Multiple sclerosis (S) belongs to a group of chronic demyelinating diseases that affect the central nervous system. In the vast majority of cases, the first phase of the disease progresses with periods of remission and relapses - alternating. Relapses are typical of the clinical picture of the disease and unfortunately, as of today, this is a stage of the disease that is unpredictable and highly variable - clinically unexplained. The early phase after a flare is usually associated with neurological improvement in the patient's condition, in contrast to the later stages, which may leave residual symptoms. It is worth remembering, however, that not all neurological deterioration is a throw, and may be the result of stress or a reaction to an ongoing infection in the body, in which case it is known as a 'pseudo-cast'. To alleviate the symptoms of a flare, glucocorticosteroids are used to improve the patient's neurological condition. According to clinical studies and numerous observations, glucocorticosteroids are effective in the context of symptomatic treatment without clinical consequences in terms of halting the progression of the disease over time.

In order to initiate glucocorticosteroids, it is necessary to exclude other causes that may cause neurological deterioration of the patient's condition, so not every suspected flare requires glucocorticosteroid treatment.

Flares in S

Relapses are a typical clinical feature in the early stages and their appearance in specific anatomical areas, in many cases, makes for a rapid and accurate diagnosis. However, what is a flare in the context of S? A flare is a worsening of the neurological condition, characterised by the appearance of a new symptom (or a group of new symptoms) or an exacerbation of existing symptoms, which lasts no less than 24 hours. Moreover, this worsening of the condition is the reason for the patient's reduced performance. It is worth noting, however, that if a worsening of symptoms occurs within 30 days of a previous episode, they are considered a continuation of the previous episode and not the appearance of a new episode.

"Pseudo-relapses" are also present during the course of the disease and do not warrant treatment, hence the importance of excluding other possible causes of the patient's neurological deterioration (such as infection or severe stress).

photo: panthermedia

In the early stages of the disease, episodes of remission can be distinguished, but the duration of this phase is very difficult to predict. The role of flares itself is also not fully understood and explained - the common view is that the consequences of successive flares can be cumulative, leading to cachexia and disability, but this is not yet clinically proven. The symptoms of flares tend to diminish or disappear altogether within two to three months, but can sometimes last for up to a year. To make these symptoms milder and for the patient's neurological condition to improve, glucocorticosteroids are used as standard treatment. However, this does not change the fact, also observed by specialists, that the symptoms of a relapse left untreated also disappear, but last slightly longer than the symptoms of untreated relapses.

Glucocorticosteroids (CSCs)

ICSs are agents used primarily for the treatment of autoimmune disorders due to their immunosuppressive effects. However, it is worth remembering that they affect not only metabolic processes, but also the water and mineral balance of the human body.

In the course of S, adrenocorticotropin (ACTH), which was administered intramuscularly, was used for the first time. After a clinical trial with ACTH and placebo, it was noted that the neurological condition of S patients improved within four weeks for those who received ACTH.

As there is currently no clinically validated regimen for the treatment of S symptoms with ICS, different routes and different sequences of administration of different ICS preparations are used in the course of combating neurological symptoms. The length of the therapy itself is also not specified in the recommendations and hence also varies according to the patient's condition.

The Cochrane analysis also showed that similar efficacy is observed for oral and intravenous administration of GSK.

"Pseudoradults"

The use of GCSs for pseudarthrosis is not clinically justifiable. This means that neurological deterioration may have other causes, not directly related to S, and symptoms may also persist for some time. A reassessment of the patient's condition should take place 30 days after treatment of the cause of the symptoms has been completed (e.g. after treatment of an infection). If the symptoms persist, then one can speak of a flare and then it becomes reasonable to administer ICS to alleviate them.

ICS - side effects

ICSs are generally considered to be safe agents, producing mainly typical side effects of mild to moderate intensity. However, it should not be forgotten that, like any pharmacological agents, they carry a risk of side effects that may endanger the patient's health and life. The first and principal type of such reaction is anaphylactic shock, in addition to cardiac arrhythmias or autoimmune hepatitis, the occurrence of which during therapy has not yet been described in detail in the specialist literature.

The use of ICS in S

The inclusion of ICS therapy in S should always have a medical justification and should not be a chronic or regular treatment. Above all, any consideration of the inclusion of ICS should be preceded by the exclusion of both pseudo-relapses and all possible contraindications and risks associated with other comorbidities.

An additional aspect of the use of GCSs is to reduce the number of steroid therapies used, although there are currently no indications, recommendations or restrictions on the amount or duration of steroid therapy in S. Furthermore, when S progresses to a chronic progressive form, at later stages of therapy, there is a decline in the effectiveness of GCSs in relieving the symptoms of flares, hence there is no justifiable basis for their administration. Therapy is then based on symptomatic treatment of the complaints reported by the patient. [1]