From the Guidelines
The most appropriate treatment for an acute multiple sclerosis relapse characterized by weakness and severe spasticity is high-dose intravenous methylprednisolone (1,000 mg daily for at least three days). This treatment approach is supported by the most recent and highest quality studies, which prioritize reducing inflammation and suppressing immune responses that damage myelin in MS, thereby shortening the duration and severity of the relapse 1.
Treatment Options
- High-dose intravenous methylprednisolone is the preferred treatment for acute MS relapses, as it has been shown to be effective in reducing inflammation and improving symptoms 1.
- For patients who cannot tolerate or do not respond to IV steroids, alternative treatments such as ACTH (adrenocorticotropic hormone) or plasma exchange may be considered.
- To specifically address the severe spasticity component, additional symptomatic treatments such as baclofen, tizanidine, or diazepam may be prescribed concurrently.
- Physical therapy should also be initiated promptly to maintain range of motion and prevent contractures.
Rationale
The use of high-dose intravenous methylprednisolone is supported by recent studies, including those published in 2025, which endorse its effectiveness in treating relapsing-remitting MS 1. While other treatment options, such as autologous haematopoietic stem cell transplantation, may be considered for selected indications, high-dose corticosteroids remain the first-line treatment for acute MS relapses.
Symptomatic Treatment
For severe spasticity, symptomatic treatments such as baclofen (starting at 5 mg three times daily and gradually increasing to 20-25 mg three times daily as tolerated), tizanidine (2-4 mg every 6-8 hours, maximum 36 mg/day), or diazepam (2-10 mg daily in divided doses) may be prescribed concurrently, as supported by earlier studies 1. However, the primary focus should be on reducing inflammation and suppressing immune responses with high-dose corticosteroids.
From the FDA Drug Label
Dimethyl fumarate is indicated for the treatment of relapsing forms of multiple sclerosis (MS), to include clinically isolated syndrome, relapsing-remitting disease, and active secondary progressive disease, in adults.
The most appropriate treatment for an acute multiple sclerosis (MS) relapse characterized by weakness and severe spasticity is High-dose intravenous methylprednisolone (1,000 mg daily for at least three days).
- Dimethyl Fumarate (Tecfidera) is used for the treatment of relapsing forms of MS, but it is not typically used for the treatment of an acute attack/relapse of MS.
- Baclofen may be used to treat severe spasticity, but it is not typically used to treat an acute attack/relapse of MS.
- The FDA drug label for Dimethyl Fumarate does not provide information on the use of IV immunoglobulin, Tizanidine, Ocrelizumab, or Amantadine for the treatment of an acute MS relapse. 2
From the Research
Treatment Options for Acute MS Relapse
The treatment of an acute multiple sclerosis (MS) relapse characterized by weakness and severe spasticity involves the use of corticosteroids to reduce inflammation and hasten recovery.
- High-dose intravenous methylprednisolone is a commonly used treatment for acute MS relapses, as seen in studies 3, 4, 5.
- The dosage of 1,000 mg daily for at least three days is a standard regimen for treating acute relapses in MS, as mentioned in the question options.
- Oral methylprednisolone has also been compared to intravenous methylprednisolone in several studies, with some suggesting that oral steroids may be as effective as intravenous steroids for MS relapses 6, 7.
- However, the optimal dose and route of administration may vary depending on the individual patient and the severity of the relapse.
Comparison of Treatment Options
The provided studies compare the efficacy of different corticosteroid regimens for treating acute MS relapses.
- Study 3 found no significant difference between oral and intravenous methylprednisolone in promoting recovery from acute relapses in MS.
- Study 4 suggested that intravenous methylprednisolone produces a more rapid clinical improvement than ACTH, but confers no longer-term benefit.
- Study 5 found that high-dose intravenous methylprednisolone is a safe alternative to ACTH in the management of acute relapse in MS.
- Study 6 concluded that oral and intravenous steroids for MS relapses may have similar clinical, radiological, and pharmacological outcomes.
- Study 7 compared two high doses of oral methylprednisolone and found that a lesser high-dose regimen may not be inferior to the standard high dose in terms of clinical and radiological response.
Answer to the Question
Based on the provided studies, the most appropriate treatment for an acute MS relapse characterized by weakness and severe spasticity is high-dose intravenous methylprednisolone, as mentioned in option B.