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Ask the Expert: Treating MS Relapses and Acute Exacerbations

What is an acute exacerbation of multiple sclerosis (MS)?

An acute exacerbation of MS is also known as an MS relapse or MS attack. It’s defined as a new or worsening set of neurologic symptoms that last more than 24 hours in a person who lives with relapsing MS. This is caused by an immune-related injury to the brain or spinal cord. When such an injury occurs, new symptoms typically develop over hours or days. Symptoms might include numbness or tingling, weakness or difficulty with coordination, changes in vision, and changes in bladder or bowel function.

But not all exacerbations are due to an MS relapse. Common stresses on the body, such as infections — including upper respiratory, gastrointestinal, urinary tract infections — and elevated body temperature, can unmask symptoms due to a prior neurologic injury. This is considered a “pseudo-relapse.” A pseudo-relapse doesn’t require the same treatment as an MS attack. This is a complex issue. The distinction between a relapse and a pseudo-relapse should be made by your neurologist.

Do I need to go to the hospital if I experience an MS relapse? If yes, what should I expect there?

If you’re experiencing new neurologic symptoms, contact your neurologist or primary care doctor right away. Depending on the severity of your symptoms, you might need to go to the hospital. At the hospital, you can get an MRI scan and other diagnostic tests right away.

In general, you should go to the hospital if you have new significant physical disability. For example, you should go to the hospital if you suddenly can’t see, walk, or use your limbs. If you go to the hospital, you might be admitted for a few days. You might also be allowed to go home if your symptoms improve. If you don’t have significant disability, you can get diagnostic testing as an outpatient, provided that you are closely monitored by your doctor.

What are the main treatments for an MS relapse?

The main treatment for a new MS relapse is corticosteroids. The goal of therapy is to minimize injuries caused by inflammation and reduce the recovery time. The typical treatment includes 3 to 5 days of high-dose “pulse” corticosteroids. This treatment can be given intravenously or orally. It’s usually followed by 3 to 4 weeks of “tapering” with oral medication. This involves taking progressively lower doses of the medication until the treatment is completed.

High-dose intravenous steroids can be given in the hospital or at an outpatient infusion center. High-dose oral steroids are just as effective and can be taken at home, but involve taking up to 20 pills daily.

Some people have acute, severe neurologic symptoms due to MS but respond poorly to corticosteroids. They usually need to be hospitalized, and they might receive a treatment called “plasma exchange” for 3 to 5 days. It involves filtering the blood to remove potentially harmful antibodies. Treatment with plasma exchange isn’t used for most people with MS.

What are some of the most common side effects of treatments for an MS relapse?

Side effects of high-dose corticosteroids might include mood changes, upset stomach, insomnia, and risk for infections. Abnormalities on laboratory testing are another possible side effect, and could include having elevated blood glucose and white blood cell count.

While being treated with corticosteroids, you might also be prescribed medications for gastric protection, to help with sleep, and to prevent infections.

Are there any other risks associated with treating an MS relapse?

Short-term treatment with high-dose steroids carries a low risk of lasting health issues. However, chronic treatment increases the risk for several conditions including infections, decreased bone mineral density, prediabetes, and metabolic syndrome. This highlights the importance of using steroid-sparing therapies, also known as disease-modifying therapies (DMTs), to prevent MS relapses.

In addition, people with diabetes who receive treatment with high-dose corticosteroids may need to be monitored in the hospital for possible complications.

Will an MS relapse or exacerbation ever subside on its own, without treatment?

Without treatment, symptoms due to an MS relapse generally improve over weeks to months in people with relapsing multiple sclerosis. However, the recovery might be less complete and take longer. Speak with your neurologist about the benefits and risks of treatment.

How long does it usually take for treatment of an MS relapse to work? How will I know the treatment is working?

Treatment with high-dose corticosteroids reduces active injury due to MS within hours to days. If your symptoms are caused by an MS relapse, they should stabilize within days. Your symptoms should continue to improve over weeks or months. If this is not the case, speak with your doctor to discuss next steps, which might include additional testing and treatment.

If I experience an MS relapse, does it mean that my overall treatment plan for MS needs to change?

If you experience an MS relapse within six months of starting a new disease-modifying therapy, this might be because the therapy has not yet achieved full efficacy. This isn’t considered a treatment failure.

However, if you experience two or more confirmed MS relapses in one year, or have an attack that causes significant disability while on therapy, you should revisit your treatment plan with your neurologist.

Do treatments for MS relapses or exacerbations include treatments that target specific symptoms of MS?

Yes. Depending on the type and severity of your symptoms, you might receive additional treatments. This could include physical therapy, occupational therapy, or speech therapy. It might also include medications that help with specific symptoms, such as neuropathic pain, muscle spasms, bowel and bladder symptoms, and fatigue. These treatments are personalized to your symptoms and tapered as your symptoms improve.

If I experience an MS relapse, will I need to go to a rehabilitation program?

Most people who experience an MS relapse don’t need to go to an inpatient rehabilitation program, unless there is significant physical disability. For example, if a person experienced an MS relapse and could no longer walk due to a spinal cord injury, they would need to go to a rehabilitation program.

For most people, a rehabilitation program isn’t necessary after an MS relapse. If needed, physical therapy can be done on an outpatient basis several times per week, and tapered as your symptoms improve.

Xiaoming (Sherman) Jia, MD, MEng is a graduate of Massachusetts Institute of Technology and Harvard Medical School. Dr. Jia trained in internal medicine at Beth Israel Deaconess Medical Center and in neurology at the University of California San Francisco. In addition to specializing in treatment of patients with multiple sclerosis, Dr. Jia conducts research on the genetics of neurologic disorders. He led one of the first studies to identify genetic factors that influence a progressive disease course in MS. His early work focused on understanding the genetics of the human immune system, and significantly advanced understanding of immune-mediated disorders including MS, rheumatoid arthritis, and HIV-1 infection. Dr. Jia is a recipient of the HHMI Medical Fellowship, the NINDS R25 award, and the UCSF CTSI Fellowship. Aside from being a neurologist and statistical geneticist, he is a lifelong violinist and served as Concertmaster of the Longwood Symphony, an orchestra of medical professionals in Boston, MA.

How to recover from an MS attack

Some people who have MS might find that they need to adapt their daily routine to accommodate the symptoms of a particular attack, which some people may find emotionally and physically disruptive.

Those with the disease may have to alter their habits and activities to account for reduced energy and physical movement.

Sleep hygiene

It is essential that people with MS get enough rest. Establishing a good bedtime routine will help ensure they get restful sleep.

MS can cause debilitating fatigue. Although getting plenty of sleep can help, one symptom of fatigue is waking up from rest feeling unrefreshed.

Sleeping for longer before potentially demanding, draining, or important events can also help a person with MS preserve energy.

During a relapse of symptoms, a person with MS may need more sleep and rest than usual and should allow for extra sleep time at the end of their day.

Exercising

The World Health Organization (WHO) recommend that all adults do at least 150 minutes of exercise every week.

For people with MS, exercise can reduce the impact of symptoms by:

  • improving cardiovascular health
  • reducing weakness and better strength and movement
  • improving function in the bowel and bladder
  • promoting better mood and reducing fatigue
  • encouraging participation in social events and engagements

Some forms of exercise, such as yoga, can also help relieve painful muscle spasms. Exercise can also counter MS-related fatigue and boost mood.

Managing stress

Share on PinterestCareful planning can reduce stress for people who have MS.

While there is mixed research around the links between stress and relapses of MS, experts think that managing stress can still play a significant role in reducing the impact of the disease on everyday life.

Scientists are not clear whether stress might cause MS symptoms. It can, however, make symptoms feel worse on an individual basis.

Steps to reduce stress with MS include:

  • Planning for particularly stressful or demanding situations. This might involve taking a distraction, such as a book, to appointments that might require waiting.
  • Reducing pressure from daily chores and tasks. People experiencing an MS relapse who are having difficulties adjusting to tasks need to assess the importance of the task and the standards it requires. Asking for help can also relieve stress during these times.
  • Handling less pleasant tasks earlier in the day can help a person with MS maintain energy for more enjoyable tasks and activities.
  • Ordering more medication before it runs out to avoid the stress of a shortage.
  • Recognizing signs of stress, such as shallow breathing, and taking measures to relax. Practicing controlled breathing can help a person alleviate this symptom of stress.
  • Engaging in at least one enjoyable activity every day.
  • Avoiding extremely hot or cold temperatures to reduce discomfort. Although some people with MS may be susceptible to temperature changes, heat usually only worsens symptoms for a limited period.
  • Stress management techniques, such as guided meditation, deep breathing, and yoga might help relieve stress in times of emotional discomfort.

More detailed guidance is available on the National MS Society website.

Improving bladder control

Many people with MS experience bladder issues, such as urinary incontinence, difficulties starting urination, problems emptying their bladder, and bladder urgency, which is the sensation of wanting to urinate frequently even when there is very little urine in the bladder.

Anyone experiencing bladder problems should inform their doctor who will likely check for a urinary tract infection (UTI).

Scheduled voiding, or going to the bathroom at a set time, can help train the bladder to hold urine for a longer time. This may decrease persistent feelings of needing to urinate. Also, medications are available that may help with bladder symptoms.

Seeking support

People with MS have a high risk of depression, isolation, and feelings of loneliness, especially during a relapse. People with MS might choose to talk to a counselor or support group to help cope with depression and feelings of anger over the disease.

Many people with MS find it helpful to develop a network of people who can help with the remitting effects of the disease.

Healthline offers an app called MS Buddy that can help connect people with MS for emotional and practical support.

MS In America – Relapse Frequency and Duration

MS relapses occur when you experience new symptoms or when existing symptoms suddenly worsen. To be considered a relapse, these symptoms must last for at least 24 hours. Relapses are considered separate incidents when they occur at least 30 days apart. They are also referred to as attacks, exacerbations, or flares.

Relapses are caused by inflammation in the central nervous system. The location of the inflammation can affect the type of symptoms you experience (inflammation can also occur in more than one place). Individuals with Relapsing-Remitting MS (RRMS), the most common type of MS, typically experience clearly defined relapses followed by periods of remission when the inflammation has ended.

Frequency, duration, and severity of MS relapses/exacerbations can vary dramatically from one person to the next. The unpredictability of these relapses is one of the many frustrating aspects of MS.

In our MS in America Study, just over 30% of respondents noted that they experienced relapses less than once a year. The remaining responses ranged from once a month to once a year, with most relapses lasting from one week to one month:


How often do you experience relapses and how long do symptoms last? Please share in the comments!

Poll

The MS in America Study was conducted over the internet from November 2012 until January 2013. The primary goal of the study was to establish an understanding of the current state and trends of patients affected by Multiple Sclerosis. The survey included over 100 questions on a broad range of topics. A total of 3,437 people started the survey while 2,562 people completed the survey resulting in a high completion rate of 74.5%. To qualify for the survey, participants had to be MS patients over 18 years old and a US resident or US citizen living abroad.

The study was solely developed and funded by Health Union, LLC which does not manufacture, sell nor market any product to diagnose, prevent or treat MS or any other disease.

Multiple sclerosis (MS) flare-ups are distinct, sudden episodes of either new symptoms or a worsening of existing symptoms. They are characteristic in relapsing-remitting MS (RRMS), which is marked by recurrent acute flares (relapses) followed by partial or complete recovery (remission).

Approximately 85 percent of all MS patients are diagnosed initially with RRMS. The remaining 15 percent have what is called primary-progressive MS (PPMS), and undergo a gradual physical decline with no noticeable remissions.

Characteristics of MS flare-ups

A flare-up may consist of one or more symptoms that last for at least 24 hours and up to weeks or months. To be a flare-up symptoms must be specific to MS and not due to other factors, such as an infection. Two distinct flares-ups are separated by a remission period of at least 30 days.

Flare-ups also are known as attacks, relapses, episodes, or exacerbations.

The underlying mechanism of a flare-up is the immune attack on the myelin sheath (outer insulating layer on nerve fibers), which causes slow or interrupted neuronal signals in the brain and spinal cord. This results in flare-up symptoms such as problems with balance, coordination, eyesight, bladder function, memory or concentration, mobility, fatigue, weakness, numbness or needle-like sensations. Remission occurs when acute inflammation decreases.

Flare-ups could be triggered by various factors such as stress, infections, or pregnancy and symptoms may vary from mild to severe.

Managing relapses

Mild symptoms such as fatigue, numbness, and needle-like sensations could be left to subside and may need no treatment.

For severe flare-ups such as vision loss, extreme weakness, and poor balance that interfere with patients’ everyday activities, experts recommend a short-course with high-dose of corticosteroids. These facilitate recovery from a relapse by reducing inflammation, but do not affect the course of the disease. The most common treatment regime is a three-to-five day course of intravenous Solu-Medrol (methylprednisolone). Oral Deltasone (prednisone) also may be used.

Steroid treatment works best if started immediately after the onset of the flare-up. However, steroids have side effects that may include increased appetite, weight gain, high blood pressure, and thinning of bones.

For MS patients who do not tolerate the side effects of high doses of corticosteroids, or who have been treated unsuccessfully with corticosteroids, H.P. Acthar Gel (adrenocorticotropic hormone, ACTH) is used as a second-line therapy. Acthar Gel is administered via under the skin (subcutaneously) or into a muscle self-injection.

Plasmapheresis, a blood-cleansing method to remove the myelin-attacking antibodies from the blood, is another option for treating severe relapses that do not respond to the standard steroid treatment.

Patient rehabilitation aims to restore the essential everyday functions after a relapse. It combines different approaches, including physiotherapy, dietary advice, employment services, and support at home. The rehabilitation team can help the patient with difficulties in swallowing, mobility, dressing, personal care, and office work.

Recovery from a relapse may take weeks or months, with symptoms disappearing partially or completely.

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Multiple Sclerosis News Today is strictly a news and information website about the disease. It does not provide medical advice, diagnosis, or treatment. This content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read on this website.

How to Spot the Signs of an MS Flare

Symptoms of a Flare

The signs and symptoms of an impending MS flare include virtually any of the possible symptoms caused by MS. They vary from person to person and from flare to flare.

“My first warning is being overemotional,” says Corinne Sheh, a mother of two in Randolph, Massachusetts, who was diagnosed with MS at 25. “I may start crying for no reason. After that I feel physically and emotionally clumsy, almost like having a hangover.”

Other possible signs include:

  • Increased fatigue
  • Tingling or numbness anywhere on the body
  • Brain fog, or difficulty thinking
  • Muscle spasms
  • Depression
  • Visual changes such as blurring or double vision
  • Pain
  • Tremors
  • Severe balance problems
  • Severe weakness
  • Dizziness
  • Bladder changes
  • Any combination of these symptoms

Getting to know how MS usually affects you and monitoring how you feel from day to day can help you catch potential flares early. At the same time, being overly vigilant can have a negative effect on your mental health.

It’s best — although not easy — to find a way to strike a balance between noticing what’s happening in your body and worrying about every change or sensation.

It’s also important to consider other possible causes of your symptoms; they may have nothing to do with MS, but they may still need to be checked out by a medical professional.

Preventing Flares

MS flares may not be completely preventable, but the newer disease-modifying medications for MS have been shown to greatly reduce relapses. However, it can take a few tries to find the drug that works best for the individual.

Aside from medications, “The best way you can prevent MS flares is to take good care of yourself,” Sheh says. “You also need to let your friends and family know how MS symptoms affect you so you can ask for help when you need it.”

Here are some tips for good MS self-care:

Fatigue. MS fatigue is not like normal fatigue. It can be so severe that it’s disabling. But “having good sleep habits, avoiding caffeine and too much alcohol, and getting some daily exercise are good ways to prevent MS fatigue,” says Dr. McCoyd. There are also medications that help fight MS fatigue.

Tingling. Sheh says that for her, tingling is most often caused by heat. “Tingling feels like pins and needles in your hands and feet and can move all the way into your trunk area,” she says. Planning ahead for exercise and hot weather may help you avoid tingling if overheating triggers it for you.

Brain fog. Slowed thinking, confusion, and difficulty concentrating are frequent but underrecognized MS symptoms. Avoid multitasking and write things down to help you stay focused and remember things better. Cognitive rehabilitation can also help.

Muscle spasms. Discomfort from muscle spasms — also called spasticity — can range from mild stiffness to painful cramping. “I usually feel spasticity in my neck and shoulder areas,” Sheh says. “Ice helps sometimes, but the only thing that really helps is a muscle relaxant medication.”

Depression. “Depression is common in MS and often goes unrecognized,” McCoyd says. “It is important for people with MS to have lots of support, exercise regularly, and use stress-reduction techniques like yoga or meditation to combat this MS symptom.”

Recovery

Severe MS flares are usually treated with several days of high-dose, intravenous steroids, which can be administered at a medical facility or self-administered at home.

Steroids reduce inflammation and speed recovery from a flare, although they don’t correct the damage to the nervous system.

Some people recover fully from a flare, while in others, symptoms experienced during the flare linger afterward, though they may gradually improve over time.

Various forms of rehabilitation can help restore physical and mental functioning that’s been affected by an MS flare.

Multiple Sclerosis

Multiple sclerosis treatment

There is currently no cure for MS. The goal of treatment is to help you cope with and relieve symptoms, slow the progress of the disease and maintain a good quality of life. This can be done through a combination of medicine and physical, occupational, and speech therapy.

Medicine

People who have mild symptoms may choose not to take medicine due to potential risks and side effects. Talk to your doctor about the benefits and risks of all drug options.

Certain medicines can help relieve symptoms and treat short-term problems caused by MS.

  • Bladder problems: tolterodine, oxybutynin.
  • Constipation: stool softener, laxative.
  • Depression: venlafaxine, paroxetine.
  • Pain: phenytoin, gabapentin.
  • Muscle stiffness and spasms: dantrolene, baclofen.
  • Urinary problems: desmopressin, methenamine, phenazopyridine.
  • Erectile dysfunction: tadalafil, alprostadil.

Other types of medicine can affect the long-term outcomes of the disease.

  • Interferons are a group of natural proteins made by human cells. Studies show they can slow down the worsening of symptoms. These medicines are often given as an injection (a shot). Examples of interferons used to treat MS are IFN Beta-1a and IFN Beta-1b. Interferons may cause serious liver damage. Other side effects include flu-like symptoms and depression.
  • Glatiramer acetates are thought to block the cells that damage myelin. It can lead to fewer relapses and fewer new lesions. The medicine is taken as a shot once a day. Side effects may include hives or pain at the injection site, heart tremors, and shortness of breath.

Two other type of medicine may be used to treat severe or advanced MS.

  • Natalizumab: This is an option for people who have tried other drugs first and not had good results. It can have serious side effects, and should not be used in combination with other disease-modifying drugs. One known side effect is an increased risk of a fatal brain infection.
  • Mitoxantrone: This is an option for people who have increased relapse and remission periods, progressive MS, or worsened symptoms. Side effects include weakened immune system and an increased risk of blood and heart disease.

During relapses, affected nerve areas can become inflamed. You may have severe pain and loss of vision or bodily function. Steroids can reduce swelling and allow you to return to normal function sooner. Examples of steroids used to treat MS are prednisone (a pill) and methylprednisolone (a shot). Steroids should be taken to treat short-term symptoms. They do not treat long-term effects of MS.

Therapy

Different therapies can be helpful for people who have MS.

  • Physical Therapy (PT)can help with walking, strength, balance, posture, fatigue, and pain. PT can include stretching and strengthening exercises, and training to use mobility aids like canes, scooters, or wheelchairs. Your therapist can help you adapt your exercise routine to accommodate your symptoms and flare-ups.
  • Occupational Therapy (OT) can improve your level of freedom and safety at home and at work. Your therapist can show you how to use tools to help in daily tasks. They can also recommend changes to your home or work space to make tasks easier. Your therapist may help you learn how to adapt to activities or hobbies that you enjoy.
  • Speech Therapy can help you better control muscles used for talking and swallowing.
  • Pre-pregnancy planning is important for women. Certain medicines used to treat MS symptoms are not safe for your baby during pregnancy. These include medicines called “disease-modifying drugs.” Another group is called “chemotherapeutic drugs.” This includes azathioprine or methotrexate. Your doctor may suggest that you stop taking these medicines before trying to get pregnant. Some other medicines that are considered safe during pregnancy can be helpful in treating MS symptoms. Your doctor may recommend that you change medicines while you are trying to get pregnant and during your pregnancy. Some medicines used to treat MS may be passed on to babies during breastfeeding. This is not safe for the baby. Talk to your doctor about your breastfeeding plans.

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