Multiple sclerosis relapse management — high-dose IV methylprednisolone vs oral steroids, when to use?

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### Management of Multiple Sclerosis Relapse: IV vs. Oral Steroids **1. Definitions and Indications** An MS relapse (exacerbation) is defined as new or worsening neurological symptoms lasting >24 hours in the absence of fever or infection (pseudo-relapse). Treatment is indicated for relapses that cause functional impairment or significant disability (e.g., optic neuritis, transverse myelitis, or motor weakness). **2. High-Dose IV Methylprednisolone (IVMP) vs. Oral Steroids** * **IVMP:** The traditional gold standard is 1000 mg daily for 3–5 days. It is often preferred for severe relapses or when hospitalization is required. * **Oral Methylprednisolone/Prednisone:** Several randomized controlled trials (e.g., the COPOUSEP trial) have demonstrated that high-dose oral steroids (e.g., 1000 mg/day of methylprednisolone) are non-inferior to IVMP in terms of clinical recovery and MRI outcomes at 4 weeks. * **Patient Choice:** Oral administration is more convenient, avoids the need for IV access, and is generally more cost-effective. **3. Clinical Considerations in this Case (28F on Natalizumab)** * **Safety:** In a patient on Natalizumab with a high JC virus (JCV) index (2.8), there is a significant risk of Progressive Multifocal Leukoencephalopathy (PML). While the current presentation (new gadolinium-enhancing lesion) is consistent with an MS relapse, a "high index of suspicion" for PML must be maintained. PML typically presents with subacute progressive symptoms rather than a discrete "attack," but imaging can sometimes overlap. * **Management:** If PML is ruled out (consider CSF JC virus PCR if suspicious), high-dose steroids (IV or Oral) are appropriate. Plasmapheresis (PLEX) may be considered if steroids fail, especially in severe relapsing disease. **4. Conclusion on Steroid Choice** For most MS relapses, high-dose oral steroids are an evidence-based alternative to IVMP. The choice should be shared with the patient, considering severity, venous access, and logistical factors. **References:** 1. Le Page E, et al. Oral versus intravenous methylprednisolone for relapses of multiple sclerosis (COPOUSEP): a randomised, controlled, double-blind, non-inferiority trial. *Lancet*. 2015. 2. Thompson AJ, et al. Diagnosis of multiple sclerosis: 2017 revisions of the McDonald criteria. *Lancet Neurol*. 2018. 3. Rae-Grant A, et al. Comprehensive systematic review summary: Disease-modifying therapies for adults with multiple sclerosis. *Neurology*. 2018 (reaffirmed 2021).