Medical Considerations

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If the origin of the palsy is viral, both the virus and the inflammation are likely to run their natural course in a short period of time even without medication. There is no firm proof that medication is beneficial for Bell’s palsy. The number of quality studies published to date (non-biased with correct controls & methods) is limited. It is likely that medications will be effective only if administered shortly after onset. For Bell’s palsy, seven days is viewed as the outside limit. For Ramsey Hunt Syndrome, if no anti-viral was given immediately after paralysis, it can be started at any time blisters appear, even if the 7-day period has passed.

The medications currently used for Bells palsy and Ramsey Hunt Syndrome are the same: an anti-viral and Prednisone, which is an efficient, fast acting anti-inflammatory agent.

Prednisone for Bell’s Palsy…

Prednisone is a synthetic hormone that mimics a natural steroid called cortisol that the body produces. Under stress (injury or illness) cortisol production is increased fourfold as part of the body’s normal reaction to the stress. Prednisone has approximately five times the potency of cortisol. 20mg of Prednisone is roughly equal to the amount of cortisol the body normally produces in a day while under stress.

Inflammation is an integral component of the body’s response to an injury or illness. Among the many things that occur, substances called cytokines are secreted as part of the immune system response to the stress. Cytokines work to “rev up” the immune system. As the immune system functions increase under stress, antibodies are produced and inflammation results. The antibodies kill cells that the body interprets are foreign, such as viruses and bacteria.

In part, Prednisone works as an anti-inflammatory by its effect on immune cells. It acts as an immuno-suppressant, inhibiting the secretion of cytokines. The result is that antibody production is suppressed, and the inflammatory process is slowed and weakened, quickly reducing the inflammation compressing the nerve. Because Prednisone works by an immuno-suppressant process, it cannot be administered to patients with existing immune system problems.

Prednisone’s rapid anti-inflammatory action makes it a worthwhile medication for most patients in spite of its effect on the immune system.

Assuming there are no medical conditions that would negate the use of Prednisone, it can be used by children and adults.

Before Taking Prednisone

Some conditions that may affect a doctor’s decision to prescribe Prednisone…
Diabetes
Heart Problems
Recent Surgery
Pending Surgery
Seizures
Some cancers
Stomach or intestinal disorders
Under-active thyroid
Pregnancy
Nursing
Compromised immune system
HIV
Medications that may interact or interfere with Prednisone
Diuretics
Birth Control Pills
Blood Thinners
NSAIDS
Ibuprofen
Barbutuates
Acetazolamide
Amphotericin B
Digoxin
Phenytoin
Rifampin
Rifabutin

 

Adverse Effects
Side effects are sometimes associated with Prednisone. They tend to be directly related to the amount of Prednisone taken, and how long it’s taken. For facial paralysis, usage is short term. The effects tend to decrease as you reduce your dosage, and disappear rapidly when you stop taking the medication.

Potential side effects
Stomach pain (take medication with a meal, milk or antacid)
High blood pressure (restrict salt usage)
Increased appetite & weight gain
Acne
Sweating
Insomnia (take the medication in the morning if possible)
Mood swings
Personality changes
Sensitivity to the sun
Temporary muscle weakness
Fluid retention (restrict salt usage)
Hyperglycemia
Reduced immunity to infections
Increased potassium depletion (eat fruit with high potassium levels)
Swelling of the face, back of neck or ankles


Anti-Virals for Bell’s Palsy and Ramsey Hunt Syndrome

Antivirals work by binding to viral enzymes so that the cells cannot replicate. Unable to replicate, the virus runs its course faster. The inflammation at the nerve should be less than without an anti-viral and is eliminated in a shorter time.

Famciclovir (Famvir) and acyclovir (Zovirax) are frequently prescribed anti-virals. A newer anti-viral, valacyclovir (Valtrex) appears to work faster. Adverse effects of valacyclovir can include headache, nausea, diarrhea, constipation and dizziness.

With a diagnosis of Ramsay Hunt syndrome, administration of an anti-viral should start within 72 hours of the blisters’ appearance, even if blisters do not appear until a week or more after onset of facial palsy. Secondary infections may occur with RHS. The patient should be made aware of this, and be instructed to notify the physician of any signs indicating a bacterial infection. An antibiotic will be prescribed in addtion to the antiviral.

HIV carriers may find they are resistant to the standard anti-virals. Immuno-compromised patients should ask about Foscarnet (Foscavir), a recently approved anti-viral that may be more effective for compromised immune systems.

The AAN 2001 evaluation mentioned above states that antivirals are possibly effective. It should be noted that the term “possibly” must be used with only one study considered acceptable for evaluation. A single study can not provide sufficient data for a firm conclusion or recommendation. The conclusions of that single study (Adour ’96) were favorable to treatment with acyclovir plus Prednisone.


B Vitamins

Many of the B vitamins are essential for proper nervous system functioning. Addition of a basic B-complex vitamin to the daily routine may be a good idea during recovery. Some B’s that may be particularly beneficial are:

B1 – enhances circulation (circulation is reduced in muscles that are not active) and may retard muscle atrophy.

B6 – assists in the creation of amino acids needed in the creation of new cells.

B12 – when taken as part of a “B-complex” vitamin, may help reduce inflammations and strengthen the immune system. Methylcobalamin is a form of B12 that is not a component of basic B-complex vitamins, and is important to nerve growth and maintenance.


Methylcobalamin

Methylcobalamin is an essential component in the process of building nervous tissue. It is important contributor to nerve growth, and maintains and repairs the critical, protective nerve sheath.

Methylcobalamin’s action is directed at the nerve’s myelin sheath, which is like a layer of insulation around the nerve. It protects the nerve and helps the signal travel along its designated path correctly. It appears to promote protein synthesis, accelerating cell division. Myelin sheath formation at the site of the damage is enhanced. This may, in part, explain recent findings that ultra-high doses may enhance nerve regeneration.

A small 1995 Malaysian study (MA Jalaludin) concluded that the subjects had faster recoveries with Prednisone plus methylcobalamin versus Prednisone alone. However, the results of this study have not been validated, and the quality of the study and its references require evaluation. While methylcobalamin is showing potential as treatment for some neuropathologies, it is not acknowledged as a treatment with any benefit for Bell’s palsy. The primary therapeutic benefit of methylcobalamin relates to pernicious anemia, which is not a factor in Bell’s palsy. There is no proof of its effectiveness for Bell’s palsy. Its benefit, even for new cases, is still considered to be questionable. There don’t appear to be any adverse effects associated with high doses of methylcobalamin, so it may best come under a heading of “it can’t hurt to try”. Methylcobalamin is not known to be therapeutically beneficial in cases of longstanding facial paralysis, nor is there reason to believe that it can help prevent recurrences.