| Management of MS Exacerbations |
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A common characteristic of multiple sclerosis is the unpredictable appearance of increased
disease activity or exacerbations. The increase in symptoms can often disrupt daily
activities including work, family life and recreation, and may be very frustrating and
confusing for people with MS and their families.
An acute relapse or exacerbation is defined as an increase and maintenance of a change
in symptoms for at least 24-48 hours. This could be a recurrence of past symptoms,
worsening of existing symptoms or the appearance of new symptoms. Relapses may be
triggered by external factors, such as infections, or fevers. Relapses tend to
be associated with the appearance of inflammatory changes seen on MRI and tend to
be more frequent in the first 5-10 years of the disease.
Prevention or reduction in exacerbations is the first management technique. With
disease modifying agents (DMA), including interferons and glatiramer acetate, the
frequency of exacerbations is reduced, as are the number of new inflammatory lesions
seen on MRI. These agents have been approved by the FDA for relapsing-remitting MS
and should be strongly considered in the treatment of MS.
Despite the use of DMAs, exacerbations do occur. Appropriate medical management of
acute relapses can decrease the duration of the exacerbation. In addition, an
interdisciplinary approach can provide the necessary rehabilitation, counseling and
emotional support to maintain and/or improve function lost as the result of the relapse.
Medical management of an acute relapse includes reduction of inflammation secondary
to the exacerbation as well as symptom management medications. Steroids are commonly
used to decrease the inflammation which is thought to occur around existing or new lesions.
Steroids are generally used to shorten the duration and severity of an acute attack, although there is no evidence that they impact the long-term course of the disease.
Traditionally, steroids are administered intravenously or orally.
Intravenous (IV) steroids are more commonly used for more severe exacerbations,
and may be given at home or in an out patient setting. The usual course is 3-5 days
of IV sometimes followed by a 1-2 week oral taper. Oral steroids alone are usually
given in a tapering fashion over 1-2 weeks. Tapering the medication includes
gradually reducing the amount of medication over time. Common side effects of
steroids include stomach irritation, irritability or mood changes, insomnia,
acne or weight gain. Any steroid use increases the risk for an individual to
develop osteoporosis, hypertension, diabetes and avascular necrosis
(decreased blood supply to certain bones). Steroid treatments should be
closely monitored by a physician and/or nurse who are part of the MS team.
Symptom management may include medications to treat increases in spasticity,
bowel/bladder dysfunction, depression, fatigue or pain. Many symptoms are also
managed through intervention from the interdisciplinary rehabilitation team.
Depression, sadness and even a grief process may be triggered by an acute relapse.
A relapse is an emotional, as well as physical, intrusion that is unexpected and unwanted.
The unpredictability of symptoms may cause feelings of being “out of control”.
Anxiety, frustration and fear are also common responses to acute relapses.
Uncertainty about the future is always anxiety provoking and the need to
accommodate variable and even annoying symptoms will impact both the individual
with MS and his/her family. Creating opportunities for discussion of feelings
or the development of alternative plans for adapting to symptoms can change
worrying alone and helplessness to identifying effective coping strategies.
Seeking information from competent resources, taking control of factors within
one’s control and seeking connection with others are primary ways to minimize
the emotional impacts of an acute relapse.
Acute relapses can be frustrating and frightening to families living with MS.
However, timely recognition and management can reduce the effects on overall
quality of life.
Mark Dietz, MD
Patricia Kennedy, RN, ANP, MSCN
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| - reprinted with permision from- The Heuga Center. |
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