Corticosteroids are the mainstay of management of the acute relapse.
Steroids will reduce the severity and duration of a relapse, probably by reducing oedema, but the progression of disability is not affected.
Most physicians will use steroids mainly for:
- disabling motor relapses
- brainstem relapses
- disabling sensory symptoms
Recognising a relapse (1)
- diagnose a relapse of MS if the person:
- develops new symptoms or
- has worsening of existing symptoms
- and these last for more than 24 hours in the absence of infection or any other cause after a stable period of at least 1 month
- before diagnosing a relapse of MS:
- rule out infection - particularly urinary tract and respiratory infections and
- discriminate between the relapse and fluctuations in disease or progression
- assess and offer treatment for relapses of MS, that affect the person's ability to perform their usual tasks, as early as possible and within 14 days of onset of symptoms.
- do not routinely diagnose a relapse of MS if symptoms are present for more than 3 months
Treatment of a relapse
NICE suggest that any individual who experiences an acute episode (including optic neuritis) sufficient to cause distressing symptoms or an increased limitation on activities should be offered a course of high-dose corticosteroids (1):
- assess and offer treatment for relapses of MS that affect the person's ability to perform their usual tasks, as early as possible and within 14 days of onset of symptoms
- offer treatment for relapse of MS with oral methylprednisolone 0.5 g daily for 5 days
- consider intravenous methylprednisolone 1 g daily for 3-5 days as an alternative for people with MS:
- in whom oral steroids have failed or not been tolerated or
- who need admitting to hospital for a severe relapse or monitoring of medical or psychological conditions such as diabetes or depression
- non-specialists should discuss a person's diagnosis of relapse and whether to offer steroids with a healthcare professional with expertise in MS because not all relapses need treating with steroid
- do not prescribe steroids at lower doses than methylprednisolone 0.5 g daily for 5 days to treat an acute relapse of MS
- do not give people with MS a supply of steroids to self-administer at home for future relapses
Notes:
- prior to treatment, possible precipitants, particularly infections, should be sought. Urinary tract infections may be asymptomatic and so all patients should have Multistix tests of their urine for protein and nitrites (2)
- the use of a proton pump inhibitor in conjunction with the short term steroid therapy will minimise risk of peptic ulceration
- in catastrophic relapses of inflammatory demyelination that are unresponsive to corticosteroids, seven alternate-day plasma exchange may lead to substantial clinical improvement in 40% (3)
- treatment with beta-interferon may delay the development of further relapses (3)
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