Multiple Sclerosis Centers of Excellence
Treatments for Multiple Sclerosis Relapses
Michelle Cameron, MD, PT, MCR
MS relapses, also referred to as episodes, exacerbations, flares, and attacks, are new neurological symptoms, or a worsening of existing symptoms, in a person with MS that come on quickly and last for at least 24 hours, in the absence of fever or infection.
MS relapse symptoms generally appear over hours to a couple of days and can affect anything controlled by the brain, spinal cord, or optic nerves. MS relapses often cause changes in sensation, bladder or bowel symptoms, muscle strength, or vision. Most people with MS experience relapses and the timing of these relapses is unpredictable. People with MS should contact their health care provider promptly if they suspect they are experiencing a relapse.
The standard treatment for MS relapses associated with significant disability is high dose corticosteroids for 3 to 5 days. This is usually 1,000 mg of intravenous methylprednisolone (IVMP) in 100 cc of normal saline over 1 hour daily for 3 to 5 days. Intravenous dexamethasone at 140 to 200 mg/day for 3 to 5 days is occasionally used in place of IVMP in cases of allergy or intolerance of methylprednisolone or oral prednisone at 1250 mg/day for 3 to 5 days if intravenous treatment is not practical. The high dose corticosteroids may be followed by a short taper of oral prednisone but this oral steroid taper has unclear benefit. Intravenous steroids may be administered in several settings including a VA Medical Center or Community Based Outpatient Clinics (CBOC).
High dose corticosteroids given early in a relapse generally shortens the duration of the relapse to a few weeks. However, treatment of relapses with corticosteroids does not affect the long-term course of MS. Mild relapses therefore do not necessarily require treatment. The decision to treat with corticosteroids often depends on how bothersome the symptoms are to the patient and their tolerance of corticosteroids.
Side Effects of Corticosteroids
- Metallic taste in the mouth during the infusion
- Stomach irritation – may be managed with antacids and H2 blockers
- Difficulty sleeping, restlessness, anxiety, or mood change – may be managed with hypnotics
- Increased appetite resulting in weight gain
- Increased blood sugar in people with diabetes – may need to cover with insulin
- Fluid retention
- Excessive sweating
- Aseptic necrosis of the hips, moon face, or swelling between the shoulder blades and osteoporosis can occur with corticosteroid use but are not usually an issue with short courses of corticosteroids
For severe MS relapses that do not respond to high dose corticosteroids, plasma exchange may be considered. The side effects of plasma exchange must be balanced against the severity of symptoms. This treatment usually requires hospitalization. A course of treatment consists of plasma exchange every other day for five treatments. Others use daily plasma exchange for five treatments.
Side Effects of Plasma Exchange
- Bleeding due to placement of the intravenous lines or due to thrombocytopenia
- Infection due to placement of the intravenous lines
- Damage to lungs or other tissues due to placement of the intravenous lines
- Episodes of low blood pressure during treatments
- Episodes of irregular heartbeats during treatment
- Allergic reactions to portions of the blood plasma
- Electrolyte abnormalities during treatment
- Thrombocytopenia due to heparin used during the treatment
- Hypercoagulable state with risk of thrombosis
Relapse management may also include rehabilitation such as physical, occupational, or speech therapy to help with symptom management and potentially lessen the overall effects of the acute neurological event and any problems remaining after the relapse.
- Relapse = "exacerbation" or "flare."
- Symptom onset is over hours or a few days, lasting at least 24 hours.
- Relapse can present with new or old symptoms.
- Not related to infection, illness, heat, or increased psychological stress ("pseudo-relapse").
- Screen for infection recommended (urinary tract infections are most common).
- Duration is generally several weeks to a couple of months without treatment.
- First line treatment with high dose steroids is recommended if relapse symptoms affect functioning and the benefits outweigh the risks.
- Steroid treatment of a relapse does not affect the long-term course of MS.
- Plasma exchange may be considered for severe relapses that do not respond to high dose corticosteroids.
- Rehabilitation may also be helpful.