Multiple Sclerosis Acute Relapse Management

Algorithm Steps

1. ▶

   Start

   Suspected MS Relapse

   New or worsening neurological symptoms in MS patient

   1. ●

      Action

      Confirm True Relapse

      Rule out pseudorelapse

      • New symptoms lasting >24 hours
      • No fever or infection present
      • At least 30 days since last relapse
      • Exclude UTI, other infections
      • Check for medication changes
      1. ◆

         Decision

         Pseudorelapse?

         Transient worsening due to other factors

         • Infection (UTI most common)
         • Fever, heat exposure
         • Stress, fatigue
         • Uhthoff's phenomenon
         1. ●

            Action

            Treat Underlying Trigger

            Address pseudorelapse cause

            • Treat infection (antibiotics if UTI)
            • Reduce body temperature
            • Rest, hydration
            • Symptoms resolve when trigger addressed
         2. ◆

            Decision

            Assess Relapse Severity

            Mild vs moderate/severe

            • Sensory-only: often mild
            • Motor weakness: moderate/severe
            • Optic neuritis: moderate
            • Brainstem symptoms: can be severe
            • Functional impairment level
            1. ●

               Action

               Mild Relapse

               Observation may be reasonable

               • Purely sensory symptoms
               • Minimal functional impact
               • Steroids optional
               • Steroids shorten duration, not final outcome
               • Patient preference matters
               1. ●

                  Action

                  High-Dose Corticosteroids

                  First-line for moderate/severe relapse

                  • IV methylprednisolone 1g daily × 3-5 days
                  • OR high-dose oral prednisone 1250 mg daily × 3-5 days
                  • No taper typically needed for short course
                  • Shortens relapse duration
                  • Does NOT affect long-term outcome
                  1. ⚠

                     Warning

                     ⚠️ Steroid Precautions

                     Monitor for adverse effects

                     • Check glucose (especially in diabetics)
                     • GI prophylaxis (PPI if needed)
                     • Insomnia, mood changes common
                     • Avoid in active infection
                     • Caution in osteoporosis
                  2. ◆

                     Decision

                     Response to Steroids?

                     Evaluate after 5-7 days

                     • Most improve within 3-5 days
                     • Full recovery may take weeks
                     • Incomplete recovery common
                     1. ●

                        Action

                        Good Response

                        Continue observation

                        • Monitor for full recovery
                        • May take weeks to months
                        • Physical therapy if motor deficit
                        • Review DMT efficacy
                        1. ●

                           Action

                           Review DMT Strategy

                           Relapse indicates possible DMT failure

                           • First relapse on DMT: may continue same
                           • Multiple relapses: consider switching
                           • Escalate to higher-efficacy DMT
                           • Discuss with MS specialist
                           1. ✓

                              Outcome

                              Follow-up Plan

                              Post-relapse care

                              • Neurology follow-up in 4-6 weeks
                              • Consider repeat MRI in 3 months
                              • DMT adherence counseling
                              • Patient education on relapse signs
                        2. ●

                           Action

                           Rehabilitation

                           Maximize recovery

                           • Physical therapy for motor deficits
                           • Occupational therapy for function
                           • Vision therapy for optic neuritis
                           • Cognitive rehabilitation if needed
                     2. ●

                        Action

                        Poor or No Response

                        Consider escalation

                        • Additional steroid course (controversial)
                        • Plasma exchange (PLEX)
                        • ACTH gel (Acthar) alternative
                        • Specialist consultation
                        1. ●

                           Action

                           Plasma Exchange (PLEX)

                           For steroid-refractory severe relapse

                           • 5-7 exchanges over 10-14 days
                           • Best evidence for severe relapses
                           • Optic neuritis, myelitis, brainstem
                           • Requires central access
                           • ~40-50% response rate if steroids fail