This is an excellent question. Although patients recover from attacks of MS with or without drug treatment, recovery is hastened with ACTH treatment.
In the 1970 national study, MS patients in relapse were all placed at rest in hospitals. In this relatively small study, despite being in hospitalized and benefiting from rest, actively treated patients receiving ACTH were significantly better after 1,2, and 3 weeks of ACTH treatment compared with those receiving placebo injections. Although the patients had less disability at 4 weeks (1 week after termination of treatment) as compared with placebo recipients, the difference was not statistically significant. Other studies probably should have been done to answer questions of dose as well as those related to dose forms, but they weren't. Despite their importance, it is unlikely that any such studies will be carried out on a significant scale anytime in the future.
It should be appreciated that physical rest, without the addition of drugs, is in itself beneficial and will result in faster recovery from attacks of MS. Recovery will eventually prevail to the extent that recovery will occur in any given attack. There is no evidence that treatment of MS attacks with any available treatment results in superior long-term results. In general, if an attack is minor, treatment does not provide any advantage and is better avoided. For example, if a person has decreased vision to 20/40 or even 20/60 in one eye, vision will return without treatment, often quite quickly. Apart from the cost, high-dose steroids certainly have potential side effects and would be best avoided in such an attack. However, based on our experience, in those rare patients who suffer a complete loss of vision in one or both eyes, high-dose steroids result in the recovery of usable vision in a greater proportion of patients.
Side effects of steroids are common whether they are administered by mouth or IV. There are several categories of side effects: alteration of mood, formation of cataracts, increased risk of infection, impaired wound healing, loss of calcium from bone, ischemic necrosis of bone, and muscle damage, to mention only the more commonly recognized problems.
Cataracts: Cataracts are a well-known complication of steroid use. The risk of cataracts is related to the total dose of steroid used but varies greatly from person to person. The type of cataract is unique to the use of steroids and is easily recognized by ophthalmologists. As with other cataracts, extraction with lens replacement is the only real treatment. There seems to be little or no risk associated with ACTH use in MS.
Physicians specialized in the diagnosis and treatment of diseases of the eye.
Weight gain and altered body habitus: Steroids and ACTH result in an increased appetite. Their use can result in tremendous weight gain, even as high as 70 pounds in a few days. There is also a redistribution of body fat that women in particular do not like. Fat is deposited over the face and upper part of the chest and neck, abdomen, and buttocks. As easy as it is to gain the weight, it is difficult to take it off. When caloric intake is managed (restricted), the deposition of fat over the upper back, abdomen, and buttocks is minimized, but not eliminated. The alteration of body image may be traumatic, particularly to women. Acne often accompanies the use of steroids and ACTH. It can be easily managed with use of low doses of tetracy-cline antibiotics.
Infection: Infections complicating the use of steroids include an increased risk of infection of all types, including viral, bacterial, fungal, and parasitic disease. Although viral infections are usually mentioned as a risk with steroid administration, including a risk of progressive multifocal leukoencephalopathy (PML), these infections are relatively uncommon. Shingles (herpes zoster) and flares of genital herpes are probably the most common viral infections seen.
Shingles skin infection caused by the herpes zoster virus.
Genital herpes a contagious viral infection primarily affecting the genitals of men and women caused by the herpes simplex-2 virus (HSV-2).
Cystitis inflammation of the bladder associated with symptoms of urinary frequency and urgency. Pyelonephritis an acute infection of the kidney associated with fever, contrasting with cystitis (a bladder infection) where fever does not occur. Thrush throat infection by the yeast Candida albicans. It commonly complicates treatment with antibiotics and steroids. Yeast vaginitis a common infection due to the yeast Candida albicans. Systemic infections as opposed to a localized infection, a system infection is any infection that causes generalized symptoms.
Toxoplasmosis infestation of the human body by the one celled animal Toxoplasma gondii.
Pneumocystis a one cell organism that causes rapidly fatal lung infestations in AIDS patients.
Compared with viral infections, bacterial infections are a more practical problem. The most commonly encountered bacterial infections complicating the use of steroids include flare-ups of bladder and kidney infections (cystitis and pyelonephritis). Less commonly, skin wounds, pneumonias, and rarer infections can be problematic.
Although yeast infestation of throat (thrush) and yeast vaginitis are relatively common problems with steroid treatment, they are usually generally easy to manage. Systemic infections are rare, but these can occasionally be very serious. Fungal infections are unusual except accompanying chronic steroid use.
Parasitic infections such as toxoplasmosis and pneu-mocystis, which complicate HIV infection, are not common, but they may complicate chronic steroid use, particularly if the steroids are used in combination with drugs such as Imuran and methotrexate.
Wound healing: Surgical and other wounds heal more slowly in patients on steroids and are more likely to become infected. For those with bed sores, steroids are particularly problematic. Management of these patients should avoid even short-term steroids.
Bone damage: The use of steroids results in the loss of calcium from bones that underlies the development of osteopenia and osteoporosis. Subsequently, this may lead to the collapse of vertebrae and an increased risk of fracture of the long bones. Even more serious is the increased likelihood of ischemic (aseptic) necrosis of the hips and other joints. When diagnosed early, treatment can reverse or limit permanent damage. Con versely, advanced joint damage leaves only joint replacement as an option. Physicians and patients have to be aware of such potential complications. Difficulty in walking or pain in the knee may actually signify or indicate damage to a hip rather than a knee. In my long experience, I have never seen this complication in ACTH-treated patients.
Muscle damage: Steroid therapy by any route, but especially with high-dose IV administration, weakens muscles. High-dose IV therapy carries with it the risk of severe muscle weakness, which fortunately, is usually reversible. This complication is not seen with ACTH.
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