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. 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

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.

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 halt acute damage. 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 can’t be used in all patients, such as those with other conditions like diabetes, major depression, or heart problems.1

Corticosteroid treatment may be used repeatedly over the course of an individual’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 can be used to treat relapses?

An alternative to corticosteroids to treat severe exacerbations is plasmapheresis (plasma exchange). Plasmapheresis involves 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 causing MS.4

Written by Emily Downward | Last review date: April 2018.
View References
  1. Krieger S, Sorrells SF, Nickerson M, et al. Mechanistic insights in to corticosteroids in multiple sclerosis: War horse or chameleon? Clinical Neurology and Neurosurgery. 2014 Apr;119:6-16. doi: https://doi.org/10.1016/j.clineuro.2013.12.021.
  2. Treating Multiple Sclerosis Relapses. Multiple Sclerosis Association of America. Available at https://mymsaa.org/ms-information/treatments/relapses/. Accessed 4/13/18.
  3. Fields TR. Steroid side effects: how to reduce corticosteroid side effects. Hospital for Special Surgery. Available at https://www.hss.edu/conditions_steroid-side-effects-how-to-reduce-corticosteroid-side-effects.asp. Accessed 4/13/18.
  4. Luzzio C. Multiple sclerosis treatment & management. Medscape. Available at https://emedicine.medscape.com/article/1146199-treatment. Accessed 4/5/18.