteroids.

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Plasma Exchange

Plasma exchange is used only for severe attacks that do not respond to corticosteroids. The severity of symptoms must warrant the side effects of plasma exchange. This treatment usually requires hospitalization. A course of treatment consists of plasma exchange every other day for five treatments. Others use daily plasma exchange for five treatments.

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 Side Effects of Plasma Exchange

  • Bleeding due to placement of the intravenous lines or due to thrombocytopenia
  • Infection due to placement of the intravenous lines.
  • Damage to lungs or other tissues due to placement of the intravenous lines.
  • Episodes of low blood pressure during treatments.
  • Episodes of irregular heartbeats during treatment.
  • Allergic reactions to portions of the blood plasma.
  • Electrolyte abnormalities during treatment.
  • Thrombocytopenia due to heparin used during the treatment.
  • Hypercoagulable state with risk of thrombosis

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For More Information

It is highly recommended for people who are experiencing an acute attack to contact their healthcare provider to discuss the appropriate treatment response.  For more information, refer to additional articles on this website about Acute Attacks:

  • Definition and Diagnosing MS Acute
  • Treatments for Acute Attacks

 

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Last Updated: November 2009