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Did you know that the effectiveness of high-dose steroids to treat a relapse is small? In reality, there is no difference in outcome at 6 months between relapses treated with steroids and those managed without steroids. In reality, high-dose steroids simply speed up recovery of function by about 2 weeks. So if you are not disabled by your relapse and it has not affected your day-to-day functioning it is better not to have them.
High-dose steroids don’t come without risks, i.e. psychosis, insomnia, depression, avascular necrosis of the hip, hypertension, diabetes, infections, blunted vaccine responses, higher risk of severe COVID-19, etc. So then why do we prescribe them so frequently? Money, money, money!
In many fee-for-service healthcare systems, neurologists and healthcare institutions make money out of admissions and intravenous infusions, which acts as a perverse incentive to prescribe steroids. The good news is that high-dose oral steroids for relapses, taken as an outpatient, work as well.
The French study below shows how much money could be saved from shifting from inpatient intravenous to outpatient oral steroid use (25 million euros per year in France). I doubt this will change behaviour when there is money to be earned. As the saying goes ‘turkeys voting for Christmas’; not on your life.
So the next time you are offered inpatient-intravenous steroids for a relapse you should ask for home-oral steroids instead and see what response you get from your HCP.
Michel et al. Cost-utility of oral methylprednisolone in the treatment of multiple sclerosis relapses: Results from the COPOUSEP trial. Rev Neurol (Paris). 2021 Sep 28;S0035-3787(21)00664-0.
Background: Studies have shown that oral high-dose methylprednisolone (MP) is non-inferior to intravenous MP in treating multiple sclerosis relapses in terms of effectiveness and tolerance. In order to assist with resource allocation and decision-making, its cost-effectiveness must also be assessed. Our objective was to evaluate the cost-utility of per os high-dose MP as well as the cost-savings associated with implementing the strategy.
Methods: A cost-utility analysis at 28 days was carried out using data from the French COPOUSEP multicenter, double-blind randomized controlled non-inferiority trial and the statutory health insurance reimbursement database. Costs were calculated using a societal perspective, including both direct and indirect costs. An incremental cost-effectiveness ratio was calculated and bootstrapping methods assessed the uncertainty surrounding the results. An alternative scenario analysis in which MP was administered at home was also carried out. A budgetary impact analysis was carried at five years.
Results: In the conditions of the trial (hospitalized patients), there was no significant difference in utilities and costs at 28 days. The incremental cost-effectiveness ratio was €15,360 per quality-adjusted life-year gained. If multiple sclerosis relapses were treated at home, oral MP would be more effective, less costly and associated with annual savings up to 25 million euros for the French healthcare system.
Conclusions: Oral MP is cost-effective in the treatment of multiple sclerosis relapses and associated with major savings.
General Disclaimer: Please note that the opinions expressed here are those of Professor Giovannoni and do not necessarily reflect the positions of the Barts and The London School of Medicine and Dentistry nor Barts Health NHS Trust and are not meant to be interpreted as personal clinical advice.