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Lin et al., 2013A relapse is considered any new or acutely worsening neurological symptoms with objective evidence that: Is consistent with inflammation and demyelination Lasts for more than 24 hours Is separated by at least 30 days from the onset of the last relapse Is not related to an infection, fever or other stresses Has no other explanation Determining whether a person is having a true relapse can be challenging. Pseudorelapses (also called pseudoexacerbations) can be caused by fatigue, overexertion, fever, infection (such as a UTI) and exposure to heat and humidity. And fluctuations in symptoms can occur for reasons other than a relapse. An infection is associated with an increased relapse risk, typically 3-6 weeks after the infection has resolved. Evidence also points to an association between known MS risk-associated single nucleotide polymorphisms (SNPs) and MS relapses (Lin et al., 2013 ). Lin et al., 2013A relapse is considered any new or acutely worsening neurological symptoms with objective evidence that: Is consistent with inflammation and demyelination Lasts for more than 24 hours Is separated by at least 30 days from the onset of the last relapse Is not related to an infection, fever or other stresses Has no other explanation Determining whether a person is having a true relapse can be challenging. Pseudorelapses (also called pseudoexacerbations) can be caused by fatigue, overexertion, fever, infection (such as a UTI) and exposure to heat and humidity. And fluctuations in symptoms can occur for reasons other than a relapse. An infection is associated with an increased relapse risk, typically 3-6 weeks after the infection has resolved. Evidence also points to an association between known MS risk-associated single nucleotide polymorphisms (SNPs) and MS relapses (Lin et al., 2013 ).
Medication Options Beck et al., 1992High Dose Oral Prednisone A 1,250 mg dose of oral prednisone has a bioavailability equal to 1 g IVMP (Morrow et al, 2004 ). Several studies have found high dose intravenous and high dose oral corticosteroids to be equally efficacious in accelerating recovery from relapses (Liu et al., 2017 ). However, the lower cost of oral prednisone may be a consideration.Intramuscular adrenocorticotrophic hormone (ACTH) ACTH is FDA-approved and available for the treatment of relapses of MS in adults. Although ACTH has been shown to be as effective as IVMP in managing relapses, it is prescribed much less often because of its high cost (Kalinsik 2015 , Arnason et al., 2013 ).Plasmapheresis In 2011, the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology (AAN) recommended plasmapheresis as a second-line treatment for steroid-resistant relapses in relapsing forms of MS (Cortese et al., 2011 ).Intravenous Immunoglobulin (IVIG) IVIG may be considered for relapses during pregnancy (during which time steroids should be avoided if possible), and it may reduce the risk of post-partum relapses (Hellwig et al., 2009 ; Achiron et al., 2004 ). IVIG is sometimes used to treat relapses that don’t respond to corticosteroids, although the supportive evidence is limited (Thrower 2009 ). During pregnancy , relapses severe enough to warrant treatment can be safely managed with a short course of corticosteroids after the first trimester. Methylprednisolone is the preferred drug because it is metabolized before crossing the placenta. IVIG is safe for use during pregnancy and may provide some benefit (Ferrero et al., 2004 , Winkelmann et al., 2018 ). " c-nmssatomrichtext_nmssatomrichtext-host="">IV Methylprednisolone (IVMP) The pivotal Optic Neuritis Treatment Trial (ONTT) demonstrated the efficacy of IVMP 1 g/day for 3 days in acute optic neuritis, thus laying the foundation for the treatment of MS relapses (Beck et al., 1992 ). IVMP for 3 days was also shown to significantly delay the development of MS within the first 2 years.High Dose Oral Prednisone A 1,250 mg dose of oral prednisone has a bioavailability equal to 1 g IVMP (Morrow et al, 2004 ). Several studies have found high dose intravenous and high dose oral corticosteroids to be equally efficacious in accelerating recovery from relapses (Liu et al., 2017 ). However, the lower cost of oral prednisone may be a consideration.Intramuscular adrenocorticotrophic hormone (ACTH) ACTH is FDA-approved and available for the treatment of relapses of MS in adults. Although ACTH has been shown to be as effective as IVMP in managing relapses, it is prescribed much less often because of its high cost (Kalinsik 2015 , Arnason et al., 2013 ).Plasmapheresis In 2011, the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology (AAN) recommended plasmapheresis as a second-line treatment for steroid-resistant relapses in relapsing forms of MS (Cortese et al., 2011 ).Intravenous Immunoglobulin (IVIG) IVIG may be considered for relapses during pregnancy (during which time steroids should be avoided if possible), and it may reduce the risk of post-partum relapses (Hellwig et al., 2009 ; Achiron et al., 2004 ). IVIG is sometimes used to treat relapses that don’t respond to corticosteroids, although the supportive evidence is limited (Thrower 2009 ). During pregnancy , relapses severe enough to warrant treatment can be safely managed with a short course of corticosteroids after the first trimester. Methylprednisolone is the preferred drug because it is metabolized before crossing the placenta. IVIG is safe for use during pregnancy and may provide some benefit (Ferrero et al., 2004 , Winkelmann et al., 2018 ). Beck et al., 1992High Dose Oral Prednisone A 1,250 mg dose of oral prednisone has a bioavailability equal to 1 g IVMP (Morrow et al, 2004 ). Several studies have found high dose intravenous and high dose oral corticosteroids to be equally efficacious in accelerating recovery from relapses (Liu et al., 2017 ). However, the lower cost of oral prednisone may be a consideration.Intramuscular adrenocorticotrophic hormone (ACTH) ACTH is FDA-approved and available for the treatment of relapses of MS in adults. Although ACTH has been shown to be as effective as IVMP in managing relapses, it is prescribed much less often because of its high cost (Kalinsik 2015 , Arnason et al., 2013 ).Plasmapheresis In 2011, the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology (AAN) recommended plasmapheresis as a second-line treatment for steroid-resistant relapses in relapsing forms of MS (Cortese et al., 2011 ).Intravenous Immunoglobulin (IVIG) IVIG may be considered for relapses during pregnancy (during which time steroids should be avoided if possible), and it may reduce the risk of post-partum relapses (Hellwig et al., 2009 ; Achiron et al., 2004 ). IVIG is sometimes used to treat relapses that don’t respond to corticosteroids, although the supportive evidence is limited (Thrower 2009 ). During pregnancy , relapses severe enough to warrant treatment can be safely managed with a short course of corticosteroids after the first trimester. Methylprednisolone is the preferred drug because it is metabolized before crossing the placenta. IVIG is safe for use during pregnancy and may provide some benefit (Ferrero et al., 2004 , Winkelmann et al., 2018 ). " c-nmssatomrichtext_nmssatomrichtext-host="">IV Methylprednisolone (IVMP) The pivotal Optic Neuritis Treatment Trial (ONTT) demonstrated the efficacy of IVMP 1 g/day for 3 days in acute optic neuritis, thus laying the foundation for the treatment of MS relapses (Beck et al., 1992 ). IVMP for 3 days was also shown to significantly delay the development of MS within the first 2 years.High Dose Oral Prednisone A 1,250 mg dose of oral prednisone has a bioavailability equal to 1 g IVMP (Morrow et al, 2004 ). Several studies have found high dose intravenous and high dose oral corticosteroids to be equally efficacious in accelerating recovery from relapses (Liu et al., 2017 ). However, the lower cost of oral prednisone may be a consideration.Intramuscular adrenocorticotrophic hormone (ACTH) ACTH is FDA-approved and available for the treatment of relapses of MS in adults. Although ACTH has been shown to be as effective as IVMP in managing relapses, it is prescribed much less often because of its high cost (Kalinsik 2015 , Arnason et al., 2013 ).Plasmapheresis In 2011, the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology (AAN) recommended plasmapheresis as a second-line treatment for steroid-resistant relapses in relapsing forms of MS (Cortese et al., 2011 ).Intravenous Immunoglobulin (IVIG) IVIG may be considered for relapses during pregnancy (during which time steroids should be avoided if possible), and it may reduce the risk of post-partum relapses (Hellwig et al., 2009 ; Achiron et al., 2004 ). IVIG is sometimes used to treat relapses that don’t respond to corticosteroids, although the supportive evidence is limited (Thrower 2009 ). During pregnancy , relapses severe enough to warrant treatment can be safely managed with a short course of corticosteroids after the first trimester. Methylprednisolone is the preferred drug because it is metabolized before crossing the placenta. IVIG is safe for use during pregnancy and may provide some benefit (Ferrero et al., 2004 , Winkelmann et al., 2018 ).
Role of Rehabilitation rehabilitation team helps people regain and/or optimize function following a relapse. Published data suggest that IVMP and rehabilitation supported by a multidisciplinary team is more effective than IVMP alone in relapse management (Craig et al., 2003 ; Nedeljkovic et al., 2016 ). Rehabilitation is also useful for individuals with relapsing-remitting MS who have accumulated moderate to severe disability as a result of incomplete recovery from relapses (Liu et al., 2003 ). A 2017 review identified evidence supporting a variety of rehabilitation strategies in MS (Khan and Amatya, 2017 ). Rehabilitation strategies targeted to the needs of the individual might include: Physical therapy (an exercise program to enhance strength balance/stability, gait and endurance, as well as assessment for and use of mobility aids) Occupational therapy (energy conservation, use of adaptive equipment in the home and workplace and cognitive strategies) Speech/language pathology (assessment and management of dysarthria, dysphonia and dysphagia) Nursing (bladder and bowel management) These multidisciplinary strategies work to enhance function and promote safety and quality of life throughout the disease course. " c-nmssatomrichtext_nmssatomrichtext-host="">The rehabilitation team helps people regain and/or optimize function following a relapse. Published data suggest that IVMP and rehabilitation supported by a multidisciplinary team is more effective than IVMP alone in relapse management (Craig et al., 2003 ; Nedeljkovic et al., 2016 ). Rehabilitation is also useful for individuals with relapsing-remitting MS who have accumulated moderate to severe disability as a result of incomplete recovery from relapses (Liu et al., 2003 ). A 2017 review identified evidence supporting a variety of rehabilitation strategies in MS (Khan and Amatya, 2017 ). Rehabilitation strategies targeted to the needs of the individual might include: Physical therapy (an exercise program to enhance strength balance/stability, gait and endurance, as well as assessment for and use of mobility aids) Occupational therapy (energy conservation, use of adaptive equipment in the home and workplace and cognitive strategies) Speech/language pathology (assessment and management of dysarthria, dysphonia and dysphagia) Nursing (bladder and bowel management) These multidisciplinary strategies work to enhance function and promote safety and quality of life throughout the disease course. rehabilitation team helps people regain and/or optimize function following a relapse. Published data suggest that IVMP and rehabilitation supported by a multidisciplinary team is more effective than IVMP alone in relapse management (Craig et al., 2003 ; Nedeljkovic et al., 2016 ). Rehabilitation is also useful for individuals with relapsing-remitting MS who have accumulated moderate to severe disability as a result of incomplete recovery from relapses (Liu et al., 2003 ). A 2017 review identified evidence supporting a variety of rehabilitation strategies in MS (Khan and Amatya, 2017 ). Rehabilitation strategies targeted to the needs of the individual might include: Physical therapy (an exercise program to enhance strength balance/stability, gait and endurance, as well as assessment for and use of mobility aids) Occupational therapy (energy conservation, use of adaptive equipment in the home and workplace and cognitive strategies) Speech/language pathology (assessment and management of dysarthria, dysphonia and dysphagia) Nursing (bladder and bowel management) These multidisciplinary strategies work to enhance function and promote safety and quality of life throughout the disease course. " c-nmssatomrichtext_nmssatomrichtext-host="">The rehabilitation team helps people regain and/or optimize function following a relapse. Published data suggest that IVMP and rehabilitation supported by a multidisciplinary team is more effective than IVMP alone in relapse management (Craig et al., 2003 ; Nedeljkovic et al., 2016 ). Rehabilitation is also useful for individuals with relapsing-remitting MS who have accumulated moderate to severe disability as a result of incomplete recovery from relapses (Liu et al., 2003 ). A 2017 review identified evidence supporting a variety of rehabilitation strategies in MS (Khan and Amatya, 2017 ). Rehabilitation strategies targeted to the needs of the individual might include: Physical therapy (an exercise program to enhance strength balance/stability, gait and endurance, as well as assessment for and use of mobility aids) Occupational therapy (energy conservation, use of adaptive equipment in the home and workplace and cognitive strategies) Speech/language pathology (assessment and management of dysarthria, dysphonia and dysphagia) Nursing (bladder and bowel management) These multidisciplinary strategies work to enhance function and promote safety and quality of life throughout the disease course.
Emotional Support clinician-patient communicationKalb, 2007 )." c-nmssatomrichtext_nmssatomrichtext-host="">Patients and families experience acute relapses of MS as crises that disrupt the status quo. These events elicit strong emotional reactions, including grief, anxiety, anger and guilt, which need to be acknowledged and understood in order to ensure effective clinician-patient communication about the disease and its management (Kalb, 2007 ). clinician-patient communicationKalb, 2007 )." c-nmssatomrichtext_nmssatomrichtext-host="">Patients and families experience acute relapses of MS as crises that disrupt the status quo. These events elicit strong emotional reactions, including grief, anxiety, anger and guilt, which need to be acknowledged and understood in order to ensure effective clinician-patient communication about the disease and its management (Kalb, 2007 ).
Relapse Management