Sporadic corticosteroid pulses and osteoporosis in multiple sclerosis

Exercise and Multiple Sclerosis

The pathophysiology of multiple sclerosis (MS) is characterised by fatigue, motor weakness, spasticity, poor balance, heat sensitivity and mental depression. Also, MS symptoms may lead to physical inactivity associated with the development of secondary diseases. Persons with MS are thus challenged by their disability when attempting to pursue an active lifestyle compatible with health-related fitness. Although exercise prescription is gaining favour as a therapeutic strategy to minimise the loss of functional capacity in chronic diseases, it remains under-utilised as an intervention strategy in the MS population. However, a growing number of studies indicate that exercise in patients with mild-to-moderate MS provides similar fitness and psychological benefits as it does in healthy controls. We reviewed numerous studies describing the responses of selected MS patients to acute and chronic exercise compared with healthy controls. All training studies reported positive outcomes that outweighed potential adverse effects of the exercise intervention. Based on our review, this article highlights the role of exercise prescription in the multidisciplinary approach to MS disease management for improving and maintaining functional capacity. Despite the often unpredictable clinical course of MS, exercise programmes designed to increase cardiorespiratory fitness, muscle strength and mobility provide benefits that enhance lifestyle activity and quality of life while reducing risk of secondary disorders. Recommendations for the evaluation of cardiorespiratory fitness, muscle performance and flexibility are presented as well as basic guidelines for individualised exercise testing and training in MS. Special considerations for exercise, including medical management concerns, programme modifications and supervision, in the MS population are discussed.

Effects of high doses of corticosteroids on bone metabolism

The effects of a chronic treatment with corticosteroids on bone are well known, but few data are available regarding the acute effect of these drugs on bone turnover. This study was aimed at evaluating the effects of high doses of corticosteroids administered for a short period on bone metabolism. We assessed 23 subjects (15 women and 8 men) suffering from multiple sclerosis and treated with methylprednisolone (1 g i.v. for 10 days) followed by oral prednisone for 9 days; patients affected by diseases involving bone or treated during the previous 6 months with drugs influencing bone metabolism were excluded. We observed a significant decrease of ALP and bone glia protein (BGP), in these subjects, and a significant sudden increase of urinary calcium/creatinine and urinary cross-laps after 3 days of treatment. All of these parameters, except urinary calcium/creatinine, returned to basal levels after 30 days from the beginning of treatment (11 days after the interruption of corticosteroids administration). Serum phosphorus showed a significant decrease after 3 days of treatment, but returned to basal levels after 10 days. These data suggest that high doses of corticosteroids administered for a short period are able to induce an increase of bone resorption and a decrease of bone formation; moreover, bone turnover returns to basal levels when the treatment is stopped.

Corticosteroid-Induced Osteoporosis

Corticosteroid-induced osteoporosis is the leading cause of secondary osteoporosis and a significant cause of morbidity in both men and women. Long-term use of even low-dose corticosteroids has been associated with increased risk of bone loss. Recent large randomized controlled trials have generated new knowledge on treatment strategies for patients with corticosteroid-induced osteoporosis. However, the majority of individuals receiving corticosteroids are not receiving prophylaxis for osteoporosis. Calcium and vitamin D should be recommended to patients initiating therapy with corticosteroids (and should be adequate for those receiving corticosteroids for less than 3 months). For those receiving corticosteroids for greater than 3 months, bisphosphonates are the therapy of choice, with both alendronate (alendronic acid) and risedronate (risedronic acid) approved by the US FDA for use in this indication. Calcitonin can be considered a second-line agent and should be reserved for patients who are intolerant of bisphosphonates or who are experiencing pain from a vertebral fracture. Hormone replacement therapy or testosterone therapy may be offered to those individuals on long-term corticosteroid treatment who are hypogonadal. Teriparatide (recombinant human parathyroid hormone 1-34) shows promise as a future anabolic agent for the prevention and treatment of patients with corticosteroid-induced osteoporosis.

Pulse glucocorticoids

High-dose intravenous (i.v.) methylprednisolone has been used therapeutically in a number of medical fields to avoid the complications and side effects of long-term glucocorticoid (GC) therapy and because of the perception that high-dose i.v. methylprednisolone may have "special" therapeutic effects. It is possible that aggressive early therapy with GCs allows for a more rapid taper of GCs and therefore prevents some of the dose-related side effects associated with long-term use. Some of the neurologic and rheumatologic literature related to multiple sclerosis and lupus nephritis suggest that i.v. methylprednisolone has therapeutic effects that are different from those of conventional doses of oral prednisone. There is still considerable debate about this in nondermatologic fields, and extrapolation of the role of pulse i.v. methylprednisolone to dermatologic disease, where trials are lacking, is difficult. Given this subset of possible candidates of this therapy as suggested by anecdotal reports, there is at least a rationale for considering the use of this modality in a subset of patients.

Preventive healthcare in women with multiple sclerosis

The health maintenance of women with diverse disabilities and chronic disabling conditions has been neglected by medical professionals. Interest in their basic health promotion has been eclipsed by the narrowed focus on their underlying conditions. We surveyed preventive medical practices of 220 women with multiple sclerosis (MS). The objectives of this study were to evaluate the adequacy of preventive healthcare delivery for women with MS and to explore the adequacy of the detection, prevention, and treatment of osteoporosis in this high-risk population. Our survey revealed that 50% of the women do not get regular medical preventive checkups. Twenty-five percent do not have regular pelvic examinations, and 11% have not had a Pap smear within 3-5 years. In women over 40 years old, 52% do not have yearly mammograms. Risk factors for premature osteoporosis in our sample included impaired mobility (53%), corticosteroid use (82%), and vitamin D deficiency as a result of avoidance of sunlight. Despite these risks, 85% have never had bone density testing, 50% are not taking calcium supplements, and 71% are not taking vitamin D. Among the postmenopausal sample, 81% have never had bone density testing, 50% are not taking calcium supplements, and 70% are not receiving hormone replacement therapy (HRT). Only 1% are taking bone resorption inhibitors. The benefits of preventive healthcare and cancer prevention screening should be stressed to women with MS. Referrals should be facilitated by neurologists for dignified, knowledgeable examinations in fully accessible facilities. Osteoporosis prevention, screening, and treatment protocols must be part of the medical plan for all women with MS.

Management of corticosteroid-induced osteoporosis

OBJECTIVES

To educate scientists and health care providers about the effects of corticosteroids on bone, and advise clinicians of the appropriate treatments for patients receiving corticosteroids.

METHODS

This review summarizes the pathophysiology of corticosteroid-induced osteoporosis, describes the assessment methods used to evaluate this condition, examines the results of clinical trials of drugs, and explores a practical approach to the management of corticosteroid-induced osteoporosis based on data collected from published articles.

RESULTS

Despite our lack of understanding about the biological mechanisms leading to corticosteroid-induced bone loss, effective therapy has been developed. Bisphosphonate therapy is beneficial in both the prevention and treatment of corticosteroid-induced osteoporosis. The data for the bisphosphonates are more compelling than for any other agent. For patients who have been treated but continue to lose bone, hormone replacement therapy, calcitonin, fluoride, or anabolic hormones should be considered. Calcium should be used only as an adjunctive therapy in the treatment or prevention of corticosteroid-induced bone loss and should be administered in combination with other agents.

CONCLUSIONS

Bisphosphonates have shown significant treatment benefit and are the agents of choice for both the treatment and prevention of corticosteroid-induced osteoporosis.

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).

Glucocorticosteroid therapy for multiple sclerosis: a critical review

Controversy remains as to the efficacy, route of administration and dose of glucocorticosteroid (GCS) in multiple sclerosis (MS) therapy. With the recent approval of new disease modifying treatments and increasing interest in cost-benefit assessments, it is timely to critically consider their role in MS therapeutics. In this paper we review our current understanding of the cellular and molecular mechanisms of action of GCS as they relate to the postulated pathophysiology of MS. We also critically review the use of glucocorticosteroid therapy to: (1) improve recovery from exacerbations of MS, (2) delay the onset of MS in patients who experience a first episode of monosymptomatic optic neuritis, and (3) delay the time to onset of sustained progression of disability in patients with clinically definite MS.