Friday, 19 May 2017

Steroids and relapse route does not matter

Lattanzi S, Cagnetti C, Danni M, Provinciali L, Silvestrini M.Oral and intravenous steroids for multiple sclerosis relapse: a systematic review and meta-analysis. J Neurol. 2017 . doi: 10.1007/s00415-017-8505-0.

Glucocorticoids are the standard of care for multiple sclerosis (MS) relapses, but the most desirable route of administration is still matter of debate. The aim of the study was to compare the efficacy and safety of oral versus intravenous steroids for treatment of acute relapses in patients with MS. Randomized or quasi-randomized, parallel group trials with direct comparison between oral and intravenous steroid treatment in MS patients with acute relapse were identified through a systematic literature search. Six trials were included involving 419 participants, 210 for oral, and 209 for intravenous groups, respectively. The weighted mean differences (WMDs) in the Kurtzke's Expanded Disability Status Scale (EDSS) score reduction between the oral and intravenous groups were 0.32 [(-0.09 to 0.73); p = 0.129] and 0.11 [(-0.12 to 0.33); p = 0.355] at 1 and 4 weeks after treatment, respectively. The risk ratios (RRs) for improvement by at least one EDSS point were 0.79 [(0.37-1.68); p = 0.539] at week 1 and 0.92 (0.76-1.12); p = 0.400] at week 4. There were no differences in the relapse rate and relapse freedom at 6 months between groups. The WMDs in the mean percentage reduction of Gadolinium-enhancing lesions between oral and intravenous arms were 0.14 (-0.02, 0.29); p = 0.083] and 0.04 (-0.19, 0.28); p = 0.705] at 1 and 4 weeks from treatment. Among the adverse events, insomnia was significantly associated with the oral route of steroid administration [RR 1.25 (1.07-1.46); p = 0.005]. In adult patients with acute MS relapse, there were no clear-cut differences in the efficacy and overall tolerability between oral and intravenous steroids

Steroids are a standard treatment for relapses. They may aid in a quicker recovery and their value has been rehearsed by prof G a number of times. The basis of the study was to suggest that it was not clear if oral verses intravenous is better and a meta analysis is done. The answer in their analysis is their is no difference. 
So perhaps rather than a meta analysis, perhaps a quick trip to pharmacokinetics should be done. You can work out how quick 
and how much a drug gets on board via the oral and intravenous route. DrK below found the difference was amount given to amount gets in the blood, oral and cladribine you get 40% on board and intravenously and subcutaneously you get 100% on board, so no particular advantage except you can use half the amount of drug verses oral. For my own drug if it goes oral to a mouse the maximum amount is their in 15minutes after oral compared to instant with intravenous. You save a few minutes is this important?

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