Treatment Of Acute Relapses Research Articles

Analyzing the impact of pulse steroid therapy on relapse rates and disease progression in relapsing-remitting multiple sclerosis: a comprehensive retrospective study

Background and Objective: Relapsing remitting MS (RRMS) is characterized by recurrent relapses with remissions. Over an extended time-frame, high-dose steroid administration has primarily centered on the treatment of acute relapses, rather than relapse prevention. The objective of this retrospective study is to assess the long-term impact of administering three monthly pulse steroid therapy for three days on relapse rates and the Expanded Disability Status Scale (EDSS) scores in patients with RRMS. Methods: This study was conducted at Neurology ward of Chandka Medical College Hospital in Larkana from January 2021 to January 2023. A retrospective analysis of historical patient data, focusing on individuals with RRMS who received three monthly pulse steroid therapy over a specified period. Data was collected through patient records, including details of treatment, relapse history, and EDSS scores. Results: Thirty MS patients including 25 females and five males received one gram methylprednisolone intravenously every three months for three days. The mean age range was 18-50 years. Among them, three experienced no relapses, 11 had one relapse, 13 encountered two relapses, and three had three relapses over next consecutive two years. The severity of relapses varied, with 20 classified as moderate and seven as severe. A reduction in relapse rates and notable improvements in EDSS scores were observed. Conclusion: The initial findings from this retrospective analysis suggest that three monthly pulse steroid therapy is associated with positive outcomes in RRMS patients. These results support the need for further investigation into the potential benefits of continuous steroid therapy in managing RRMS.

The role of autoimmune processes in demyelinating diseases of the nervous system: focus on multiple sclerosis

Background. Demyelinating diseases of the central nervous system (CNS) are a heterogeneous group of disorders characterized by a damage to the myelin sheath of nerve cell axons. Multiple sclerosis (MS) is the most common chronic inflammatory demyelinating disease of the CNS affecting more than 2.9 million people worldwide. The purpose was to summarize current information about the features of the immunopathogenesis of multiple sclerosis according to the data from open sources of information. Materials and methods. The selection of publications covering the features of the immunopathogenesis of multiple sclerosis was carried out in the PubMed, Clinical Key Elsevier, Cochrane Library, eBook Business Collection and Google Scholar databases using the following keywords: multiple sclerosis, demyelinating diseases, neurodegeneration, oligodendrocytes. Results. The course of MS has three successive phases/forms known as relapsing-remitting, primary progressive and secondary progressive. Abnormalities of immune mechanisms are proposed as protagonists of the pathogenesis of MS. Autoreactive myelin-specific lymphocytes are activated outside the CNS, they cross the blood-brain barrier and form new inflammatory demyelinating lesions. The myelinating oligodendrocyte is a target during the adaptive immune response in MS. The inflammatory reaction in the brain of patients with progressive MS is observed mainly in the large connective tissues of the meninges and the periventricular space. Treatment of MS can be divided into three categories: treatment of acute relapse, disease-modifying treatment, and symptomatic treatment. Conclusions. On the T cell side, both hel-per (CD4+) and cytotoxic (CD8+) T cells are involved in the CNS damage in MS. Peripherally activated subsets of T cells (CD4+ Th1 and Th17, CD8+) migrate through the blood-brain barrier and activate B-cells and macrophages, which causes a neuroinflammatory reaction and leads to demyelination and neurodegeneration in the CNS. Oligodendrocyte progenitor cells, which are widely distributed throughout the CNS, mediate myelination and remyelination. One of the desired features of new methods for treating MS is the restoration of antigen-specific tolerance.

Comparison of Effectiveness of Leflunomide against High Dose Methyl-Prednisolone in Multiple Sclerosis

Background: Leflunomide is a disease-modifying, anti-rheumatic drug, whose active metabolite Teriflu-nomide is licensed drug therapy for reducing progression in Multiple sclerosis. Intravenous high dose Methyl-Prednisolone is an established treatment for acute relapses of multiple sclerosis that escalates reco-very. Intravenous methyl-prednisone also being used anecdotally for the prevention of relapses. Methods: Each patient after enrollment in the study received treatment for 1 year. A total of 30 patients, 15 patients in each group were taken. Patients fulfilling inclusion criteria and giving written informed con-sent were randomly divided into 2 groups (Group A and Group B) using a computer-generated random numbers table. Group A patients received Leflunomide 20mg with a loading dose of 3 tablets for 3 days and then once daily for one year. And group B patients received high-dose intravenous Methyl Prednisolone 1g monthly for a period of one year. Results: Methyl Prednisolone group, 5 (33.3%) had only 1(%) relapse and 10 (66.7%) cases had no relapse. In contrast, Leflunomide group, no relapse was recorded. The frequency of relapse was consequently statistically higher in Methyl Prednisolone group, p-value < 0.05. In respect of, a number of lesions on MRI; Methyl Prednisolone group demonstrated no change in 4 (26.67%) cases and 11 (73.33%) cases had lesions increased from baseline. Whereas, in the Leflunomide group the number of lesions significantly decreased (p-value < 0.05). Significant improvement in Expanded disability status was observed leflunomide group (p-value < 0.05). Conclusion: Leflunomide was more effective in preventing relapses and in decreasing disease activity on MRI, as compared with high dose monthly Methyl-prednisone in patients with Multiple Sclerosis.

Update on neuromyelitis optica spectrum disorder.

Neuromyelitis optica spectrum disorder is an autoimmune disease that causes optic neuritis and transverse myelitis. Attacks can cause severe neurological damage leading to blindness and paralysis. Understanding of the immunopathogenesis of this disease has led to major breakthroughs in diagnosis and treatment. In the past 18 months, three successful phase 3 clinical trials have been published using targeted approaches to preventing relapses. Updates in epidemiology, imaging, quality of life and treatment for acute relapse and prevention have been published in the past 18 months. Epidemiology studies are distinguishing patients based on their antigen specificity for aquaporin-4 and myelin oligodendrocyte glycoprotein, which are increasingly recognized as separate immunological conditions. Imaging by MRI and optical coherence tomography continue to be developed as tools to distinguish neuromyelitis optica spectrum disorders (NMOSD) from other diseases. This is especially relevant as the recent clinical trials showed differences in response between aquaporin-4 seropositive and seronegative patients. The three drugs that were tested for prevention of NMOSD relapses were eculizumab, inebilizumab, and satralizumab. All of the trials were worldwide, placebo-controlled, double-masked studies that demonstrated a clear benefit with each approach. Recent research in NMOSD has resulted in improved diagnosis and approved treatments.

Therapeutic Apheresis in Acute Relapsing Multiple Sclerosis: Current Evidence and Unmet Needs—A Systematic Review

Multiple sclerosis (MS) is the most abundant inflammatory demyelinating disorder of the central nervous system. Despite recent advances in its long-term immunomodulatory treatment, MS patients still suffer from relapses, significantly contributing to disability accrual. In recent years, apheresis procedures such as therapeutic plasma exchange (TPE) and immunoadsorption (IA) have been recognized as two options for treating MS relapses, that do not respond to standard treatment with corticosteroids. TPE is already incorporated in most international guidelines, although evidence for its use resulted mostly from either case series or small unblinded and/or non-randomized trials. Data on IA are still sparse, but several studies indicate comparable efficacy between both apheresis procedures. This article gives an overview of the published evidence on TPE and IA in the treatment of acute relapses in MS. Further, we outline current evidence regarding individual outcome predictors, describe technical details of apheresis procedures, and discuss apheresis treatment in children and during pregnancy.

Treatment of Neuromyelitis Optica Spectrum Disorder: Acute, Preventive, and Symptomatic.

Neuromyelitis optica spectrum disorder (NMOSD) is a rare, autoimmune disease of the central nervous system that primarily attacks the optic nerves and spinal cord leading to blindness and paralysis. The spectrum of the disease has expanded based on the specificity of the autoimmune response to the aquaporin-4 water channel on astrocytes. With wider recognition of NMOSD, a standard of care for treatment of this condition has condition based on a growing series of retrospective and prospective studies. This review covers the present state of the field in the treatment of acute relapses, preventive approaches, and therapies for symptoms of NMOSD.

Treatment of acute relapses in neuromyelitis optica: Steroids alone versus steroids plus plasma exchange

Background: Although adding plasma exchange (PLEX) to steroids in severe neuromyelitis optica (NMO) attacks is common practice in steroid-resistant cases, the benefit of this strategy has not been previously quantified. Objective: The objective of this paper is to compare the efficacy of high-dose intravenous methylprednisolone (IVMP) versus IVMP+PLEX in treatment of acute NMO relapses. Methods: We conducted a retrospective review of the last 83 NMO admissions to the Johns Hopkins Hospital treated with IVMP alone versus IVMP+PLEX (for steroid-resistant cases). Extended Disability Status Scale (EDSS) score was calculated at baseline, at presentation, at discharge, and on follow-up. Results: Eighteen NMO relapses (16 patients, 87% female, mean age at relapse: 33.9±23.8, median baseline EDSS 2.5) were treated with IVMP alone and 65 relapses (43 patients, 95% female, mean age at relapse: 43.8±15.7, median baseline EDSS 5.75) were treated with IVMP + PLEX. Sixty-five percent of IVMP + PLEX patients achieved an EDSS equal or below their baseline at follow-up while only 35% of the IVMP-only patients achieved their baseline EDSS on follow-up (odds ratio=3.36, 95% CI 1.0657 to 10.6004, p = 0.0386). PLEX was more effective in improving EDSS in patients on preventive immunosuppressive medications at time of relapse. Conclusions: PLEX+IVMP are more likely to improve EDSS after NMO relapses compared to IVMP alone, especially in patients taking preventive medications.

Role of intravenous immunoglobulin in the treatment of acute relapses of neuromyelitis optica: experience in 10 patients

Prompt treatment of neuromyelitis optica (NMO) relapses with steroids or plasma exchange (PLEX) often prevents irreversible disability. The objective of this study is to report the use of intravenous immunoglobulins (IVIG) as treatment for acute relapses in NMO. A retrospective review of 10 patients treated with IVIG for acute relapses was conducted. IVIG was used in the majority of cases because of lack of response to steroids with/without PLEX. Improvement was noted in five of 11 (45.5%) events; the remaining had no further worsening. One patient, a 79-year-old woman, had a myocardial infarction seven days after IVIG. IVIG may have a role in treating acute NMO relapses.

Treatment of acute relapses in multiple sclerosis.

Multiple sclerosis (MS) is a chronic progressive inflammatory demyelinating disease affecting the central nervous system. The most common clinical type of MS tends to follow a relapsing course, affecting the vast majority of patients living with this disease. Relapses are a hallmark of MS, and are often associated with significant functional impairment and decreased quality of life. Although usually followed by a period of remission, residual symptoms after MS relapses may persist and lead to sustained disability. Adequate management of MS relapses is important, as it may help to shorten and lessen the disability associated with their course. Historically, treatment of MS relapse was the first approach (and for a period of time, the only approach) to MS treatment in general. Systemic corticosteroids and adrenocorticotropic hormone (ACTH) have broad regulatory approval and remain the most established and validated treatment options for MS relapse. Therapeutic mechanisms of ACTH were previously associated (perhaps mistakenly) with only corticotropic actions; however, recently the direct anti-inflammatory effects and immunomodulatory activity of ACTH gel acting through melanocortin pathways have been shown. Second-line treatments of steroid-unresponsive MS relapses and a possible algorithm for MS relapse management are also reviewed in this article.

The Role of the Primary-Care Physician in Treating Relapses in Multiple Sclerosis Patients

Multiple sclerosis (MS) is a common disabling neurologic disease with an overall prevalence in Canada of 240 in 100,000. Multiple sclerosis clinics are located at tertiary-care centers that may be difficult for a patient to access during an acute relapse. Many relapses are evaluated by primary-care physicians in private clinics or emergency departments, but these physicians' familiarity with MS is not known. Therefore, a survey was undertaken to determine the knowledge and experience of primary-care physicians regarding the diagnosis and treatment of MS relapses. A total of 1282 licensed primary-care physicians in the catchment area of the London (Ontario, Canada) Multiple Sclerosis Clinic were identified and mailed a two-page anonymous survey. A total of 237 (18.5%) responses were obtained, but only 216 (16.8%) of these respondents were still in active practice. Of these 216 physicians, only 9% reported having no MS patients in their practice, while 70% had one to five patients, 16.7% had six to ten, and 1.9% had more than ten (3.7% did not respond to this question). Corticosteroids were recognized as an MS treatment by 49.5% of the respondents, but only 43.1% identified them as a treatment for acute relapses. In addition, 31% did not know how to diagnose a relapse, and only 37% identified new signs or symptoms of neurologic dysfunction as indicating a potential relapse. Despite the high prevalence of MS in Canada, primary-care physicians require more education and support from specialists in MS care regarding the diagnosis and treatment of MS relapses.

Informed shared decision making in multiple sclerosis—inevitable or impossible?

Patients and health authorities increasingly claim active roles in health care decision making processes. As immune therapies in MS are partially effective MS is a prototypic condition for a shared decision making process. The treatment of acute relapses and the initiation, change or withdrawal of so called disease-modifying treatments are key decisions in MS management. We developed two decision aids following the phased approach of the framework of increasing evidence for complex interventions for these key decisions. In prestudies we found that 80% of MS patients demand autonomous roles in treatment decisions which contrasts with a poor knowledge of risks. On the other hand MS patients are not disturbed by evidence-based, balanced complex information. MS patients do understand this kind of information and are able to transfer new abilities to other situations. Currently we study the effects of a 4-hour education programme on relapse management versus an information leaflet in controls in 150 MS patients. In a second trial with n = 298 MS patients we study the effects of an evidence-based patient information on immunotherapy on decisional role preference and performance in the patient physician encounter. Results in early 2007 will show to which extent patient education with a focus on evidence-based patient information influences participation in the decision making process.

Role of aripiprazole in treating mood disorders

Atypical antipsychotics have been used to treat patients with schizophrenia for many years, but now there is increasing evidence of their utility in the treatment of mood disorders. In the past few years, several atypical agents have received regulatory approval for use in mania. The evidence shows that atypical antipsychotics are effective in the treatment of manic symptoms, either alone or in combination with traditional mood stabilizers, such as lithium and divalproex. Although emerging data indicate that atypical antipsychotics will be a promising addition to those therapies that are currently available for managing patients during the maintenance phase of bipolar illness, their potential in the long-term management of bipolar disorder remains to be fully explored. Aripiprazole is a recently released antipsychotic medication that differs from other atypical antipsychotic agents by its mode of action as a dopamine D2 partial agonist. It is administered orally and has a long half-life. Randomized studies have demonstrated the efficacy of aripiprazole compared with placebo in the treatment of acute relapse of schizophrenia and schizoaffective disorder, maintenance treatment of schizophrenia, treatment of acute mania, and prevention of manic relapse in patients who responded to the drug during a manic episode. Further studies are ongoing in bipolar and unipolar depression. Aripiprazole is generally well tolerated compared with other antipsychotic medications, although commonly reported side effects include extrapyramidal symptoms and motoric activation similar to akathisia. Further studies and postmarketing data will be helpful in providing additional information regarding the comparative safety, efficacy and tolerability of aripiprazole in the treatment of affective disorders.

Quetiapine: efficacy, tolerability and safety in schizophrenia

Quetiapine, a dibenzothiazepine derivative, is an atypical antipsychotic, multireceptor antagonist that has a preclinical profile similar to clozapine. Randomized studies have demonstrated the efficacy of quetiapine relative to placebo in the treatment of acute relapse and the long-term management of schizophrenia. Quetiapine is generally well tolerated relative to other antipsychotic medications, although side effects include sedation, orthostatic hypotension, anticholinergic and metabolic side effects. The purpose of this article is to critically review the current literature on quetiapine with an emphasis on emergent themes and key findings in the use of this agent for the treatment of schizophrenia. There are also continued efforts to understand, predict and manage the side-effect risk with quetiapine.

Corticosteroids delay remyelination of experimental demyelination in the rodent central nervous system

High dose corticosteroid (CS) administration is a common mode of therapy in treatment of acute relapses in multiple sclerosis (MS) but the effects of CS on remyelination and the cellular mechanisms mediating this repair process are controversial. We have examined CS effects on repair of toxin-induced demyelinating lesions in the adult rat spinal cord. Corticosteroids reduced the extent of oligodendrocyte remyelination at 1 month post lesion (whereas Schwann-cell mediated repair was unaffected). However, CS did not cause permanent impairment of remyelination as lesions were fully remyelinated at 2 months after cessation of treatment. The delay in oligodendrocyte mediated repair could be attributed to inhibition of differentiation of oligodendrocyte progenitor cells (OPCs) into oligodendrocytes, with no effect of CS treatment observed on OPC colonisation of the lesions. No differences were observed in animals treated with methylprednisolone succinate alone or with a subsequent prednisone taper indicating that CS effects occur at an early stage of repair. The potential consequences of delayed remyelination in inflammatory lesions are discussed.

Aripiprazole: pharmacology, efficacy, safety and tolerability

Aripiprazole is a recently released antipsychotic medication which differs from other atypical antipsychotic agents by its partial agonist activity at postsynaptic D2 receptors. It is administered orally and is distinguished by a long elimination phase half-life relative to other antipsychotic medications. Randomized studies have demonstrated the efficacy of aripiprazole relative to placebo in the treatment of acute relapse of schizophrenia and schizoaffective disorder, maintenance treatment of schizophrenia, and treatment of acute bipolar mania. Aripiprazole is generally well tolerated relative to other antipsychotic medications, although commonly reported side effects include worsening extrapyramidal symptoms and motoric activation similar to akathisia. Further studies and postmarketing data will be helpful in providing additional information about the comparative safety, efficacy and tolerability of aripiprazole.

Intravenous Immunoglobulin and Interferon: Successful Treatment of Optic Neuritis in Pediatric Multiple Sclerosis

Optic neuritis is a common clinical condition that causes loss of vision. It can be clinically isolated or can occur as one of the manifestations of multiple sclerosis. Multiple sclerosis is a severe disabling demyelinating disease of the central nervous system, which is rare among children. The treatment of optic neuritis has been investigated in several trials, the results of which have shown that corticosteroids speed up the recovery of vision without affecting the final visual outcome. Treatment of neurologic disorders with intravenous immunoglobulin is an increasing feature of our practice for an expanding range of indications, including multiple sclerosis. Owing to its anti-inflammatory properties, intravenous immunoglobulin can be beneficial in the treatment of acute relapses and in the prevention of new relapses of multiple sclerosis. To our knowledge, there is only one experience of treatment of optic neuritis with intravenous immunoglobulin in multiple sclerosis, even if therapeutic trials are used in the therapy of multiple sclerosis. We report on a girl with optic neuritis and multiple sclerosis in whom treatment with intravenous immunoglobulin at first alone and subsequently associated with interferon achieved great improvement in visual acuity.

Steroid treatment for relapses in multiple sclerosis - the evidence urges shared decision-making.

Therapy of acute relapses in multiple sclerosis with corticosteroids (CC) remains uncertain with respect to route, dosage and effectiveness. This makes the treatment of relapses a clinical field where 'shared decision-making (SDM)' could be of advantage for the patients. A prerequisite for SDM is the provision of evidence-based information for the patients. The British General Medical Council (GMC) has published ethical guidelines on seeking patients' consent for medical interventions, formulating topics of information patients need in order to make an informed treatment decision. Medical databases were searched for evidence on the treatment of acute relapses with CC. The available evidence on relapse treatment is ambiguous and weak. It does not provide enough evidence to sufficiently inform patients following the topics formulated by the GMC. Good evidence is lacking, supporting the concept of SDM in the therapy of relapses.

The role of intravenous immunoglobulin in the treatment of multiple sclerosis

Intravenous immunoglobulin (IVIG) has several effects on the immune system that could have a beneficial influence on disease processes in multiple sclerosis (MS). Owing to its anti-inflammatory properties, IVIG may be beneficial in the treatment of acute relapses and in prevention of new relapses. By promoting remyelination, IVIG could have a beneficial effect on disability and disease progression. Four double-blind trials in relapsing–remitting MS have demonstrated that IVIG reduces the relapse rate and the number of gadolinium enhancing lesions, and in this respect seems comparable to established therapies in relapsing–remitting MS, i.e. interferon-beta and glatiramer acetate. The doses of IVIG that have been used for treatment in relapsing–remitting have varied 10-fold, and the ideal dosage of IVIG for treating MS still needs to be determined. Three studies have been performed to assess the effect of IVIG on chronic visual impairment or established motor symptoms in MS. None of these trials could confirm that established symptoms in MS can be reversed by IVIG. In secondary progressive MS, a large randomized placebo-controlled trial has recently shown that IVIG is without beneficial effects in this phase of the disease. In conclusion, IVIG is a valuable alternative for treatment of relapsing–remitting MS in patients who do not tolerate or are unwilling to take the approved injectable medications, but additional studies are needed to establish the role of IVIG in the management of multiple sclerosis.

Treatment of acute relapses in multiple sclerosis at home with oral dexamethasone: a pilot study

The objective of this study was to investigate the feasibility of treating relapses of multiple sclerosis (MS) at home with oral dexamethasone. Twenty-five out of 28 consecutive patients with MS who presented with a relapse of less than 2 weeks' duration were treated on an open basis with oral dexamethasone 16 mg per day (four divided doses) for 5 consecutive days. After one week, the expanded disability status scale (EDSS) had improved by one or more grades in 88% (22 patients) and after 4 weeks in 92% (23 patients). Treatment was well tolerated. We conclude that a course of oral dexamethasone 16 mg per day shortens the duration of an exacerbation in MS in a similar way as seen after high dose i.v. methylprednisolone. Although a randomized study is needed to test this treatment regimen against i.v. high dose corticosteroids, oral dexamethasone can be used in situations when i.v. therapy is difficult to apply.

Recent developments in drug therapy for multiple sclerosis.

Symptomatic treatment of multiple sclerosis (MS) includes a diverse range of drugs intended to relieve the specific symptoms with which a patient may present at a particular point in the progression of the disease. These drugs, not specifically designed for the treatment of MS, may include antispastic agents (e.g. baclofen), drugs to reduce tremor (e.g. clonazepam), anticholinergics (e.g. oxybutynin) which relieve urinary symptoms, anti-epileptics (e.g. carbamazepine) to control neuralgia, stimulants to reduce fatigue (e.g. amantadine), and antidepressants (e.g. fluoxetine) to treat depression. The treatment of acute relapses or exacerbations is dominated by corticosteroids such as methylprednisolone. The most active area of current investigation is the development of drugs which will inhibit the progression of the disease process itself, and in this category the beta- and alpha-interferons are the most effective drugs currently available, although many new treatments are currently in trials, including immunoglobulin, copolymer-1. bovine myelin, T-cell receptor (TCR) peptide vaccines, platelet activating factor (PAF) antagonists, matrix metallo-proteinase inhibitors, campath-1, and insulin-like growth factor (IGF).