Multiple sclerosis (MS) is a chronic and ever-changing disease of the central nervous system (CNS). Throughout the course of the disease, most individuals with MS will experience the appearance of one or more new symptoms, or a temporary worsening of existing symptoms (known as a relapse, attack, or exacerbation). MS relapses typically last for days to months, followed by a complete or partial recovery (remission).
Because of the many challenges associated with MS, effective disease management can be considered both an art and a science. It relies upon communication between patients and healthcare providers, along with adherence to one’s treatment plan. While the fluctuating nature of MS allows symptoms to develop and worsen at any time, many effective strategies are available to help reduce, treat, and manage MS relapses and lessen the accumulation of disability and additional health risks. To help individuals with MS to recognize and remember this information more easily, MSAA has developed a simple acronym know as the “A.R.T.” of MS relapse management.
A.R.T. stands for:
R. = Recognize
T. = Treat
A = Adhere:
The most effective way to manage MS relapses is to try and prevent them from occurring. This straightforward approach requires individuals with MS to initiate and adhere to their disease-modifying therapy (DMT). Presently, the only proven treatment to reduce the incidence of MS relapses is to be taking one of the 13 long-term DMTs. These have all been approved by the United States Food and Drug Administration (FDA), with the first treatments receiving approval in the mid-1990’s.
Several large clinical trials have been conducted to study these DMTs individually for their safety and effectiveness in MS. Although differences exist in study design and specific findings, trials generally showed these common results:
- Reduced the number of relapses
- Reduced the severity of relapses
- Reduced the development of new areas of inflammation as seen on magnetic resonance imaging (MRI) scans
- Demonstrated some evidence of delaying disease progression and/or disability
The documented effectiveness of each of these drugs varies to some extent and side effects always need to be considered when taking medication. However, the overwhelming majority of MS experts and advocacy organizations, including MSAA, recommend that individuals with relapsing forms of MS begin taking an approved DMT as early as possible. Adhering to one’s treatment plan is also vital for the treatment’s effectiveness.
MSAA also recognizes the complexity of this issue and the extraordinary number of factors to consider in selecting a treatment or deciding to switch from one DMT to another. To help in this regard, MSAA has also developed another useful acronym know as S.E.A.R.C.H. This six-letter memory aid represents key areas that should be considered when “searching” for the most appropriate MS treatment. To learn more, please visit the S.E.A.R.C.H. section of MSAA’s website or call MSAA’s Helpline at (800) 532-7667.
R = Recognize
As mentioned earlier, the complexity of MS requires individuals to take an active role in staying informed, updated, and assertive in managing their disease. This proactive approach applies to all aspects of MS, especially with regard to managing MS relapses.
A key factor in relapse management is to recognize the occurrence of a true MS relapse rather than a pseudoexacerbation. Acute physical symptoms and neurological signs must be present for at least 24 to 48 hours, without any signs of infection or fever, before the treating physician may consider this type of flare-up to be a true relapse. Also, an MS relapse is usually separated by at least one month from a previous relapse.
A pseudoexacerbation is a temporary worsening of symptoms without actual myelin inflammation or damage, brought on by other influences. Examples include other illnesses or infection (such as a urinary tract infection), exercise, a warm environment, depression, exhaustion, and stress. When symptoms flare, checking for a fever is important, since a slight increase in temperature can cause symptoms to appear. Additional changes in the body that might not be considered a true relapse include brief periods of numbness or tingling, a slight disruption in vision, and other minor transient issues, which will generally quiet down and subside within a day.
To help you recognize if you are experiencing an MS relapse, you might want to ask yourself some of the following questions:
- Have I been experiencing this symptom for at least 24 to 48 hours?
- Do I have a fever?
- Am I recovering from a recent inflection, such as a urinary tract infection (UTI)?
- Would I rate this symptom as significant (i.e., loss of vision, unable to walk, etc.)?
- Did I exhaust myself today by doing too much?
- Was I in a very warm environment?
- Was today an unusually stressful day?
- Did I take time to rest and let my body recover from the day’s activities?
These are just a few examples of the numerous questions that could arise from the possibility of experiencing an MS relapse. If your changes in symptoms have lasted for more than 24 hours, MSAA recommends that you contact your physician and provide him or her with as much detailed information about your condition as possible.
The ability to recognize the onset of a relapse will allow for the use of an immediate, short-term treatment (such as high-dose steroids, adrenocorticotropin [ACTH], or other options), if needed. These types of treatments are often successful in stopping the attack in its tracks and preventing the continuation of the new or worsening symptoms. While treating a relapse can shorten the duration and severity of a relapse, these treatments do not appear to affect the long-term disease process. Only through one of the approved DMTs can disease activity and progression be reduced.
T = Treat
If your physician determines that you are experiencing a less-severe relapse, he or she may decide not to treat the relapse with steroids, so their use may be reserved for more severe flare-ups. When treatment is required, relapses are usually treated with a high-dose course of powerful corticosteroids (a type of steroid) over a period of three to five days. These are given by intravenous (IV) infusion, which administers the drug directly into the bloodstream for a quicker response. This procedure may be performed in a hospital, infusion center, or sometimes at home.
Corticosteroids work by reducing inflammation in the CNS. While they usually lessen the severity and duration of a relapse, as noted earlier, they do not appear to affect the long-term progression of the disease. Common side effects include increased blood sugar, water retention, acne, weight gain, anxiety, and difficulty sleeping. A temporary rise in energy may be experienced, along with an exaggerated feeling of happiness.
As approved by the United States Food and Drug Administration (FDA), patients are often given the corticosteroid methylprednisolone (Solu-Medrol®) to treat an MS relapse. In practice, doctors may sometimes prescribe the corticosteroid dexamethasone (Decadron®), in place of methylprednisolone. An oral steroid (prednisone) may be prescribed after the high-dose treatment to ease the patient off the treatment, tapered over one to two weeks.
Acthar® Gel is also approved by the FDA to treat MS relapses and has been used as an alternative to corticosteroids for more than 30 years. This may be helpful for individuals who are not able to tolerate the side effects of steroids, who have found that previous treatments were not effective, or who may have difficulty getting timely medical support for IV infusions. Studies suggest that the effectiveness of Acthar Gel is similar to corticosteroids.
Acthar contains a highly purified form of the adrenocorticotropin (ACTH) in gelatin. It is given once daily for two to three weeks and is injected either into the muscle or under the skin. After injection, ACTH is absorbed slowly into the bloodstream. Acthar works differently than corticosteroids by helping the body to produce its own natural steroid hormones that reduce inflammation and aid in recovery.
Other therapies include plasmapheresis (plasma exchange or “PE”) and intravenous immunoglobulin (IVIG). Neither of these is approved by the FDA specifically for MS relapses, but either may sometimes be used for individuals who are experiencing a severe relapse and are not responding to other treatments. With PE, blood is taken from the patient, cleansed of potentially toxic elements, and returned to the patient. IVIG therapy uses human immunoglobulin, an antibody derived from the blood of healthy donors. With both of these therapies, more studies are needed to determine their individual effectiveness.
MSAA’s A.R.T. of MS relapse management serves as a general guide to help you to better understand this important topic. MSAA encourages you to consult your physician for more specific information about MS relapse treatments and management.