An exacerbation (known as relapse, flare-up, or episode) is defined as new or returning neurological symptoms that have evolved over at least 24-48 hours and have not been provoked by a metabolic cause – such as a fever. Exacerbations can interrupt the ability to function, thus the goal of treatment is to accelerate recovery.
For acute exacerbations of symptoms, steroids are sometimes prescribed to shorten the duration and severity of the attack. These are not the same steroids that we hear about in the news with professional athletes.
The steroids used in MS treatment are known as glucocorticoids. Glucocorticoids reduce inflammation and are used in various illnesses and conditions (such as allergic reactions and asthma). The use of steroids in MS usually involves intravenous (through a vein in the arm) methylprednisolone given once a day for three-to-five days. Sometimes the intravenous steroid is followed with steroid pills, given in a tapering dose for an additional 1-2 weeks.
Over the past 17 years, seven preventive treatments have been FDA approved to reduce the frequency and severity of multiple sclerosis exacerbations or to treat worsening MS. Briefly, these treatments include:
- Interferon beta-1a – a beta interferon which is given once a week by intramuscular injection, or a beta interferon given 3 times a week by injection under the skin.
- Interferon beta-1b – another form of beta interferon which may be given every other day by injection under the skin. The frequency will depend on the specific therapy.
- Interferon betas all work by the same mechanism which is to inhibit certain immune system cells and processes so that the inflammatory process known to occur in MS is reduced.
- Interferon betas are known to cause various side effects. Usually these include: redness and mild discomfort at the injection site, flu-like symptoms including fever, chills, achiness and fatigue and changes in liver function. Blood for safety testing must be obtained every several months while someone is taking an interferon. Other side effects such as depression and changes in menstrual cycle may also occur.
- Glatiramer acetate – a synthetic protein that is structurally similar to a component of myelin. This is given daily by injection under the skin.
- Glatiramer acetate is thought to work by inducing the immune system to produce more anti-inflammation immune cells which will then help to reduce the inflammation that is seen in MS.
- Glatiramer acetate produces various side effects including injection site redness, itching, and swelling. Also a small number of people may experience a brief “post injection reaction” that includes flushing, racing of the heart, a feeling of faintness and shortness of breath.
The interferons and glatiramer acetate are all given by injection (shots). Education programs have been developed to help patients and family members learn to inject these medications.
- Natalizumab – a monoclonal antibody that is given by intravenous (through a vein in the arm) once every 4 weeks.
- Natalizumab works by blocking the ability of immune cells known as lymphocytes from entering the central nervous system (brain and spinal cord)
- Natalizumab has been associated with a rare, serious and potentially fatal infection of the brain known as PML (progressive multifocal leukoencephalopathy)
- Mitoxantrone – a chemotherapy drug indicated for worsening forms of relapsing MS and secondary progressive MS. It is given by intravenous infusion every 3 months. Because this drug can be very toxic, it can only be given in a limited number of doses over the course of someone’s life.
- Mitoxantrone works by suppressing the immune system and reducing the overall numbers of immune cells that could be causing inflammation in MS
- Mitoxantrone is associated with many side effects including cardiotoxicity
As the inflammation and damage from multiple sclerosis can interrupt normal nerve transmission in the brain and spinal cord, many symptoms can occur. Some of these may be transient and some may become permanent. Management of symptoms requires good communication between the patient and the MS provider, persistence, and often the expertise of multiple specialists. The major goals of symptom management are to maintain independent function and improve quality of life.
Although medications are available to help with many symptoms, medications may be only part of the answer. Often, rehabilitation strategies such as physical therapy and occupational therapy are very helpful in improving and maintaining normal function. Consultation with specialists such as urologists, psychiatrists, and pain management specialists may be extremely helpful. Changes in mobility may require a specialist in orthotics as well as the physical and occupational therapist.
A coordinated, comprehensive, interdisciplinary approach to MS care is the best approach for the long-term management of multiple sclerosis.
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