When should a Multiple Sclerosis (MS) flare be treated?

When to Treat a Multiple Sclerosis Flare

MS flares should be treated when they cause functional impairment or significant symptoms that affect quality of life, with high-dose corticosteroids being the primary treatment for acute exacerbations.

Definition and Recognition of MS Flares

A flare (relapse or exacerbation) in MS is characterized by:

• New or worsening neurological symptoms
• Symptoms that develop over days to weeks
• Symptoms that persist for at least 24 hours
• Symptoms that occur in the absence of fever or infection

Criteria for Treatment

Treatment is indicated when a flare meets the following criteria:

1. Functional impairment: The flare causes significant disruption to daily activities or mobility
2. Symptom severity: Symptoms are moderate to severe and affect quality of life
3. Objective findings: Demonstrable neurological deficits on examination

Treatment Protocol

First-Line Treatment

• High-dose corticosteroids: The standard treatment for acute MS flares 1, 2
  • Intravenous methylprednisolone: 1000 mg daily for 3-5 days 1
  • Alternative: Oral prednisone 1250 mg daily for 3-5 days (equivalent dose)
  • For pediatric patients: 0.5-1.6 mg/kg/day of methylprednisolone 1

Treatment Considerations

• Treatment should be initiated promptly after confirming the flare
• No tapering is required for short-course, high-dose therapy 1, 2
• MRI may be used to confirm inflammatory activity but is not required before treatment 3

Monitoring Response

• Clinical reassessment should occur 2-4 weeks after treatment
• Follow-up MRI may be considered to evaluate treatment response 3
• Regular MRI monitoring (at least annually) is recommended for disease monitoring 3

Special Considerations

Mild Symptoms

• Flares with mild symptoms that don't affect function may be observed without treatment
• Symptomatic management may be sufficient for these cases

Severe or Refractory Symptoms

• For severe flares not responding to standard corticosteroid treatment:
  • Consider extended corticosteroid course
  • Plasma exchange may be considered in steroid-refractory cases

Pseudo-flares

• Temporary worsening of symptoms due to heat, infection, or stress should not be treated with corticosteroids
• Treat the underlying trigger instead

Potential Side Effects of Treatment

• Common side effects of high-dose corticosteroids include:

  • Insomnia
  • Mood changes
  • Metallic taste
  • Increased appetite
  • Elevated blood glucose
  • Fluid retention

• Monitor for these side effects, especially in patients with diabetes, hypertension, or psychiatric conditions

Important Caveats

1. Distinguish true flares from pseudo-flares (temporary worsening due to heat, infection)
2. Not all symptoms require treatment with corticosteroids
3. Frequent flares may indicate need for change in disease-modifying therapy
4. Chronic steroid use should be avoided due to serious side effects 3

By following these guidelines, clinicians can appropriately identify and treat MS flares that require intervention while avoiding unnecessary treatment for milder symptoms or pseudo-flares.