What is the recommended treatment for a multiple sclerosis (MS) flare?

Treatment of Multiple Sclerosis Flares

High-dose corticosteroid therapy is the mainstay of treatment for multiple sclerosis flares, typically administered as methylprednisolone 1000-1250 mg daily for 3-5 days either intravenously or orally. 1

First-Line Treatment Options

Corticosteroid Therapy

• High-dose methylprednisolone:

  • Dosage: 1000-1250 mg daily for 3-5 days
  • Can be administered intravenously or orally (equivalent efficacy)
  • Oral administration requires taking multiple tablets (25 tablets of 50mg prednisone) but has shown excellent compliance rates of 94.3% 2
  • Speeds recovery from relapses but does not affect long-term disability or prevent future relapses 3

• Mechanism of action:

  • Decreases inflammatory cytokine cascade
  • Inhibits T-cell activation
  • Reduces immune cell infiltration into CNS
  • Facilitates apoptosis of activated immune cells
  • Decreases cytotoxic effects of inflammatory mediators 4

• Common side effects:

  • Insomnia
  • Mood changes
  • Increased appetite 2

Alternative Dosing

• A lesser high-dose oral methylprednisolone regimen (625 mg/day for 3 days) may be non-inferior to standard high dose (1250 mg/day for 3 days) in terms of clinical and radiological response at 30 days, though the standard high dose provides superior improvement at 7 days 5

Second-Line Treatment Options

Plasma Exchange (Plasmapheresis)

• Indicated for patients with severe MS flares who do not respond adequately to high-dose corticosteroids 1
• Can be used as adjunctive therapy in severe cases 6

Intravenous Immunoglobulin (IVIg)

• May be considered as part of combination therapy for refractory cases 6

Disease-Modifying Therapies (DMTs)

While not specifically for acute flares, DMTs are crucial for preventing future relapses:

• First-line options:

  • Glatiramer acetate: Indicated for relapsing forms of MS 7
  • Interferon beta: Recommended starting dose is 0.0625 mg subcutaneously every other day, with gradual increase to 0.25 mg 8

• High-efficacy options for highly active MS:

  • Natalizumab
  • Ocrelizumab
  • Ofatumumab
  • These reduce annual relapse rates by 29-68% compared to placebo 6

Monitoring and Follow-up

• MRI monitoring is recommended to assess disease activity, even without clinical symptoms 6
• Regular assessment using Expanded Disability Status Scale (EDSS) 6
• Monitor for common side effects of corticosteroid therapy

Important Considerations

• Early identification and treatment during the first 2-10 years of symptom onset is critical to prevent long-term disability 6
• Patients who smoke should be strongly encouraged to quit as smoking can worsen MS progression 1
• Complete hepatitis B vaccination before starting potent MS therapy 6
• Avoid live vaccines during treatment 6

Treatment Algorithm for MS Flares

1. Confirm MS flare: New or worsening neurological symptoms lasting >24 hours without fever or infection
2. First-line: High-dose methylprednisolone (1000-1250 mg daily for 3-5 days)
3. If inadequate response: Consider plasma exchange or IVIg
4. After acute treatment: Evaluate or adjust disease-modifying therapy to prevent future relapses

Early intervention is essential for optimal outcomes, as delaying treatment can lead to worse long-term results and increased disability.