Managing Exacerbations or Relapses

Relapses (exacerbations, attacks, or flare-ups) of multiple sclerosis (MS) happen because of nerve damage caused by inflammation in the central nervous system (CNS). Acute relapses in MS are defined as new or worsened symptoms that last for longer than 24 hours, often accompanied by new MS lesions seen on imaging.

Relapses generally develop over a day or a few days, are at their worst for days or weeks and can resolve on their own over a period of weeks to months as the inflammation resolves. If symptoms during a relapse are mild and do not significantly affect functioning, the neurologist may not suggest steroid treatment. However, if symptoms are causing pain or functional difficulty, there are treatments that may help.¹

There are a wide variety of symptoms that can happen with an MS relapse; the most common include fatigue, brain fog, tingling or numbness, muscle spasms, pain, and tremors. Severe relapses can involve loss of vision, severe weakness or poor balance.

What treatments are used to manage relapses?

While disease-modifying therapies (DMTs) are used to prevent relapses and stop or slow the progression of MS, other treatments are used to manage acute symptoms that occur during a relapse. These include corticosteroids, HP Acthar Gel (ACTH hormone), and plasmapheresis.

The most commonly prescribed medication for relapses is high doses of corticosteroids. Corticosteroids are drugs that are designed to mimic cortisol, a hormone produced by the adrenal glands that has anti-inflammatory effects. Because MS exacerbations or relapses involve nerve damage caused by inflammation in the central nervous system (CNS), the goal of corticosteroid treatment is to control that inflammation and speed up recovery. In most cases, an intravenous (IV) injection of methylprednisolone is given for 3-5 days. This may be followed by a tapering dose of oral corticosteroids for 1-2 weeks.^1,2

Although corticosteroids are frequently effective for shortening relapses in people with MS, they can also cause significant side effects, including:^1,3

• Gastrointestinal disturbances, including peptic ulcers, inflammation in the stomach (gastritis) that may cause pain or nausea, and an unpleasant metallic taste in the mouth
• Changes in mood, including depression, irritability, abnormally happy (euphoria), or anxiety
• Water retention and weight gain
• Elevated blood sugar levels
• Elevated blood pressure
• Difficulty sleeping
• Acne
• Changes in heart rhythm
• Thinning of bone tissue (osteoporosis)
• Increased risk of infection
• Eye problems, including cataracts or glaucoma

Corticosteroids have a higher risk of certain side effects in some people, such as those with other conditions like diabetes, major depression, or heart problems.¹

Corticosteroid treatment may be used repeatedly over the course of a person's disease, and the response from one treatment to the next can vary even for the individual. Just because corticosteroids were effective once does not necessarily mean they will be effective in future relapses. The response to corticosteroids often decreases over time.¹

Are there alternatives to corticosteroids that can be used to treat relapses?

Adrenocorticotropic hormone (ACTH), or Acthar Gel, is an FDA-approved alternative to steroid therapy used to treat acute relapses or flares of MS. ACTH can help provide relief from symptoms of MS relapse and reduce the amount of time needed for symptom relief. It is not known exactly how Acthar Gel works, but the gel is formulated to provide an extended-release of ACTH, which works in the body to produce its own natural steroid hormones. This has both anti-inflammatory and immunomodulatory effects, and for some people may mean fewer side effects than using corticosteroids directly.

An alternative to corticosteroids and ACTH to treat severe exacerbations is plasmapheresis (plasma exchange). Plasmapheresis has not been shown to be effective but may be beneficial to those experiencing an exacerbation not responding to corticosteroids. It involves the removal of plasma (the liquid portion of the blood) and replacing it with artificial plasma. The idea behind plasmapheresis is that by removing plasma you remove whatever substance (possibly an antibody) that is circulating in the plasma and contributing to the current flare-up or relapse.⁴