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Multiple Sclerosis Centers of Excellence

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Diagnosing and Managing MS Relapses

MS relapses are also referred to as episodes, exacerbations, flares, and attacks. A relapse is defined as: The acute occurrence of new neurological symptom or a worsening of existing symptom that lasts for at least 24 hours in the absence of fever or infection. 

These symptoms generally appear or worsen in a short period and can affect bladder and bowel systems, small and large muscle groups, vision, and other neurologic functioning. Symptoms of relapses are unpredictable and are experienced in 90% of the MS population. The majority of people who get early treatment for their relapse report a shorter duration of relapse symptoms.

Treatment for relapses does not affect the long-term course of MS. Relapse management may also include rehabilitative treatments such as physical or speech therapy. Additional rehabilitative treatments will help with symptom management and may lessen the overall effects of the acute neurological event. Persons with MS should promptly contact their health care provider if they suspect they are experiencing any symptoms of relapse.

Relapse Overview
+Relapse," "exacerbation," or "flare."
+Symptom onset is over hours or a few days, lasting at least 24 hours.
+Relapse frequently presents similar to prior relapses, but may manifest with new symptoms/deficits.
+Duration is generally several weeks to months without treatment.
+Not related to infection, illness, heat, or increased psychological stress ("pseudo-relapse").
+Screen for infection recommended (Urinary Tract Infections are most common).
+Treatment is recommended if relapse symptoms affect functioning and the benefits outweigh the risks.
+Treatment of a relapse does not affect the long-term course of MS.
+Rehabilitation for residual neurological loss may be helpful.

Relapse Treatment
The standard treatment for relapses associated with significant disability is 500-1,000 mg of intravenous methylprednisolone (IVMP) over 3 to 5 days.  This may be followed by a short course of oral prednisone for a total combined IV and oral course of 2 to 3 weeks.  Intravenous dexamethasone (Decadron®) may be used in place of IVMP at 160-180 mg/day for 3 to 5 days.  

NOTE:  Clinical trial evidence indicates a short course of IVMP is the treatment of choice for acute exacerbations to diminish acute neurological dysfunction.  Intravenous steroids may be administered in several settings, including a VA medical center, Community Based Outpatient Clinics (CBOC), non-VA infusion center, or the patient’s home.  For severe MS relapses, plasma exchange may be considered.

The effect of IVMP on the long-term course of disease is not established, and mild relapses do not necessarily require treatment.  An oral taper of steroids has unclear benefit. Evaluation for referrals is especially important after acute MS exacerbations or hospitalizations for other comorbid conditions (e.g., pneumonia).  Rehabilitation consults may include physical and/or occupational therapy, or speech and swallowing therapy.

For more information use the following links:

Treatment of acute exacerbations of multiple sclerosis in adults – Olek, Gonzalez-Scarano, Dashe (July 2015)
WebMD article Treat and Prevent a Multiple Sclerosis Flare-Up – Shaw, Nazario (January 2014)
National MS Society article Managing MS Relapses

Updated: July 2015