Managing exacerbations or relapses

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MS relapses (exacerbations, attacks, or flare-ups) happen because of nerve damage caused by inflammation in the CNS. Relapses generally get better on their own when inflammation resolves. If your symptoms during a relapse are mild and do not significantly affect functioning, the neurologist may not suggest steroid treatment. However, if your symptoms are causing pain or functional difficulty, you may benefit from treatment.

What drug treatments are used to manage relapses?

The goal of drug treatment for MS exacerbations is to control CNS inflammation and limit nerve damage from demyelination and to close the leaky blood-brain barrier (BBB) so that your body can begin to heal itself. CNS inflammation begins with immune cells attacking and breaking through the blood-brain barrier (BBB) which normally keeps dangerous substances from passing from the bloodstream into the CNS, including the brain and spinal cord.

Corticosteroids (or steroids) are often given to help control the inflammation causing symptoms during a relapse. These drugs are hormones that the body produces naturally. Corticosteroids are not the same as the anabolic steroids that are sometimes used by athletes.

Some corticosteroids are given orally (one example is Deltasone® prednisone) and others  are given by IV (intravenously, by which infusion is delivered directly into a vein), such as Solu-Medrol (methylprednisolone) and Decadron (dexamethasone). Most neurologists agree that a course of high-dose corticosteroids is the best treatment for a severe MS relapse. Intravenous Solu-Medrol (IVSM) is typically given in 3- or 5-day courses with 1 gram (1000 mg) of steroids infused daily. An alternative to IVSM is the adrenocorticotropic hormone (ACTH) which is available as H.P. Acthar® Gel (repository corticotropin injection).

In cases where a relapse is not so severe, your neurologist may use a short course of high-dose oral corticosteroids.

What are the side effects of corticosteroids?

While a short course of high-dose corticosteroids is generally well tolerated, there are some common side effects that you should be aware of.

What to expect with corticosteroids

Mood changes:

  • May have a mood-elevating or energizing effect that makes you feel better while you are taking them
  • May also make you feel low

Sleep difficulties: May make it difficult to sleep

Other side effects: Although a short course of high-dose corticosteroids is generally well tolerated, it may result in side effects including stomach irritation, elevated blood sugar, water retention/weight gain, restlessness

Negative long-terms side effects:

  • Hypertension
  • Diabetes
  • Bone loss (osteoporosis)
  • Cataracts
  • Ulcers

Are there alternatives to corticosteroids for the treatment of relapses?

Although most people with MS respond well to high-dose steroid treatment, an alternative to corticosteroids in the case of 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. This treatment has been used successfully in other autoimmune diseases including myasthenia gravis and Guillain-Barré syndrome.