Relapse Treatment, Part 2

In my previous post, I discussed the treatment of relapses, primarily through the use of intravenous (IV) steroids.  In certain patients, however, IV steroids are not an option. Either they have poor intravenous access or they simply cannot tolerate the side effects.  In patients for whom an IV cannot be placed, oral steroids remain an option.  Solumedrol can be taken in liquid form, though I am told it tastes awful, and it seems to be unavailable recently.  Alternatively, oral prednisone is sometimes given.  There don’t seem to be major differences between oral and intravenous steroids, but patients will have to take dozens of pills to reach the same dose as the intravenous steroids.  Additionally, they may case more gastrointestinal side effects that steroids given intravenously.

An Option for Patients That Cannot Tolerate Steroids

Another option for patients who cannot tolerate steroids is adrenocorticotropic hormone (ACTH) called Acthar ® gel.   ACTH is a naturally occurring hormone that stimulates the adrenal glands to make several different steroid hormones.  This medication is given as an intramuscular injection given at full dose for a week, then at a lower dose for several weeks afterwards.  Patients are typically taught how to give the injections themselves.  It is as effective as intravenous steroids, and may have fewer side effects as well, though overall its side effects are similar to steroids.  The main disadvantage of this medicine is its cost, and that it can take several days for insurance companies to approve the medication.  For patients who need intravenous steroids immediately, it is usually not a reasonable option.

What is Plasmapharesis?

For patients who have significant relapses that are not responsive to intravenous steroids, we sometimes use a procedure called plasmapharesis.  Unlike IV steroids, this procedure requires that patients be hospitalized.  In this procedure, a large intravenous line is placed and the patient’s blood is then filtered through a machine with separates the actual blood cells from other components in the bloodstream.  It is usually done for 5-7 days in the hospital, and each treatment takes several hours.

There are some risks to the procedure.  The placement of the catheter itself carries a risk for infection and for a collapsed lung.  And prior to each treatment certain blood tests have to be done to make sure that there are no deficits of the blood’s coagulation proteins.  Nonetheless, I have seen several patients who have had relapses that were unresponsive to steroids improve significantly after a course of plasmapharesis.  It is certainly a procedure worth trying in patients with significant relapses not alleviated by steroids.