Understanding MS Relapses | Everyday Health

If you have the most commontype of multiple sclerosis复发缓和多发性硬化症(MS),或者名RRMS that a relapse can last anywhere from a day to several weeks or even months. And just as the symptoms of MS can vary from person to person, the experience and recovery from an exacerbation is also unique for everyone.

Even though there is a wide spectrum of possible symptoms, severity, and duration in an MS flare, knowing what causes an exacerbation and what to expect if you have one can help you navigate the unpredictability of the disease.

What’s Behind MS Symptoms?

In multiple sclerosis, the immune system mistakenly attacks the central nervous system (the brain and spinal cord), starting with the myelin sheath, the insulating layer of protein and fat that protects the part of the nerve cell known as the nerve fiber, or axon.

Damage to the myelin and to the underlying axons interrupts or stops the transmission of nerve impulses between the brain and other parts of the body, resulting in thesigns and symptoms of MS. Those can include vision loss, balance problems, fatigue,numbness and tingling, and many others, depending on where the damage occurs.

Some MS symptoms can be long-lasting or permanent, while other symptoms tend to come and go.

When existing symptoms worsen, old symptoms recur, or new symptoms appear, it is called an MS flare or, alternatively, an exacerbation, relapse, or attack.

What Defines an MS Relapse?

To be considered a true relapse, the flare must occur at least 30 days after your most recent flare, and the new, recurring, or worsening symptoms must last for at least 24 hours.

Acute symptom flares are typically followed by periods of months or even years when symptoms subside or completely disappear.

Symptoms of an MS Flare

Symptoms of MS flaresvary from person to person. Some common symptoms signaling a flare include the following:

Severe fatigue
Numbness and tingling in the arms and legs
Eye pain or blurred vision
Weakness
Balance difficulties
Bladderorbowelproblems

According toTanuja Chitnis, MD, an associate professor of neurology and the director of the Partners Pediatric MS Center at Massachusetts General Hospital for Children, in Boston, “Symptoms of an MS flare generally come on over the course of several days."

Causes of a Flare

Flares are caused by inflammation in the central nervous system that damages areas of myelin.

Exactly what triggers the inflammation can be difficult to pinpoint, Dr. Chitnis says. "Flares can be triggered by infections, includingbladder infections. Some evidence suggests that stress may trigger flares, but this is still controversial," she says.

One misconception is that vaccines increase the risk of an MS flare.

"The evidence is strong that vaccinations do not trigger flares," Chitnis says.

Preventing Exacerbations

Though flarescannot be prevented entirely, it’s sometimes possible to avoid the things that may trigger them. For example, since flares can be triggered by infection, it's important to wash your hands frequently during cold andflu seasonand to get anannual flu shot, as long as you have no medical reasons not to.

Taking steps to lower your risk ofurinary tract infectionscan help, too. These include:

Drinking plenty of water or other fluids to flush out bacteria
Urinating when you feel the urge (rather than waiting)
Seeing your doctor for treatment of any ongoing bladder problems, such asurinary incontinenceor urinary retention

Duration, Severity, and Recovery

Relapses can last anywhere from a few days to a few weeks or even months, depending on your response to treatment.

Sometimes a brief flare-up of symptoms can occur and then resolve without any treatment at all. This is called a pseudoexacerbation and is not technically classified as a relapse. Pseudoexacerbations are usually brought on byincreased body temperatureand go away when the body cools down, sometimes in a matter of minutes.

The severity of flares varies from person to person and from flare to flare. Some research, including astudy published inNeurologyin 2014, shows that people with higher levels ofvitamin Dhave less severe flares.

There’s also evidence to support supplementing with vitamin D to treat insufficiencies.Research published inMultiple Sclerosis and Related Disordersin November 2016found that participants who took oralvitamin D3supplements experienced a decrease in the number of relapses.

Recovery is also variable. Chitnis says that younger people generally recover better from flares than older people.

Poor recovery from flares in the first five years following diagnosis could be a risk factor for developing early secondary-progressive MS, according to astudy published in August 2015 inNeurology.

Treatment for MS Flares

Mild flares may not require any treatment, but more severe relapses that affect a person’s ability to function can be treated, usually with high-dose steroid medications, for several days to shorten the duration of the flare.

Steroids

Considered a first-line treatment for exacerbations, steroids reduce inflammation and relieve symptoms, but they do not reverse the damage to the nerves.

Steroids are typically given through an IV for three to five days. Depending on the type of relapse and what your doctor recommends, a tapering dose of oral steroids for one to three weeks may follow, according to theNational Multiple Sclerosis Society.

最近的研究表明,口服类固醇可能be a less costly and more convenient way to treat relapses compared with IV delivery. In a retrospective nonrandomizedstudy published in April 2018 in theEuropean Journal of Hospital Pharmacy, for example, oral steroids were just as effective as IV steroids, and 79 percent of patients preferred taking the medication orally.

Plasmapheresis

Plasmapheresis (PMP) can be used as a second-line therapy if a person can’t tolerate steroids or if steroids have been tried and haven’t been effective in treating the relapse. In this medical procedure, also known as apheresis, plasma exchange, or PLEX, whole blood is removed from a large vein and separated into the cellular components and plasma, according to theNeurological Institute at Cleveland Clinic in Ohio.

The removed plasma is discarded and replaced with colloid fluid that’s a combination of human serum albumin or fresh frozen plasma, which is then combined back with the cellular components and returned to the patient.

Astudy published inMultiple Sclerosis and Related Disordersin January 2018found that plasma exchange was relatively safe and effective, with complete recovery in 41.3 percent of patients and partial recovery in 39.1 percent.

Intravenous Immunoglobin

Intravenous immunoglobin (IVIG) can be used to treat relapses, though it is typically considered a second- or third-line treatment. At theCleveland Clinic’s Mellen Center for Multiple Sclerosis Treatment and Research, IVIG is used only if a person doesn’t respond to or can’t tolerate steroids and plasmapheresis.

Immunoglobin is the term for the fraction of plasma that contains antibodies. In IVIG, a mixture of antibodies is delivered intravenously with the aim of treating the relapse by stimulating some parts of the immune system while suppressing other parts.

Acthar Gel

Acthar gel (repositorycorticotropininjection), another second-line therapy, was found to be a more effective alternative to steroids for treating flares compared with IVIG or plasmapheresis,according to a study published in September 2019 inNeurology and Therapyconducted by Mallinckrodt, the company that manufactures the gel.

Acthar stimulates the production of the steroid hormonescortisol, corticosterone, and aldosterone, which help the body respond to stress.

In the study, Acthar successfully treatedMS relapses与50.7相比,96.9%的患者cent for plasmapheresis and 43.9 percent for intravenous immunoglobulin.

In ananalysis sponsored by Mallinckrodt, Acthar was found to be more cost-effective than PLEX or IVIG, although all three therapies are considerably more expensive than steroid treatment. In a cost per response analysis, Acthar gel cost $141,970 compared with the other therapies, which cost an average of $253,331. These costs don’t factor in medical insurance coverage that would vary from person to person.

The Role of Disease-Modifying MS Drugs in Preventing Relapses

Disease-modifying therapies (DMTs) for MSaren't used to treat flares, but some of the newer ones show promise at preventing them, saysBruce Bebo Jr., PhD, the executive vice president for research at the NationalMultiple Sclerosis Society.

“Treatments seem to be getting better at decreasing the frequency of flares and the inflammation responsible for them and the damage the flares cause to the body,” Dr. Bebo says.

Evidence supports the effectiveness of these medications, including a study that tracked the effectiveness of nine different oral and injectable DMTs,published online in April 2017 inClinicoEconomics and Outcomes Research. Investigators found that people who were adherent to the medications reduced the likelihood of relapse by 42 percent and hospitalization by 52 percent.

Aposter presentation at the Consortium of Multiple Sclerosis Centers in June 2019also found increased incidence of relapses when people stopped taking their disease-modifying therapy for more than two months. That group had nearly 28 percent more relapses, 25 percent more emergency department visits, and 40 percent more hospitalizations compared with people who continued to take their medication.

Recovering From an MS Flare

Some people regain total function after a flare, while in others the recovery may be only partial. A variety of types ofrehabilitation specialists— including physical therapists, speech language pathologists, occupational therapists, and cognitive specialists — can play an important role in helping you regain physical and mental function after a flare.

Additional reporting byBecky Upham.