The effect of corticosteroids for acute optic neuritis on the subsequent development of multiple sclerosis. The Optic Neuritis Study Group

New developments in the treatment of optic neuritis

Acute optic neuritis (ON) has various etiologies. The most common presentation is inflammatory, demyelinating, idiopathic, or "typical" ON, which may be associated with multiple sclerosis. This must be differentiated from "atypical" causes of ON, which differ in their clinical presentation, natural history, management, and prognosis. Clinical "red flags" for an atypical cause of ON include absent or persistent pain, exudates and hemorrhages on fundoscopy, very severe, bilateral, or progressive visual loss, and failure to recover. In typical ON, steroids shorten the duration of the attack, but do not influence visual outcome. This is in contrast to atypical ON associated with conditions such as sarcoidosis and neuromyelitis optica, which require aggressive immunosuppression and sometimes plasma exchange. The visual prognosis of typical ON is generally good. The prognosis in atypical ON is more variable. New developments aimed at designing better treatments for patients who fail to recover are discussed, focusing on recent research elucidating mechanisms of damage and recovery in ON. Future therapeutic directions may include enhancing repair processes, such as remyelination or adaptive neuroplasticity, or alternative methods of immunomodulation. Pilot studies investigating the safety and proof-of-principle of stem cell treatment are currently underway.

Early treatment of multiple sclerosis: a Latin American experts meeting

Patients with clinically isolated syndrome (CIS) by definition do not have multiple sclerosis (MS) but are at risk of developing it. While studies show earlier immunomodulating drug use is effective, treatment must consider likely patient prognosis. In this paper we review current diagnosis, prognosis, and treatment literature for patients with CIS within Latin American clinical settings. Latin American MS experts, convened by ACINDES (The Civil Association for Research and Development in Health), reviewed current CIS (and early MS) literature and drew consensus conclusions. Three subgroups addressed separate questionnaires on CIS issues: prognosis, diagnosis, and treatment. MRI can contribute to predicting MS risk in patients with CIS; in Latin America, investigation of haplotype presence associated with CIS would be appropriate. McDonald's criteria and subsequent revisions enable earlier, more accurate MS diagnosis. Type A evidence exists supporting all leading immunomodulating MS drugs for effective treatment of CIS with a high risk of conversion to MS. In conclusion, patients with CIS are usually young, with often-limited symptomatic manifestations, and must be adequately prepared to receive preventive treatment. This consensus review should contribute to the dialogue between physicians and patients.

Shifting the paradigm toward earlier treatment of multiple sclerosis with interferon beta

BACKGROUND

Axonal damage occurs early in the course of multiple sclerosis (MS). Among untreated patients, 85% to 94% with a first clinically isolated syndrome (CIS) suggestive of MS and positive findings on magnetic resonance imaging (MRI) are at risk for developing MS.

OBJECTIVES

This article reviews the current literature concerning early diagnosis of MS, the rationale for early immunomodulatory treatment of patients with a CIS and MRI evidence of central nervous system lesions, and the efficacy of early treatment with interferon beta (IFN-beta).

METHODS

MEDLINE was searched from 1990 through the end of 2008 for papers published in English concerning the treatment of MS. Search terms included IFN-beta, early treatment, CIS, and multiple sclerosis, and limits were set to return results related to human clinical trials in adults.

RESULTS

Three pivotal randomized controlled trials were identified, 2 involving IFN-beta-1a (30 microg IM once weekly and 22 microg SC once weekly) and 1 involving IFN-beta-1b (250 microg SC qod). In these trials, treatment with IFN-beta effectively reduced the risk of developing MS by up to 50% in patients with a CIS. Furthermore, compared with delayed treatment, early treatment was associated with a reduced risk of disease progression: a 40% reduction in risk for confirmed disability progression at 3 years and a 41% reduction in risk of MS at 3 years.

CONCLUSIONS

The evidence that axonal damage begins in the early stages of MS, before symptoms are evident, provides a rationale for early intervention with immunomodulatory agents. In 3 pivotal clinical trials, IFN-beta effectively reduced the risk of developing clinically definite MS in CIS patients with a first demyelinating event and positive brain MRI.

The effect of interferon beta-1a on optic neuritis relapse in patients with multiple sclerosis

BACKGROUND

To evaluate the clinical effect of interferon beta-1a on optic neuritis (ON) relapse in patients with multiple sclerosis (MS) in Taiwan.

METHODS

Data were collected from 23 MS patients with ON at National Taiwan University Hospital between January 1, 1993 and February 1, 2007. Twenty-three MS patients with ON received interferon beta-1a (Rebif) 44 microg via subcutaneous injection three times weekly. All patients received corticosteroids pulse therapy followed by oral prednisolone for acute ON. The annual relapse rate (ARR) of ON in these MS patients before and after the use of interferon beta-1a (Rebif) was the main clinical parameter of outcome in this study.

RESULTS

The ARR of ON was lower in the posttreatment period than in the pretreatment period (P = 0.0068). Thirteen patients (56.5%) had improved final visual acuity (>2 lines), and the other ten patients (43.5%) had stable final visual outcome (-2 lines < X < 2 lines). In addition, no recurrence of ON was noted in 15 patients (65.2%) during the posttreatment period.

CONCLUSIONS

The use of interferon beta-1a 44 microg via subcutaneous injection three times weekly did not increase the ON attacks in MS patients receiving this treatment. In addition, beneficial effects were found with the use of interferon beta-1a on these patients.

Corticosteroids in the treatment of multiple sclerosis

BACKGROUND

Multiple sclerosis (MS) is an immune-mediated inflammatory disease of the central nervous system (CNS) that usually is clinically characterized by repeated subacute relapses followed by remissions. Therapeutic strategies include corticosteroid treatment of relapses and immunomodulatory- or immunosuppressive treatment to prevent new relapses and progression of disability.

OBJECTIVES

To review the evidences for the use of corticosteroids in the treatment of relapses in MS as well as its possible disease modifying potential.

MATERIALS & METHODS

Available literature from PubMed search and personal experiences on corticosteroid treatment in multiple sclerosis were reviewed.

RESULTS

High dose short-term oral or intravenous methylprednisolone for 3-5 days speed up recovery from relapses, but the treatment has no influence on the occurrence of new relapses or long-term disability. There is also some evidence that pulsed treatment with methylprednisolone have beneficial long-term effects in multiple sclerosis.

CONCLUSION

Relapses with moderate to serious disability should be treated with high dose intravenous or oral methylprednisolone. More data is needed to determine long-term disease modifying effects of corticosteroids.

Treatment of acute demyelinating optic neuritis

Patients with typical acute monosymptomatic demyelinating optic neuritis should receive gadolinium-enhanced magnetic resonance imaging (MRI) of the brain and orbits to determine if they are at high risk for the subsequent development of clinically definite multiple sclerosis (CDMS). The presence of >or=2 white matter lesions (>or=3 mm in diameter, at least 1 lesion periventricular or ovoid) indicates high risk for CDMS; the following treatment should be considered for such patients: 1. Intravenous methylprednisolone sodium succinate (1 gram IV/day for 3 days) followed by oral prednisone (1 mg/kg/day for 11 days) with 4-day taper (20 mg on day 1, 10 mg on days 2 and 4); 2. Interferon beta 1-a (Avonex 30microg intramuscularly [IM] weekly, or Rebif 22 microg subcutaneously [SQ] weekly). These two drugs have been shown to reduce the short-term risk of CDMS in high risk monosymptomatic patients. In monosymptomatic patients with <2 white matter lesions, and in patients for whom CDMS has been established, IV methylprednisolone treatment followed by oral prednisone should be considered on an individual basis. Treatment in these patients may hasten visual recovery, but does not affect long-term visual outcome. Oral prednisone alone, without prior treatment with IV methylprednisolone, may increase the risk for recurrent optic neuritis and should be avoided.

The clinical epidemiology of multiple sclerosis

A comprehensive knowledge of the natural course and prognosis of multiple sclerosis is of utmost importance for a physician to make it affordable in simple descriptive terms to a patient when personal and medical decisions are to be taken. It is still topical because the currently acknowledged disease-modifying agents only marginally alter the overall prognosis of the disease. It provides reference for evaluating the efficacy of a therapeutic intervention in clinical trials; clues for public health services, health insurance companies, and pharmaceutical industry in their respective activities; and insights into the pathophysiology and the treatment of multiple sclerosis. Precise, consistent, and reliable data from appropriate cohorts have become available and knowledge is fairly comprehensive.

Multiple sclerosis

Multiple sclerosis is the most common disabling neurologic disease affecting young adults and adolescents in the United States. The first objective of this article is to familiarize nonspecialists with the cardinal features of multiple sclerosis and our current understanding of its etiology, epidemiology, and natural history. The second objective is to explain the approach to diagnosis. The third is to clarify current evidence-based treatment strategies and their roles in disease modification. The overall goal is to facilitate the timely evaluation and confirmation of diagnosis and enhance effective management through collaboration among primary physicians, neurologists, and other care providers who are confronted with these formidably challenging patients.

Disease-modifying agents for multiple sclerosis: recent advances and future prospects

Multiple sclerosis (MS) is a chronic autoimmune disease of the CNS. Currently, six medications are approved for immunmodulatory and immunosuppressive treatment of the relapsing disease course and secondary-progressive MS. In the first part of this review, the pathogenesis of MS and its current treatment options are discussed. During the last decade, our understanding of autoimmunity and the pathogenesis of MS has advanced substantially. This has led to the development of a number of compounds, several of which are currently undergoing clinical testing in phase II and III studies. While current treatment options are only available for parenteral administration, several oral compounds are now in clinical trials, including the immunosuppressive agents cladribine and laquinimod. A novel mode of action has been described for fingolimod, another orally available agent, which inhibits egress of activated lymphocytes from draining lymph nodes. Dimethylfumarate exhibits immunomodulatory as well as immunosuppressive activity when given orally. All of these compounds have successfully shown efficacy, at least in regards to the surrogate marker contrast-enhancing lesions on magnetic resonance imaging. Another class of agents that is highlighted in this review are biological agents, namely monoclonal antibodies (mAb) and recombinant fusion proteins. The humanized mAb daclizumab inhibits T-lymphocyte activation via blockade of the interleukin-2 receptor. Alemtuzumab and rituximab deplete leukocytes and B cells, respectively; the fusion protein atacicept inhibits specific B-cell growth factors resulting in reductions in B-cells and plasma cells. These compounds are currently being tested in phase II and III studies in patients with relapsing MS. The concept of neuro-protection and -regeneration has not advanced to a level where specific compounds have entered clinical testing. However, several agents approved for conditions other than MS are highlighted. Finally, with the advent of these highly potent novel therapies, rare, but potentially serious adverse effects have been noted, namely infections and malignancies. These are critically reviewed and put into perspective.

Relapse management in multiple sclerosis

Relapses, exacerbations, and attacks are synonymous for new or worsened neurologic symptoms that are the hallmark of relapsing-remitting multiple sclerosis. Management of relapses is not always straightforward. The clinician must distinguish between true relapses, symptom fluctuation, and pseudo-relapses. Risks and benefits of treating a relapse must be considered. Once the decision to treat is made, most clinicians would pursue a course of corticosteroids. Consensus may end there, as there is no clear-cut "best" route of administration or dosing schedule. The patient presenting with their first relapse or clinically isolated syndrome may be at risk for the development of multiple sclerosis. Clinical presentation, CSF findings, and MRI may all give clues as to the risk for future demyelinating events.

Management of optic neuritis and impact of clinical trials: an international survey

OBJECTIVE

1) To evaluate the management of acute isolated optic neuritis (ON) by ophthalmologists and neurologists; 2) to evaluate the impact of clinical trials; 3) to compare these practices among 7 countries.

METHODS

A survey on diagnosis and treatment of acute isolated ON was sent to 5,443 neurologists and 6,099 ophthalmologists in the southeast-USA, Canada, Australia/New Zealand, Denmark, France, and Thailand. USA data were compared to those of other countries.

RESULTS

We collected 3,142 surveys (1,449 neurologists/1,693 ophthalmologists) (29.8% response rate). In all countries, ON patients more frequently presented to ophthalmologists, and were subsequently referred to neurologists or subspecialists. Evaluation and management of ON varied among countries, mostly because of variations in healthcare systems, imaging access, and local guidelines. A brain MRI was obtained for 70-80% of ON patients; lumbar punctures were obtained mostly in Europe and Thailand. Although most patients received acute treatment with intravenous steroids, between 14% and 65% of neurologists and ophthalmologists still recommended oral prednisone (1 mg/kg/day) for the treatment of acute isolated ON. In all countries, steroids were often prescribed to improve visual outcome or to decrease the long-term risk of multiple sclerosis.

INTERPRETATION

Although recent clinical trials have changed the management of acute ON around the world, many neurologists and ophthalmologists do not evaluate and treat acute ON patients according to the best evidence from clinical research. This confirms that evaluation of the impact of major clinical trials ("translational T2 clinical research") is essential when assessing the effects of interventions designed to improve quality of care.

Pulse steroid therapy

Intravenous supra-pharmacological doses of corticosteroids are used in various inflammatory and autoimmune conditions because they are cumulatively less toxic than sustained steroid treatment at lower quantitative dosage. Their action is supposed to be mediated through non-genomic actions within the cell. Common indications for use in children include steroid resistant and steroid dependent nephrotic syndrome, rapidly progressive glomerulonephritis, systemic vasculitis, systemic lupus erythematosus, acute renal allograft rejection, juvenile rheumatoid arthritis, juvenile dermatomyositis, pemphigus, optic neuritis, multiple sclerosis and acute disseminated encephalomyelitis. Methylprednisolone and dexamethasone show similar efficacy in most conditions. Therapy is associated with significant side effects including worsening of hypertension, infections, dyselectrolytemia and behavioral effects. Adequate monitoring is essential during usage.

Management of optic neuritis in Canada: survey of ophthalmologists and neurologists

BACKGROUND

Acute isolated optic neuritis is often the first manifestation of multiple sclerosis (MS), and its management remains controversial. Over the past decade, with the advent of new disease-modifying agents, management of isolated optic neuritis has become more complicated.

OBJECTIVES

To evaluate the current practice patterns of Canadian ophthalmologists and neurologists in the management of acute optic neuritis, and to evaluate the impact of recently published randomized clinical trials.

DESIGN

Mail survey.

METHODS

All practicing ophthalmologists and neurologists in Canada were mailed a survey evaluating the management of isolated acute optic neuritis and familiarity with recent clinical trials. Surveys for 1158 were mailed, and completed surveys were collected anonymously through a datafax system. Second and third mailings were sent to non-respondents 6 and 12 weeks later.

RESULTS

The final response rate was 34.5%. Although many acute optic neuritis patients initially present to ophthalmologists, neurologists are the physicians primarily managing these patients. Ordering magnetic resonance imaging, and treating with high dose intravenous steroids has become the standard of care. However, 15% of physicians (14% of ophthalmologists and 16% of neurologists) continue to prescribe low dose oral steroids, and steroids are being given for reasons other than to shorten the duration of visual symptoms by 73% of ophthalmologists and 50% of neurologists. More neurologists than ophthalmologists are familiar with recent clinical trials involving disease-modifying agents.

CONCLUSION

Although the management of acute optic neuritis has been evaluated in large clinical trials that were published in major international journals, some ophthalmologists and neurologists are not following evidence-based recommendations.

[Recurrent inflammatory optic neuropathy]

PURPOSE

To analyze clinical and paraclinical characteristics of recurrent isolated optic neuropathy.

PATIENTS

and method: In three university hospitals (Montpellier, Nimes, and Strasbourg), between October 2005 and September 2006, the charts of patients with corticosensitive recurrent isolated optic neuropathy and normal cerebral magnetic resonance imaging included prospectively were reviewed. The following parameters were analyzed: date of the first relapse, age at onset, duration at the time of inclusion, recurrence after steroid withdrawal, unilateral or bilateral involvement, number of relapses, visual acuity, retinal nerve fiber layer thickness, diagnostic workup, and long-term treatment with immunosuppressive or immunomodulatory drugs.

RESULTS

During the predefined period, 13 patients (11 women, 2 men; age, 17-54 years at onset) matched the inclusion criteria. Between two and six relapses of optic neuropathy were observed. The median duration was 4 years. In untreated patients (n=7), a significant (Spearman p=0.0156) inverse correlation was observed between visual acuity and duration of the disease; this correlation was not found in the group of patients (n=6) with long-term treatment (Spearman p=0.1032).

CONCLUSION

The progressive loss of vision over time in this retrospective study of recurrent isolated optic neuropathy could be related to axonal loss. A prospective cohort study is necessary to confirm this hypothesis and to evaluate the benefit of long-term treatment on this progression.

Acute inflammatory demyelinating optic neuritis: evidence-based visual and neurological considerations

BACKGROUND

Optic neuritis (ON) is an acute inflammatory demyelinating disorder of the optic nerve that occurs most often in young adults. It can be a monophasic or polyphasic disease isolated to the optic nerve(s) or can be associated with a more widespread demyelinating disorder of the central nervous system such as multiple sclerosis (MS) or neuromyelitis optica. Advances in therapeutics that modify the risk of progression to MS have emphasized accurate diagnosis and risk assessment of patients with ON.

REVIEW SUMMARY

ON usually presents with acute unilateral visual loss associated with ocular pain exacerbated by eye movements. Similar to results found in studies assessing corticosteroid used in MS relapses, intravenous methylprednisolone accelerates visual recovery from ON but has no impact on long-term visual outcome. A clinically isolated syndrome (CIS), such as ON, is a clinical demyelinating event that is often the initial attack of relapsing-remitting MS. Disease modifying drugs, in particular interferons-beta, have been shown to reduce the risk of MS conversion in high-risk patients presenting with a CIS. The exact timing and patient selection for the initiation of treatment remain controversial.

CONCLUSION

ON is the best studied CIS. The visual prognosis is excellent in most cases regardless of whether the patient is treated with corticosteroids or not. Three recently completed prospective, randomized, double-blinded, placebo-controlled studies have shown that starting a disease-modifying drug at the time of a CIS can reduce the rate of development of MS. However, better diagnostic tools are needed to precisely predict the conversion to MS and the factors influencing disease severity to determine the most appropriate therapeutic paradigm and avoid unnecessary treatment.

Methylprednisolone induces reversible clinical and pathological remission and loss of lymphocyte reactivity to myelin oligodendrocyte glycoprotein in experimental autoimmune encephalomyelitis

Experimental autoimmune encephalomyelitis (EAE) is an animal model of human multiple sclerosis (MS). EAE, induced by immunisation with myelin-associated autoantigens, is characterised by an inflammatory infiltrate in the central nervous system (CNS) associated with axonal degeneration, demyelination and damage. We have recently shown in an experimental mouse model of autoimmune gastritis that methylprednisolone treatment induces a reversible remission of gastritis with regeneration of the gastric mucosa. Here, we examined the effect of oral methylprednisolone on the mouse EAE model of human MS induced by immunisation with myelin oligodendrocyte glycoprotein peptide (MOG(35-55)). We examined the clinical scores, CNS pathology and lymphocyte reactivity to MOG(35-55) following treatment and withdrawal of the steroid. Methylprednisolone remitted the clinical signs of EAE and the inflammatory infiltrate in the CNS, accompanied by loss of lymphocyte reactivity to MOG(35-55) peptide. Methylprednisolone withdrawal initiated relapse of the clinical features, a return of the CNS inflammatory infiltrate and lymphocyte reactivity to MOG(35-55) peptide. This is the first study to show that methylprednisolone induced a reversible remission in the clinical and pathological features of EAE in mice accompanied by loss of lymphocyte reactivity to the encephalitogen. This model will be useful for studies directed at a better understanding of mechanisms associated with steroid-induced disease remission, relapse and remyelination and also as an essential adjunct to an overall curative strategy.

Multiple sclerosis risk after optic neuritis: final optic neuritis treatment trial follow-up

OBJECTIVE

To assess the risk of developing multiple sclerosis (MS) after optic neuritis and the factors predictive of high and low risk.

DESIGN

Subjects in the Optic Neuritis Treatment Trial, who were enrolled between July 1, 1988, and June 30, 1991, were followed up prospectively for 15 years, with the final examination in 2006.

SETTING

Neurologic and ophthalmologic examinations at 13 clinical sites.

PARTICIPANTS

Three hundred eighty-nine subjects with acute optic neuritis.

MAIN OUTCOME MEASURES

Development of MS and neurologic disability assessment.

RESULTS

The cumulative probability of developing MS by 15 years after onset of optic neuritis was 50% (95% confidence interval, 44%-56%) and strongly related to presence of lesions on a baseline non-contrast-enhanced magnetic resonance imaging (MRI) of the brain. Twenty-five percent of patients with no lesions on baseline brain MRI developed MS during follow-up compared with 72% of patients with 1 or more lesions. After 10 years, the risk of developing MS was very low for patients without baseline lesions but remained substantial for those with lesions. Among patients without lesions on MRI, baseline factors associated with a substantially lower risk for MS included male sex, optic disc swelling, and certain atypical features of optic neuritis.

CONCLUSIONS

The presence of brain MRI abnormalities at the time of an optic neuritis attack is a strong predictor of the 15-year risk of MS. In the absence of MRI-detected lesions, male sex, optic disc swelling, and atypical clinical features of optic neuritis are associated with a low likelihood of developing MS. This natural history information is important when considering prophylactic treatment for MS at the time of a first acute onset of optic neuritis.

Avonex Combination Trial in relapsing—remitting MS: rationale, design and baseline data

Objective To review the rationale, design and baseline data of the Avonex Combination Trial (ACT), an investigator-run study of intramuscular interferon beta-1a (IM IFNβ-1a) combined with methotrexate (MTX) and/or IV methylprednisolone (IVMP) in relapsing—remitting multiple sclerosis (RRMS) patients with continued disease activity on IM IFNβ-1a monotherapy.

Methods Eligibility criteria included RRMS, Expanded Disability Status Scale score 0—5.5, and ≥1 relapse or gadolinium-enhancing MRI lesion in the prior year while on IM IFNβ-1a monotherapy. Subjects continued IFNβ-1a 30 mcg IM weekly and were randomized in a 2 × 2 factorial design to adjunctive weekly placebo or MTX 20 mg PO, with or without IVMP 1000 mg/day for three days every other month. ACT was industry-supported, and collaboratively designed and governed by an Investigator Steering Committee with independent Advisory and Data Safety Monitoring Committees. Study operations, MRI analysis and aggregated data were managed by the Cleveland Clinic MS Academic Coordinating Center.

Results In total 313 subjects were enrolled with clinical and MRI characteristics typical of RRMS. Most subjects (86.9%) qualified with a clinical relapse, with or without an enhancing MRI lesion, in the preceding year. At baseline, 21.4% had enhancing lesions, and 5.1% had anti-IFNβ neutralizing antibodies. ACT's management and operational structures functioned well.

Conclusion This study provides an innovative model for academic—industry collaborative MS research and will enhance understanding of the utility of combination therapy for RRMS patients with continued disease activity on an established first-line treatment. Multiple Sclerosis 2008; 14: 370—382. http://msj.sagepub.com

Hormonal influences in multiple sclerosis

The function of hormones has expanded to include immunomodulation and neuroprotection in addition to their classic roles. The story of how hormones influence inflammation and neuron and glial function is being slowly unraveled. There is increasing evidence that estrogen, progesterone, and testosterone contain immune responses and influence damage repair in the nervous system. Hormones such as prolactin and vitamin D are being explored as immunomodulators and may influence diseases such as multiple sclerosis (MS) or may be used therapeutically to modulate the immune response. More recently identified hormones, such as leptin and gherlin, may also influence the course of disease. This chapter reviews some of the evidence that supports a role for hormones in MS.

Corticosteroids for the long-term treatment in multiple sclerosis

BACKGROUND

Short term high dose corticosteroid treatment improves symptoms and short term disability after an acute exacerbation of multiple sclerosis (MS) but it is unknown whether its long-term use can reduce the accumulation of disability.

OBJECTIVES

To determine the efficacy and safety of long-term corticosteroid use in MS.

SEARCH STRATEGY

We searched the following bibliographic databases: CENTRAL (Issue 1, 2007), MEDLINE (1966 to February 2007) and EMBASE (1980 to February 2007). In an effort to identify further published, unpublished and ongoing trials we searched reference lists and contacted trial authors and one pharmaceutical company.

SELECTION CRITERIA

We considered controlled, randomised trials (RCTs), with or without blinding, of long term treatment (i.e. longer than 6 months) of any type of corticosteroid in MS, irrespective of disease course.

DATA COLLECTION AND ANALYSIS

Reviewers independently assessed trial quality and extracted data. Study authors were contacted for additional information.

MAIN RESULTS

Three trials, all classified at high risk of bias, contributed to this review (Miller 1961; BPSM 1995; Zivadinov 2001) resulting in a total of 183 participants (91 treated). Corticosteroid therapy did not reduce the risk of being worse at the end of follow-up (odds ratio [OR] 0.51, 95% confidence interval [CI] 0.26 to 1.02) but there was a substantial heterogeneity between studies (I(2): 78.4%). I. v. periodic high dose methylprednisolone (MP) was associated with a significant reduction in the risk of disability progression at 5 years in relapsing-remitting (RR) MS (OR 0.26, 95% CI 0.10 to 0.66), while oral continuous low dose prednisolone was not associated with any risk reduction in disability progression at 18 months (OR 1.23, 95% CI 0.43 to 3.56). Risk of experiencing at least one exacerbation at end of follow-up was not significantly reduced with corticosteroid treatment (OR 0.36; 95% CI 0.10 to 1.25). Only one study recorded adverse events: in one patient i. v. MP was discontinued after the fourth pulse when he developed acute glomerulonephritis; a second patient was removed from the study after the fifth i. v. MP pulse because of severe osteoporosis.

AUTHORS' CONCLUSIONS

There is no enough evidence that long-term corticosteroid treatment delays progression of long term disability in patients with MS. Since one study at high risk of bias showed that the administration of pulsed high dose i. v. MP is associated with a significant reduction in the risk of long term disability progression in patients with RR MS, an adequately powered, high quality RCT is needed to investigate this finding.

Visual function 15 years after optic neuritis: a final follow-up report from the Optic Neuritis Treatment Trial

OBJECTIVE

To assess visual function 15 years after acute unilateral optic neuritis.

DESIGN

Longitudinal follow-up of a randomized clinical trial.

PARTICIPANTS

Two hundred ninety-four patients who were randomized in the Optic Neuritis Treatment Trial between 1988 and 1991 and underwent examination in 2006.

TESTING

A neuro-ophthalmic examination included measurements of visual acuity, contrast sensitivity, and visual field. Quality of life was assessed with the National Eye Institute Visual Function Questionnaire and Neuro-ophthalmic Supplement.

MAIN OUTCOME MEASURES

Abnormal vision and health-related quality-of-life scores.

RESULTS

Seventy-two percent of the eyes affected with optic neuritis at study entry had visual acuity of > or = 20/20 and 66% of patients had > or = 20/20 acuity in both eyes. On average, visual function was slightly worse among patients with multiple sclerosis (MS) than among with those without MS. As expected, quality-of-life scores were lower when acuity was reduced and when neurologic disability from MS was present.

CONCLUSIONS

Long-term visual outcome is favorable for the majority of patients who experience optic neuritis even when MS is present.

Corticosteroids for multiple sclerosis: II. Application for disease-modifying effects

Physicians who treat multiple sclerosis (MS) face the challenge of patients exhibiting ongoing disease activity, including exacerbations, loss of functional capabilities, intellectual decline, and radiologic progression, despite being on a disease-modifying agent (DMA). After searching for factors that might at least in part explain these changes--such as nonadherent drug-taking behavior, or the presence of interferon-neutralizing antibodies--some providers may ultimately decide to switch the patient to another DMA. In most circumstances, patients likely derive only partial effects from these agents, even in the absence of compromising factors. Thus, a number of factors must be considered in order to intensify the treatment regimen in response to disease progression. In the context of an inadequate treatment response to a DMA, some clinicians will convert the patient to an alternative therapy, and others will instead use a second agent in combination with the first (the so-called platform agent). In the first of this two-part series, we explored the use of anti-inflammatory CS and ACTH to treat MS exacerbations. Although we underscored the limited availability of evidence-based studies to support specific regimens for this purpose, there is an even greater paucity of data to support the routine use of these agents in order to achieve chronic disease-modifying effects in those who continue to deteriorate clinically, radiographically, or both. Without doubt, a number of factors influence the formulation of combination treatment plan for MS. Nevertheless, we will focus on the rationale and practical schemes that can be considered for using corticosteroids (CS) (and perhaps even ACTH) in an attempt to modify various domains of ongoing disease activity.

Ophthalmic diagnoses in the ED: optic neuritis

Optic neuritis is the most common cause of decreased vision due to optic nerve dysfunction in patients who are 20 to 40 years of age. Optic neuritis, or inflammation of the optic nerve, is primarily due to idiopathic demyelination. Demyelinative lesions seen in optic neuritis are not unlike those seen in plaque associated with multiple sclerosis. In fact, acute inflammatory demyelination of the optic nerve commonly occurs as an initial manifestation of multiple sclerosis. Key features of optic neuritis include a vision loss occurring over 1 to 10 days, color vision impairment, eye pain with motility, and an afferent pupillary defect. This significant diagnosis can be challenging to an emergency physician as it is relatively infrequently observed.

Immunosuppression: Promises and failures

The author participated very early in the use of immunosuppressors in the treatment of multiple sclerosis. He reviews evidence which support their use. IV Methylprednisolone, azathioprine and mitoxantrone are supported in their use by evidence of a level appropriate to the date of their generation while Cyclosporine A and Cyclophosphamide are not. The author also reviews the benefits and side effects of each of these medications, insisting on a practical approach to their use. The author concludes that since immunomodulators have been approved, the use of the immunosuppressors has been reduced, however there is a strong possibility that their use will be rekindled in association with immunomodulatory medications.

Natural history of multiple sclerosis: risk factors and prognostic indicators

PURPOSE OF REVIEW

To highlight progress in the description of the natural course and prognosis of multiple sclerosis.

RECENT FINDINGS

The general evolution of multiple sclerosis is now well known at the level of patient groups. Characteristics of relapses early in the disease and the occurrence of a progressive phase seemed to be the most reliable prognostic factors. Recent works suggest that the progressive phase in multiple sclerosis could be an age-dependent, degenerative process, independent of previous relapses, and that the initial course of the disease does not substantially influence age at disability milestones. By contrast, a younger age at disease onset strongly correlates with a younger age when reaching disability landmarks, confirming that even if it takes longer for younger patients to accumulate irreversible disability, they are disabled at a younger age than patients with later onset. Multiple sclerosis might be considered as one disease with different clinical phenotypes, rather than an entity encompassing several distinct diseases.

SUMMARY

Overall course and prognosis in multiple sclerosis is most likely to be related to age and the occurrence of the progressive phase of the disease, rather than to relapses or other clinical parameters. Individual prognosis remains hazardous.

New directions in optic neuritis and multiple sclerosis

Optic neuritis (ON) is the initial presentation in 15% to 20% of cases of multiple sclerosis (MS). Thirty-eight percent to 50% of patients with MS develop ON at some point during the course of their disease. The Optic Neuritis Treatment Trial (ONTT) provided much prospective data about the clinical presentation, clinical course with respect to treatment, and development of MS in patients with ON. The clinical course of MS initially involves episodes of demyelination followed by full recovery; however, later attacks often leave persistent deficits that lead to secondary progression of the disease. The risk of developing progressive neurologic deficits can be reduced by starting therapy with immunomodulating drugs early in the course of the disease. Optical coherence tomography is a noninvasive way to monitor patients with ON to determine if they are undergoing subclinical axonal loss of ganglion cells. Progression of axonal loss on optical coherence tomography may prompt a change in therapy or further imaging.

Combination therapy for the treatment of multiple sclerosis: challenges and opportunities

OBJECTIVE

Multiple sclerosis (MS) is a complex, heterogeneous disease. Standard treatment of relapsing MS includes interferon beta (IFNbeta) and glatiramer acetate. These agents reduce relapse rates, and IFNbeta-1a is associated with a slowing of disease progression. Despite treatment, many patients experience disease progression, prompting neurologists to use combination therapies to delay this progression. Agents that may be considered for combination therapy are those with unique mechanisms of action that exert additive or synergistic efficacy. This article reviews combination treatment with immunosuppressive therapies and new agents for the management of MS.

METHODS

The Medline and EMBASE databases were searched for clinical trials using the following search terms: multiple sclerosis, interferon, Avonex, Betaseron, Rebif, glatiramer, copolymer 1, Copaxone, immunosuppressant, cytotoxic, corticosteroid, azathioprine, cyclophosphamide, methotrexate, mitoxantrone, natalizumab, combination therapy. The National MS Society website was searched for clinical trials of combination therapies.

RESULTS

Several small studies have analyzed the effects of immunosuppressive therapy added to IFNbeta treatment, and some encouraging results have been obtained. Few data are available on combination therapy with new drug classes; however, current data suggest that combination therapy with new agents is effective. Although the available data on combination regimens are promising, interpretation is limited by lack of controlled study design, small patient population, and short study duration.

CONCLUSIONS

Combination of standard therapies with immunosuppressive agents or with new therapies may provide synergistic effects that will likely benefit patients with MS. Larger, well-controlled trials need to be conducted.

Gastroparesis secondary to a demyelinating disease: a case series

Background

Gastroparesis has a number of etiologies. The main ones are secondary to a complication from diabetes mellitus, related to post vagotomy or post gastric surgical resections, or idiopathic when the etiology is unclear. Gastroparesis secondary to a demyelinating disease of the brain is unusual.

Case presentation

A 22-year-old woman was referred for acute onset of intractable nausea and vomiting. She also had cerebellar deficits, dysphagia and paresthesias. Magnetic resonance imaging (MRI) of the brain revealed an isolated area of demyelination in the medullary region. Another 24-year-old woman had a similar presentation with right hemiplegia and MRI of the brain revealed a distal medullary region. Both these patients had an abnormal gastric emptying test. Gastroparesis and neurological deficits improved with intravenous corticosteroids. While the former patient has had no further recurrences, the latter patient developed multiple sclerosis within three months of presentation.

Conclusion

A demyelinating disease is a rare cause gastropareis, but should be suspected when symptoms of gastroparesis are associated with neurological deficits. MRI might help in the diagnosis and intravenous coriticosteroids can address the underlying disease process and improve gastric emptying, especially when used early during the course of the disease.

High-dose intravenous methylprednisolone in recent traumatic optic neuropathy; a randomized double-masked placebo-controlled clinical trial

BACKGROUND

To compare the effect of high-dose intravenous corticosteroid therapy with placebo in the treatment of recent traumatic optic neuropathy (TON).

METHODS

In a double-masked placebo-controlled clinical trial, 31 eyes of 31 patients were randomly assigned to two groups. Patients with history of trauma < or =7 days were included. Unconscious patients, eyes with penetrating trauma and candidates for decompression surgery were excluded. The treatment group (16 eyes) received 250 mg methylprednisolone intravenously every 6 h for 3 days, then 1 mg/kg prednisolone orally for 14 days; the placebo group (15 eyes) received 50 ml normal saline intravenously every 6 h for 3 days, then placebo for 14 days. Visual improvement was considered as a decrease of at least 0.4 logMAR in final visual acuity.

RESULTS

Mean final BCVA (best corrected visual acuity) in the treatment group was 1.11+/- 1.14 and the placebo group was 1.78 +/- 1.23. This difference was not significant (P = 0.13). Visual acuity was improved in 68.8% of the treatment group and 53.3% of the placebo group, but the difference was not statistically significant (P = 0.38). The difference between initial and final BCVA in both groups was determined to be statistically significant (P < 0.001 and 0.010 respectively).

CONCLUSIONS

Our study confirms earlier findings that there is no difference in visual acuity improvement between intravenous high-dose corticosteroids and placebo in treatment of recent TNO.

Corticosteroids for treating optic neuritis

BACKGROUND

Optic neuritis is an inflammatory disease of the optic nerve. It occurs more commonly in women than in men. Usually presenting with an abrupt loss of vision, recovery of vision is almost never complete. Closely linked in pathogenesis to multiple sclerosis, it may be the initial manifestation for this condition. In certain patients, no underlying cause can be found.

OBJECTIVES

To assess the effects of corticosteroids on visual recovery of patients with acute optic neuritis.

SEARCH STRATEGY

We searched the Cochrane Controlled Trials Register (CENTRAL) (which contains the Cochrane Eyes and Vision Group Trials Register) (issue 4, 2005), MEDLINE (1966 to December 2005), EMBASE (1980 to January 2006), NNR (issue 4, 2006), LILACS and reference lists of identified trial reports.

SELECTION CRITERIA

We included randomized trials that evaluated corticosteroids, in any form, dose or route of administration, in people with acute optic neuritis.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted the data on methodological quality and outcomes for analysis.

MAIN RESULTS

We included five randomized trials which included a total of 729 participants. Two trials evaluated low dose oral corticosteroids and two trials evaluated a higher dose of intravenous corticosteroids. One three-arm trial evaluated low-dose oral corticosteroids and high-dose intravenous corticosteroids against placebo. Trials evaluating oral corticosteroids compared varying doses of corticosteroids with placebo. Hence, we did not conduct a meta-analysis of such trials. In a meta-analysis of trials evaluating corticosteroids with total dose greater than 3000 mg administered intravenously, the relative risk of normal visual acuity with intravenous corticosteroids compared with placebo was 1.06 (95% CI 0.89 to 1.27) at six months and 1.06 (95% CI 0.92 to 1.22) at one year. The risk ratio of normal contrast sensitivity for the same comparison was 1.10 (95% CI 0.92 to 1.32) at six months follow up. We did not conduct a meta-analysis for this outcome at one year follow up since there was substantial statistical heterogeneity. The risk ratio of normal visual field for this comparison was 1.08 (95% CI 0.96 to 1.22) at six months and 1.02 (95% CI 0.86 to 1.20) at one year. Quality of life was assessed and reported in one trial.

AUTHORS' CONCLUSIONS

There is no conclusive evidence of benefit in terms of recovery to normal visual acuity, visual field or contrast sensitivity with either intravenous or oral corticosteroids at the doses evaluated in trials included in this review.

Optic neuritis and the neuro-ophthalmology of multiple sclerosis

Multiple sclerosis (MS) is the most common cause of neurological disability in young adults. Since approximately 40% of the brain is devoted to vision, demyelination commonly affects visual function, resulting in a myriad of neuro-ophthalmic symptoms. In this chapter, we examine the seminal afferent and efferent neuro-ophthalmological manifestations of MS, highlighting those history and examination findings critical for the diagnosis and treatment of various visual and ocular motor disorders. Among the topics, a special emphasis will be placed on optic neuritis, the most common clinically isolated demyelinating syndrome. This chapter focuses on the evaluation and treatment of visual sensory and oculomotor disorders in MS. The objective is to provide the reader with a working model for enhancing their care of patients with demyelinating disease.

[Multiple sclerosis. An update with practical guidelines for ophthalmologists]

Multiple sclerosis (MS) is the most frequent chronic inflammatory disease of the central nervous system. Mostly young adults present with a variety of different symptoms due to the multiple localisations of the inflammatory lesions. Up to one-third of MS patients experience symptoms of optic neuritis as the initial symptom. That is the reason why the ophthalmologist often is the first physician contacted by patients later on diagnosed with MS. Today, it is known that there is already a significant irreversible axonal loss in MS patients progressing from the beginning of the disease. Therefore early, diagnosis and application of available therapeutic options are necessary for the patient's benefit. The therapeutic aim in early immunomodulatory treatment is to decrease the number of relapses and to slow down the development of clinical disability. This interdisciplinary overview presents guidelines for the clinical routine: how to assess the individual risk of each patient and how to treat the patient in accordance with current pathogenic, diagnostic and therapeutic knowledge.

Is the frequency of abnormalities on magnetic resonance imaging in isolated optic neuritis related to the prevalence of multiple sclerosis? A global comparison

The link between optic neuritis and multiple sclerosis is well established, as is the increased risk of conversion to multiple sclerosis, with lesions seen at presentation on the magnetic resonance imaging (MRI) scan of the brain. One or more asymptomatic lesions were present in 77% of the optic neuritis cohort from London, UK, a higher proportion than that reported in other large cohorts studied elsewhere, where generally lower prevalence rates for multiple sclerosis are also reported. These observations may support the hypothesis that optic neuritis is more likely to be associated with abnormalities on MRI and to be due to multiple sclerosis in geographical regions where multiple sclerosis is more common.

The brain as a target of inflammation: common pathways link inflammatory and neurodegenerative diseases

Classical knowledge distinguishes between inflammatory and non-inflammatory diseases of the brain. Either the immune system acts on the CNS and initiates a damage cascade, as in autoimmune (e.g. multiple sclerosis) and infectious conditions, or the primary insult is not inflammation but ischemia or degeneration, as in stroke and Alzheimer's disease, respectively. However, as we review here, recent advances have blurred this distinction. On the one hand, the classical inflammatory diseases of the brain also exhibit profound and early neurodegenerative features - remarkably, it has been known for more than a century that neuronal damage is a key feature of multiple sclerosis pathology, yet this was neglected until very recently. On the other hand, immune mechanisms might set the pace of progressive CNS damage in primary neurodegeneration. Despite differing initial events, increasing evidence indicates that even in clinically heterogeneous diseases, there might be common immunological pathways that result in neurotoxicity and reveal targets for more efficient therapies.

Atopic optic neuritis

PURPOSE

To report a case of optic neuritis associated with atopic dermatitis, which may represent an optic nerve counterpart of atopic myelitis.

METHODS

Clinical examination, MRI, blood investigations.

RESULTS

A 34-year-old man with severe atopic dermatitis developed a steroid-responsive bilateral optic neuritis. Serum IgE was highly elevated, with high titers of mite-specific IgE. Clinical ophthalmological fluctuations paralleled those of atopic dermatitis.

CONCLUSIONS

The clinical features and parallel fluctuations strongly suggest that the patient's optic neuritis was related to atopic dermatitis. This atopic optic neuritis may represent the optic nerve equivalent of atopic myelitis.

New ways to look at an old problem

A 32-year-old man presented with optic neuritis (papillitis). A discussion of optic neuritis, the role of magnetic resonance imaging, and possible treatment options are presented. The role of optical coherence tomography in following patients with optic neuritis is discussed.

Low Conversion Rate to Multiple Sclerosis in Idiopathic Optic Neuritis Patients in Taiwan

PURPOSE

To investigate the clinical characteristics of patients with idiopathic optic neuritis (ON) in Taiwan and to assess the conversion rate to multiple sclerosis (MS) in these patients.

METHODS

We studied the medical records of a total of 109 patients with a clinical diagnosis of idiopathic ON treated in the Taipei Veterans General Hospital during the period from January 1986 to May 2003. Clinical characteristics, management, and disease courses were retrospectively reviewed. Our main focus was on the development of multiple sclerosis after an ON attack. Univariate and multivariate analyses were used to evaluate the risk indicators for MS conversion.

RESULTS

The patients (58 women, 51 men) had a mean age of 41.2 years at onset. ON was retrobulbar in 46.8% of the patients. Management with or without pulse therapy did not affect the final visual outcome. Female sex, retrobulbar type ON, recurrent cases, elevated cerebrospinal fluid (CSF) IgG index, and central nervous system (CNS) imaging abnormalities were identified as risk indicators for the development of MS (P < 0.05). The 2-year cumulative probability of developing MS was 5.92%, and the 5-year cumulative probability was 14.28%. The conversion rate to MS did not differ among treatment groups.

CONCLUSIONS

Idiopathic ON patients in Taiwan have an older age at onset and a higher percentage of optic disc edema than reported in previous literature. The characteristic features of ON patients associated with a high risk of developing MS are female sex, retrobulbar type ON, CNS imaging abnormalities, elevated CSF IgG index, and recurrence. Idiopathic ON patients in Taiwan display a significantly lower conversion rate to MS.