How to Manage Multiple Sclerosis (MS) Relapses

When a person has multiple sclerosis (MS), their immune system mistakenly attacks the protective myelin sheath that covers the nerves in the central nervous system. This damages nerves in the brain and spinal cord, causing symptoms like vision loss, stiff muscles, and/or fatigue. But not every case of MS is the same, as nerves are affected in different ways, resulting in a variety of symptoms.

Most people with MS—roughly 85% of patients—are initially diagnosed with relapsing-remitting MS, a form of the disease in which flare-ups, or relapses, of neurological symptoms, such as muscle weakness, balance problems, or vertigo, occur. Then, after a period of time, their symptoms partially or completely resolve, or go into remission. The frequency of relapses varies, ranging from less than one relapse per year to more than two relapses per year.

Other less common forms of MS include primary progressive MS and secondary progressive MS. In the former, patients experience ongoing neurological symptoms and the progression of disability from the time they’re diagnosed, without initial periods of relapses and remissions. In the latter, patients initially diagnosed with relapsing-remitting MS start to experience a constant worsening of symptoms over time, rather than having intermittent symptoms. The diagnosis changes from relapsing-remitting to secondary progressive MS.

The good news is that there are newer MS treatments that can help patients experience fewer relapses and less disability. Medicines that deplete circulating B cells (more on that below), such as ocrelizumab (brand name: Ocrevus®) and ofatumumab (brand name: Kesimpta®), can prevent relapses and are thought to slow the progression of the disease. (Ocrevus received Food and Drug Administration [FDA] approval in 2017; Kesimpta was FDA-approved in 2020.)

“We’ve reached a very interesting new stage in the treatment of MS,” says David A. Hafler, MD, an MS expert and chair of the Department of Neurology at Yale School of Medicine. “We have an incredibly effective treatment if it is used early in the course of the disease.”

We talk more with Dr. Hafler about how to recognize an MS relapse and what to do about it.

During MS relapses, self-reactive immune T cells wrongly attack the myelin sheath that surrounds nerves in the brain and spinal cord. This causes inflammation and harm to the myelin and the nerves. The damage interrupts messages the brain sends through the nervous system to different parts of the body. It also causes scars (lesions) in the brain and/or spinal cord.

MS relapses may cause a variety of symptoms, including:

• Numbness, weakness, or tingling in the arms or legs
• Difficulty walking or maintaining balance
• Fatigue
• Vertigo
• Stiffness or muscle spasticity
• Vision problems, including blurred vision, double vision, or temporary vision loss
• Cognitive problems
• Bladder or bowel dysfunction problems, such as urinary frequency or urgency, constipation, and loss of bladder or bowel control

Patients with relapsing-remitting disease who experience common MS symptoms will likely know that they’re having a relapse based on how they’re feeling.

However, some relapses are silent, especially early in the course of the disease. These relapses may damage the myelin and cause new lesions without perceived symptoms or disability. Silent relapses can be detected by magnetic resonance imaging (MRI), which may be recommended periodically for patients who have recently been diagnosed with the disease.

“If you do MRIs looking for new lesions at the beginning of the disease, lesions are occurring all the time,” Dr. Hafler says. “You could go years with this happening and not have an ‘attack’ or relapse. It’s only when you have a lesion in a part of the brain—like the optic nerve, the spinal cord, or the brainstem—where there’s a lot going on in a small area, that you have this so-called ‘clinical relapse’ with accompanying symptoms.”

When patients with relapsing-remitting MS experience flare-ups, doctors may prescribe intravenous corticosteroids. These powerful medications help reduce inflammation in the body and shorten the duration of exacerbations, but they do not have a long-term benefit for treating the disease.

When patients with relapsing-remitting MS are diagnosed, they are prescribed medications to take regularly to decrease the risk of relapses. For many years, doctors prescribed immunomodulatory drugs, such as beta interferons and Copaxone®. These medications modulated the immune system, but had only mild effects in terms of stopping disease flare-ups.

In recent years, neurologists have turned to more effective treatments that target different white blood cells in the immune system—known as B cells. B cells and T cells normally protect the body. When people have MS, it is now thought that B cells activate the T cells, which damage the myelin. Treatments, known as monoclonal antibodies, are used to deplete the B cells, limiting damage to the myelin. Doctors often prescribe Ocrevus, which is given by infusion twice a year, or Kesimpta, which is given under the skin each month.

“If you deplete the circulating B cells, it’s 98% effective in stopping relapses. Neurologists now typically prescribe B cell-depleting monoclonal antibodies to patients who are newly diagnosed with MS; we basically treat everyone with Ocrevus or its equivalent. The best thing to do is treat patients before they have any clinical symptoms," Dr. Hafler says. "For example, let’s say there is a patient who has a headache or minor head trauma and gets an MRI. If we see lesions on the MRI that look like MS, we would do a spinal tap, and if that shows inflammation, we could then diagnose them with MS and start treatment.”

For patients with pre-existing relapsing-remitting MS who have taken other drugs for years, doctors may choose to keep them on their existing medication regimen. “If you're doing well on the drug you’ve been on for a long time, then we typically continue that drug, but we still monitor you very closely,” Dr. Hafler says.

B cell-depleting drugs, such as ocrelizumab, have also been successful in slowing the accrual of disability in patients with primary progressive MS and secondary progressive MS, adds Dr. Hafler.

“We’ve been very effective in stopping the inflammatory part of MS and the attacks, but it will take decades to know how effective early treatment is in preventing the progression of the disease,” Dr. Hafler says.

Certain habits may help patients with relapsing-remitting MS manage their health:

• Adopt a healthy diet. Doctors who treat patients with MS recommend a low-fat, low-salt diet. “A low-salt diet helps because research shows that salt is highly inflammatory,” Dr. Hafler says.
• Exercise. Getting 30 minutes of physical activity at least five times a week may help patients feel stronger, improve their sense of balance, increase flexibility, and minimize stiffness.
• Quit smoking. Cigarette smoking isn’t healthy for anyone, but it’s especially harmful for MS patients. Smoking may increase inflammation in the body and cause the disease to progress more quickly.
• Seek physical therapy as needed. Some patients with relapsing-remitting MS benefit from physical therapy, “particularly patients developing disabilities,” Dr. Hafler says.

When patients with relapsing-remitting MS begin taking medication soon after their diagnosis, they’re more likely to have fewer relapses and less disability from the disease.

Often, patients with suspected MS must wait several months before they’re able to get an appointment with a neurologist for a definitive diagnosis. This significantly delays the start of their treatment.

“The Yale Multiple Sclerosis Center’s MS Access Program helps patients with suspected MS get diagnosed and treated as soon as possible,” says Dr. Hafler. “Physicians can contact the program to refer patients when MRI results suggest that MS is present. Anyone who contacts us with a positive MRI and new onset will be seen within 24 hours. We rush to get them in, work them up, and get them on the B-cell depletion therapy. It’s the only drug we use in our clinic. We’re changing the course of the disease.”

The message is that the earlier you treat, the better the outcome, he adds. “The key is early diagnosis, early treatment,” Dr. Hafler says.