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Therapeutic Management of Severe Relapses in Multiple Sclerosis

  • Multiple Sclerosis and Related Disorders (P Villoslada, Section Editor)
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Opinion statement

While not all multiple sclerosis (MS) relapses require treatment, relapses that are bothersome or that impair function should prompt consideration of timely treatment to restore function and minimize disability. Patients with suspected MS relapses should be evaluated to confirm the diagnosis, exclude other causes of neurological dysfunction, and identify potential triggers for relapse or pseudo-relapse, such as urinary tract infections, fever, or metabolic derangements. The diagnosis of an MS relapse is clinical, but MRI may be useful for confirmation and to evaluate for multifocal disease activity. High-dose oral or intravenous glucocorticoids, with or without an oral taper, are first-line therapy for MS relapses. Adrenocorticotropic hormone (ACTH) provides an alternative to glucocorticoid treatment but is currently much more expensive and does not have proven superiority. If the acute neurological deficits remain severe after steroid treatment, and particularly if there is persistent abnormal contrast-enhancement of the symptomatic lesion on repeat MRI, plasma exchange (PLEX) should be considered as an acute rescue therapy for relapse. In exceptional cases, particularly fulminant or tumefactive disease that fails to improve following treatment with steroids and PLEX, cytoxic agents such as cyclophosphamide or B cell-depleting regimens such as rituximab may be considered, although risk must be carefully weighed and the kinetics of such regimens indicate that they probably serve more to accelerate remission of disease activity than as an immediate relapse remedy. A single dose of natalizumab given as acute therapy for MS relapse was shown not to improve clinical outcomes in a randomized controlled trial. Attention to symptom management and promotion of neurorehabilitation are important aspects of MS relapse care. Neuroprotective and neuroreparative therapies remain under investigation, but are likely to become important complementary elements of relapse therapy in the future. Relapses serve as important indicators of MS disease activity. In the context of the emerging treatment paradigm of targeting freedom from evidence of MS disease activity, relapses should prompt consideration of transitioning to a disease-modifying treatment that may offer better efficacy.

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Acknowledgments

Funding was provided through the National MS Society Institutional Clinician Training Award and NIH KL2TR000143.

Compliance with Ethics Guidelines

Conflict of Interest

Carolyn Bevan declares no conflict of interest.

Jeffrey M. Gelfand declares that he has received compensation for medical legal consulting relating to CNS inflammatory disease. Dr. Gelfand has also received compensation for consulting for MedImmune and Quest Diagnostics.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by the authors.

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  1. MS Center, Department of Neurology, University of California, 675 Nelson Rising Lane, Box 3206, San Francisco, CA, 94158-3206, USA

    Carolyn Bevan MD, MS & Jeffrey M. Gelfand MD, MAS

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  1. Carolyn Bevan MD, MS
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  2. Jeffrey M. Gelfand MD, MAS
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Correspondence to Jeffrey M. Gelfand MD, MAS.

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This article is part of the Topical Collection on Multiple Sclerosis and Related Disorders

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Bevan, C., Gelfand, J.M. Therapeutic Management of Severe Relapses in Multiple Sclerosis. Curr Treat Options Neurol 17, 17 (2015). https://doi.org/10.1007/s11940-015-0345-6

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