What is the role of steroids in progressive MS?
While it is now common practice to use steroids for MS relapses, the situation in other types of MS is not well documented, and trials are needed: there are no proper data of the treatment of progressive MS with continuous steroid therapy over years. Steroids are not usually indicated, therefore, for either primary or secondary progressive MS as they are of no proven benefit, and are potentially harmful in the long-term. Any consideration of longer term steroid use in MS is inappropriate in our present state of knowledge. In other words, the potential risks outweigh the potential benefits.
The only exception to this rule is the very occasional patient with true steroid-dependency, in whom withdrawal leads to an objective neurological deterioration (not just a feeling of unwellness). Such patients are uncommon, and indeed it may be difficult to be sure that some other process such as sarcoidosis or a vasculitis is not responsible.
Having stated that in our present state of knowledge, long-term steroids currently have no place in the management of MS, many clinicians feel that no patient with progressive neurological disability due to MS should been allowed to worsen without at least once being given a course of steroids: occasionally the response is worthwhile, and the risk is minimal. It is not always easy to make a judgement on the pattern of the disease, and some patients who appear to be progressing, are, in fact, having relapses. It is these patients that need to be identified, and lend justification to the policy, not universally held, of giving steroids at least once to every MS sufferer.
It has been suggested by a few studies that some patients with secondary progressive MS do seem clearly to benefit from a three or four monthly course of oral prednisolone, even though in general steroids are not used in progressive MS of any kind unless there is a superimposed relapse of sufficient severity to justify their prescription. This policy is supported by the sparse literature available on the subject which suggests that in the short term there may be benefit, particularly in pyramidal function from regular steroid courses.