MS and steroids

[AlmostAnMD]

Dear neurology folks

I come in peace from the EM world

In residency, a neurologist told me to always give 1 g solumedrol prior to admit for patients symptomatic from an obvious MS exacerbation (optic neuritis stuff, weakness or paresthesias similar to prior exacerbations). Years later, I continue to do this. But a random neurologist told me recently that it will disrupt any MRI they do and want to wait until the patient is seen before giving steroids

Maybe that was just that guy? Or maybe stuff has changed since my residency? I exclusively work nights and neuro doesn't come in for this stuff or like to be paged for non-critical things so I've never ask prior to admission.

Do you guys care? I always thought I was being helpful starting steroids but if practice/times have changed I can just slide them into a bed and do nothing.

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[Telamir]

In my experience most of the "MS exacerbations" that come through the E.D. or into the hospital are either pseudoexacerbations or just plain bogus. I also question most diagnoses of MS until I get a scan.

My personal approach is to image wherever the symptoms localize to and if there is a new lesion then I give steroids. This helps patients in two ways in my opinion. If there is no lesion then they know this is a pseudoexacerbation or worsening of their baseline MS symptoms, and it prevents needless steroid use which as you know is not side effect free and could cause the patient to then go to their neurologist talking of their multiple exacerbations which may trigger a change of medication.

Ultimately steroids only increase the speed of recovery, but don't really change how much recovery there's going to be if that makes sense so I don't know that the one dose overnight is going to make much of a difference.

Also I don't think that one dose of steroids will change your "scans" significantly. If there's inflammation there it will take up contrast and one dose of Solu-Medrol won't change that.

 

[Thama]

Dear neurology folks

I come in peace from the EM world

In residency, a neurologist told me to always give 1 g solumedrol prior to admit for patients symptomatic from an obvious MS exacerbation (optic neuritis stuff, weakness or paresthesias similar to prior exacerbations). Years later, I continue to do this. But a random neurologist told me recently that it will disrupt any MRI they do and want to wait until the patient is seen before giving steroids

Maybe that was just that guy? Or maybe stuff has changed since my residency? I exclusively work nights and neuro doesn't come in for this stuff or like to be paged for non-critical things so I've never ask prior to admission.

Do you guys care? I always thought I was being helpful starting steroids but if practice/times have changed I can just slide them into a bed and do nothing.

Yeah that thing about it disrupting the MRI is nonsense.

But a true MS exacerbation presents with *different* symptoms to prior exacerbations. It's by definition a new lesion anatomically. If it's the same symptoms as previous, 99/100 times it's a pseudoexacerbation due to infection or other trigger.

 

[AlmostAnMD]

Huh.

Well, up to you guys to determine pseudo or not, I suppose. Sometimes that kind of thing is obvious to me, other times less so.

So steroids still good?

 

[xenotype]

Huh.

Well, up to you guys to determine pseudo or not, I suppose. Sometimes that kind of thing is obvious to me, other times less so.

So steroids still good?

Talk to your neurologist first, and often you'll be stuck calling to admit these patients as PT eval is often the most immediate thing they need. These 'MS' patients often have a questionable MS diagnosis to begin with or the symptoms they are showing up with are not a true exacerbation. We often end up being nice and giving steroids anyways, but it isn't anything you need to worry about in the ER.

Things to worry about in the ED for you:
1) Always get a chest XR, UA, and basic labs. We want to be sure there's no UTI or mild/atypical PNA to explain why they feel worse before we blast steroids. This goes for almost every patient with neuro complaints- just do it so there's no question later even if they don't have symptoms right now. Some of these patients are immunosuppressed anyways.

2) Optic neuritis in one eye with a history of prior optic neuritis/something that also sounds like optic neuritis in the other eye, especially if rapid and severe onset. Or new bilateral ON. Plus or minus can't walk/sensory symptoms suggestive of cord involvement with rapid onset. This is potentially bad- could be NMO, or mimics of NMO like MOG. Symptom onset and progression is more rapid than MS, often occurring over hours instead of a few days and the patients often have multiple neurologic symptoms. NMO is bad, very disabling, and probably needs steroids in your ER if present. Talk to a neurologist to figure out if this might be the case. These patients get very disabled, permanent damage happens faster, and they need more aggressive treatment.

3) Check the lymphocyte count on the CBC, and ask them if they are on natalizumab before giving any high dose steroids. Controversial, but many argue you can trigger PML by giving steroids in a natalizumab patient with either unknown JC titer, or elevated JC titer, or in patients with depleted absolute lymphocyte counts (Aubagio, tecfidera). Also, patients on strong immunosuppression like these agents for MS will rarely have true exacerbations, and if they really have new symptoms it could rarely be PML you are dealing with anyways.

I'm not an MS specialist, so they can probably explain things better and add detail I am missing.

 

[Thama]

If it's a true exacerbation, then yes steroids are good. Depending on severity, that doesn't always need to be IV. I virtually never treat an exacerbation without MRI+c as a) all the stuff above about mimics, risks, etc, and b) MS patients are universally terrible historians.

 

[AlmostAnMD]

I'm not an MS specialist, so they can probably explain things better and add detail I am missing.

No, no.....that was about the level of detail my tiny EM-brain needed.

Thanks all!

 

[neglect]

Dear neurology folks

I come in peace from the EM world

In residency, a neurologist told me to always give 1 g solumedrol prior to admit for patients symptomatic from an obvious MS exacerbation (optic neuritis stuff, weakness or paresthesias similar to prior exacerbations). Years later, I continue to do this. But a random neurologist told me recently that it will disrupt any MRI they do and want to wait until the patient is seen before giving steroids

Maybe that was just that guy? Or maybe stuff has changed since my residency? I exclusively work nights and neuro doesn't come in for this stuff or like to be paged for non-critical things so I've never ask prior to admission.

Do you guys care? I always thought I was being helpful starting steroids but if practice/times have changed I can just slide them into a bed and do nothing.

I tell people I WISH steroids worked that well and that quickly. They don't.

Just beware of treating an old but unmasked MS lesion that got worse due to non-brain/myelin insults like UTI, dehydration, viral syndrome. MS people get sick, even a slight change out of homeostasis (temp from 98 to 99.5) will really make them MUCH worse. Those people: good news, you have something reversible with fluids and abx.

Not to get complicated, but MS patients on no therapy, injectables (Copaxone, INF) will get relapses. Relapses are rare with newer and highly effective meds (B-cell depletion, Tysabri, even Gilenya). I use this as part of my impression.

In the absence of a UTI, PNA, other illness, using a dose of steroids for a true relapse is a good move. It makes them better, shortens their hospital stay. The problem is that some neurologists won't treat minor sensory relapses. So there's a ton of individual variation.

 

[xenotype]

I tell people I WISH steroids worked that well and that quickly. They don't.

Just beware of treating an old but unmasked MS lesion that got worse due to non-brain/myelin insults like UTI, dehydration, viral syndrome. MS people get sick, even a slight change out of homeostasis (temp from 98 to 99.5) will really make them MUCH worse. Those people: good news, you have something reversible with fluids and abx.

Not to get complicated, but MS patients on no therapy, injectables (Copaxone, INF) will get relapses. Relapses are rare with newer and highly effective meds (B-cell depletion, Tysabri, even Gilenya). I use this as part of my impression.

In the absence of a UTI, PNA, other illness, using a dose of steroids for a true relapse is a good move. It makes them better, shortens their hospital stay. The problem is that some neurologists won't treat minor sensory relapses. So there's a ton of individual variation.

Will get relapses off therapy is too strong a statement- plenty of patients with 'burned out' MS stop having relapses despite significant disability, and plenty of patients with mild disease also may have no relapses off therapy.

 

[neglect]

Will get relapses off therapy is too strong a statement- plenty of patients with 'burned out' MS stop having relapses despite significant disability, and plenty of patients with mild disease also may have no relapses off therapy.

Meh. While it is true that I wasn't thinking of the >65 yo with EDSS of either 0 or 9, mild disease can turn bad. It isn't the fall that gets you, always the landing. I profoundly disagree that we can safely predict benign disease in anyone under 55 to the point of recommending no therapy.

 

[xenotype]

Meh. While it is true that I wasn't thinking of the >65 yo with EDSS of either 0 or 9, mild disease can turn bad. It isn't the fall that gets you, always the landing. I profoundly disagree that we can safely predict benign disease in anyone under 55 to the point of recommending no therapy.

Very true, early in disease course with a 'mild' case you have no idea what direction it'll go in. I certainly would advocate for early and at least moderate strength therapy (eg not copaxone or betaserons) to start. I am referring to the patients with established MS diagnosis with 3 measly lesions after >10 years of regular monitoring.

 

[deathmerchant]

Dear neurology folks

I come in peace from the EM world

In residency, a neurologist told me to always give 1 g solumedrol prior to admit for patients symptomatic from an obvious MS exacerbation (optic neuritis stuff, weakness or paresthesias similar to prior exacerbations). Years later, I continue to do this. But a random neurologist told me recently that it will disrupt any MRI they do and want to wait until the patient is seen before giving steroids

Maybe that was just that guy? Or maybe stuff has changed since my residency? I exclusively work nights and neuro doesn't come in for this stuff or like to be paged for non-critical things so I've never ask prior to admission.

Do you guys care? I always thought I was being helpful starting steroids but if practice/times have changed I can just slide them into a bed and do nothing.

If you are working nights, I wouldn't worry about giving steroids. The neurologist can decide in the morning. 12 hours won't make a difference. Just check basic workup for alternative diagnoses and exacerbating illnesses as mentioned above. Unless there is serious deficits like vision loss/leg weakness etc, then you can consider giving a single dose. Most likely steroids just hasten recovery by a bit and don't affect the residual deficits.

Either way, a one time dose of steroid will not disrupt the MRI.

 

[neglect]

Very true, early in disease course with a 'mild' case you have no idea what direction it'll go in. I certainly would advocate for early and at least moderate strength therapy (eg not copaxone or betaserons) to start. I am referring to the patients with established MS diagnosis with 3 measly lesions after >10 years of regular monitoring.

Yes, each case of MS is different. It is very difficult to predict activity in these people.

A few years ago I saw a patient with seeming benign MS (although perhaps not the 3 lesions, stable over 10 years) who took herself off copaxone due to intolerance. She then had 3 relapses in 6 months, wanted a second opinion to support her decision. Then accused me of being a pharma shill because I told her there were other drugs out there. Such a difficult disease to deal with, not just because it is so random, but because they have altered cognition and neuropsych issues.

 

[cerebral edema]

In my experience most of the "MS exacerbations" that come through the E.D. or into the hospital are either pseudoexacerbations or just plain bogus. I also question most diagnoses of MS until I get a scan.

My personal approach is to image wherever the symptoms localize to and if there is a new lesion then I give steroids. This helps patients in two ways in my opinion. If there is no lesion then they know this is a pseudoexacerbation or worsening of their baseline MS symptoms, and it prevents needless steroid use which as you know is not side effect free and could cause the patient to then go to their neurologist talking of their multiple exacerbations which may trigger a change of medication.

Ultimately steroids only increase the speed of recovery, but don't really change how much recovery there's going to be if that makes sense so I don't know that the one dose overnight is going to make much of a difference.

Also I don't think that one dose of steroids will change your "scans" significantly. If there's inflammation there it will take up contrast and one dose of Solu-Medrol won't change that.

This is exactly what I do