Acute Management of Multiple Sclerosis Relapse
The acute management of this patient presenting with MS relapse (acute weakness, lower extremity ataxia, and hyperreflexia) requires pulse-dose corticosteroids (Answer B). This represents an acute exacerbation requiring immediate high-dose intravenous corticosteroid therapy to speed resolution of the relapse.
Rationale for Pulse-Dose Corticosteroids
High-dose intravenous methylprednisolone is the standard treatment for acute MS relapses, with the established regimen being 160 mg daily for one week 1. The FDA-approved dosing for acute MS exacerbations specifically states that "daily doses of 160 mg of methylprednisolone for a week followed by 64 mg every other day for 1 month have been shown to be effective" 1.
- Corticosteroids are the mainstay of treatment for acute MS attacks and work by reducing inflammation and speeding recovery from relapses 2, 3
- The mechanism involves suppressing the autoimmune inflammatory response targeting CNS myelin 4, 5
- Clinical trials have demonstrated that high-dose corticosteroids are effective in speeding the resolution of acute MS exacerbations 1, 2
Why Not the Other Options
Low-dose corticosteroids (Option A) are inadequate for acute MS relapses. The evidence specifically supports high-dose pulse therapy, not low-dose regimens 1, 5. Low doses would not provide sufficient anti-inflammatory effect to address the acute demyelinating attack.
Baclofen (Option C) is not appropriate for acute management of MS relapses. While baclofen may be used for chronic spasticity management in MS patients, it does not address the underlying inflammatory process of an acute relapse 3. The patient's hyperreflexia is a sign of upper motor neuron involvement from active demyelination, not chronic spasticity requiring muscle relaxants.
Tolterodine (Option D) is an anticholinergic medication used for bladder dysfunction in MS patients but has no role in treating acute relapses 3. It addresses a chronic symptom, not the acute inflammatory demyelination causing this patient's weakness and ataxia.
Clinical Presentation Confirms Acute Relapse
This patient's presentation is characteristic of an acute MS relapse:
- Acute onset of new neurological symptoms (weakness and ataxia) developing over days 5, 6
- Upper motor neuron signs (hyperreflexia) indicating CNS white matter involvement 7, 6
- Lower extremity involvement with ataxia suggesting spinal cord or cerebellar pathway demyelination 6
Administration Protocol
Intravenous methylprednisolone should be administered as follows:
- Dose: 160 mg daily (or alternatively, 1 gram daily for 3-5 days is commonly used in practice) 1
- Route: Intravenous administration preferred for initial emergency use 1
- Duration: Typically 3-7 days of high-dose therapy 1, 3
- May be followed by: Oral prednisone taper (64 mg every other day for 1 month) 1
Monitoring Considerations
- Patients should be monitored for corticosteroid adverse effects including hyperglycemia (particularly important given this patient's diabetes), hypertension, mood changes, and infection risk 1
- Blood glucose monitoring is essential in this diabetic patient receiving high-dose steroids 1
- Blood pressure should be monitored given the patient's hypertension history 1
Steroid-Refractory Cases
If the patient fails to respond adequately to high-dose corticosteroids, plasma exchange (plasmapheresis) should be considered as second-line therapy 3, 5. This is reserved for severe relapses that do not improve with standard corticosteroid treatment 3.
Important Caveats
- Corticosteroids speed recovery from acute relapses but do not alter the long-term course or ultimate outcome of MS 1, 2
- The goal is to reduce acute inflammation and accelerate recovery, not to prevent future relapses (which requires disease-modifying therapy) 4, 5
- This patient will need evaluation for initiation or optimization of disease-modifying therapy after the acute relapse is treated 4, 5