Treating Multiple Sclerosis Relapses
Relapses, also referred to as exacerbations, attacks, flare-ups, episodes, or bouts, are initially experienced by most people diagnosed with multiple sclerosis (MS). Relapses occur with relapsing-remitting and sometimes secondary-progressive forms of MS. Relapses do not occur with primary-progressive MS, although patients may experience day-to-day fluctuations in how they feel.
During a relapse, patients will have a temporary worsening or recurrence of existing symptoms and/or the appearance of new symptoms. This typically lasts for a few days to a few months, followed by a complete or partial recovery (remission). Acute physical symptoms and neurological signs must be present for at least 24 to 48 hours, without any signs of infection or fever, before the treating physician may consider this type of flare-up to be a true relapse.
With relapses, inflammation is occurring along the nerves and the myelin. Myelin is the protective covering that insulates the nerves of the central nervous system (CNS) – a system that consists of the brain, spinal cord, and optic nerves. Please visit the MS Overview section of MSAA’s website for more information about the MS process and what happens during an MS relapse.
Less-severe relapses are usually not treated with steroids, so their use may be reserved for more severe flare-ups. When treatment is required, relapses are usually treated with a high-dose course of powerful corticosteroids (a type of steroid) over a period of three to five days. These are given by intravenous (IV) infusion, providing the drug directly into the bloodstream for a quicker response. Administration may be performed in a hospital, infusion center, or sometimes at home. Corticosteroids work by reducing inflammation in the CNS. While they usually lessen the severity and duration of a relapse, they do not appear to affect the long-term progression of the disease.
As approved by the United States Food and Drug Administration (FDA), patients are often given methylprednisolone (Solu-Medrol®) to treat an MS relapse. In practice, doctors may sometimes prescribe the corticosteroid dexamethasone (Decadron®), in place of methylprednisolone. An oral steroid (prednisone) may be prescribed after the high-dose treatment to ease the patient off the treatment, tapered over one to two weeks.
Acthar® Gel is also approved by the FDA to treat MS relapses and has been used as an alternative to corticosteroids for more than 30 years. This may be helpful for individuals who are not able to tolerate the side effects of steroids, who have found that previous treatments were not effective, or who may have difficulty getting timely medical support for IV infusions. Studies suggest that the effectiveness of Acthar Gel is similar to corticosteroids.
Acthar contains a highly purified form of the adrenocorticotropin (ACTH) in gelatin. It is given once daily for two to three weeks and is injected either into the muscle or under the skin. This is then absorbed slowly into the bloodstream. Acthar works differently than corticosteroids by helping the body to produce its own natural steroid hormones that reduce inflammation and aid in recovery. For more information, please visit acthar.com/multiple-sclerosis-attacks or call (877) 503-7746.
Similar to Acthar Gel, Purified Cortrophin® Gel (Repository Corticotropin Injection USP) is also a purified preparation of the hormone adrenocorticotropin (ACTH) in gelatin. The commercial launch of this second ACTH product was announced in January 2022. This medication is indicated for the treatment of acute relapses in multiple sclerosis (MS), as well as certain other chronic autoimmune disorders, such as rheumatoid arthritis (RA).
Cortrophin Gel is now available by prescription through a network of specialty pharmacies and distributors, providing a second treatment option for individuals who do not tolerate or derive benefit from IV steroids. The makers of Cortrophin Gel have created “Cortrophin In Your Corner,” a support program for patients and their carepartners, as well as healthcare professionals and their staff. For more information, please visit cortrophin.com or call (800) 805-5258.
Other therapies include plasmapheresis (plasma exchange or “PE”) and intravenous immunoglobulin (IVIG). Neither of these is approved by the FDA specifically for MS relapses, but either may sometimes be used for individuals who are experiencing a severe relapse and are not responding to other treatments. With PE, blood is taken from the patient, cleansed of potentially toxic elements, and returned to the patient. IVIG therapy uses human immunoglobulin, an antibody derived from the blood of healthy donors. With both of these therapies, more studies are needed to determine their individual effectiveness.
To follow is a list of drugs and therapies that may be used in the treatment of an MS relapse. Not all of these treatments are approved by the United States Food & Drug Administration (FDA) specifically for the treatment of MS.
- Solu-Medrol® (IV methylprednisolone)
- Decadron® (dexamethasone)
- Acthar® Gel
- Purified Cortrophin® Gel
- Plasmapheresis (plasma exchange or PE)*
- Intravenous immunoglobulin (IVIG) therapy*
*Please note that with these latter two therapies, clinical trial results have been mixed. Studies continue to determine the effectiveness of these treatments with MS.
For more information, including details on the effectiveness and side effects of the different treatments for relapses, please visit MSAA’s online MS Relapse Resource Center. Individuals may also view MSAA’s brochure, Understanding and Treating MS Relapses, as well as MSAA’s MS Relapse Toolkit.
Please note that MSAA does not endorse or recommend any specific drug or treatment. Individuals are advised to consult with a physician about the potential benefits and risks of the different treatment therapies.