BACKGROUND

The objective of this study was to evaluate monthly intramuscular adrenocorticotropic hormone (ACTH) gel intravenous methylprednisolone (IVMP) add-on therapy to interferon β for breakthrough disease in patients with relapsing forms of multiple sclerosis.

METHODS

This was a prospective, open-label, examiner-blinded, 15-month pilot study evaluating patients with Expanded Disability Status Scale (EDSS) score 3.0-6.5 and at least one clinical relapse or new T2 or gadolinium-enhanced lesion in the previous year. Twenty-three patients were randomized to ACTH ( = 12) or IVMP ( = 11) and completed the study. The primary outcome measure was the cumulative number of relapses. Secondary outcomes included EDSS, Mental Health Inventory (MHI), plasma cytokines, MS Functional Composite (MSFC), Quality-of-Life (MS-QOL) score, bone mineral density (BMD), and new or worsened psychiatric symptoms per month. Brain magnetic resonance imaging was analyzed . This was a preliminary and small-scale study.

RESULTS

Relapse rates differed significantly [ACTH 0.08, 95% confidence interval (CI) 0.01-0.54 IVMP 0.80, 95% CI 0.36-1.75; rate ratio, IVMP ACTH: 9.56, 95% CI 1.23-74.6; = 0.03]. ACTH improved ( = 0.03) MHI (slope 0.95 ± 0.38 points/month; = 0.02 slope -0.38 ± 0.43 points/month; = 0.39). On-study decreases (all < 0.05) in eight cytokine levels occurred only in the ACTH group. However, on-study EDSS, MSFC, MS-QOL, BMD, and MRI lesion changes were not significant between groups. Psychiatric symptoms per patient were greater with IVMP than ACTH (0.55, 95% CI 0.12-2.6 0; < 0.0001). Other common adverse events were insomnia and urinary tract infections (IVMP, seven events each) and fatigue or flu symptoms (ACTH, five events each).

CONCLUSIONS

This study provided class II evidence that ACTH produced better examiner-assessed cumulative rates of relapses per patient than IVMP in the adjunctive treatment of breakthrough disease in multiple sclerosis.