Managing multiple sclerosis (MS) takes a three-pronged approach: treatment strategies to modify the long-term course of the disease, symptom control and relapse management.

Sarah A. Morrow, MD, FRCP(C)

MS is a leading cause of nontraumatic disability for young adults worldwide¹ and it is especially common in Canada — 240 Canadians out of 100,000 live with this chronic neurological disease². Yet, a survey in Southwestern Ontario found that although 92.2% of general practitioners (GPs) treated MS patients, only 43.1% of respondents correctly identified the appropriate treatment, and a mere 16% identified the appropriate dose³. The situation is bleaker still when it comes to managing MS relapses. Specialized care for relapses may be rendered inaccessible to some patients since MS Clinics in Canada are often located at tertiary care centres. Consequently, the task of treating relapses often falls to GPs at community clinics or in emergency departments. However, GPs are often unfamiliar with the approach to a potential relapse in MS patients. To close the gap in MS patient care, the following guidelines and treatment algorithm were developed to help GPs navigate through the diagnosis and treatment of relapses.

The Rundown on Relapses

Of the different forms of MS, 85% of cases present with the relapsing-remitting (RRMS) type⁴, characterized by periods of relapse with possible residual deficit separated in time by quiescent periods. Fifteen percent of cases are slowly progressive from the onset (primary progressive, PPMS), and 50% of RRMS will evolve into a progressive form (secondary progressive, SPMS). Relapses are most prevalent in RRMS although many with a progressive course can also have super-imposed relapses^4,5.

A relapse is defined as a new neurological symptom lasting for more than 24 hours or worsening of neurological symptoms that have been stable for at least 30 days^6,7. Onset of these symptoms may either be acute or subacute. The most common presentations are optic neuritis, brainstem syndromes such as ocular motor syndromes, and acute partial transverse myelitis.

Pseudo-relapse: Eliminate the Possibility

Although the clinical definition is helpful, distinguishing between what is a relapse and what is not can be tricky. In order to diagnose a relapse, it is first necessary to rule out a “pseudo-relapse.” A pseudo-relapse is a neurological worsening caused by an increase in body temperature that is sparked by an underlying infection — which may not yet be symptomatic, an increase in ambient temperature due to a hot shower or a hot/humid environment, or physical or psychological stress. Typically, once the underlying cause of the pseudo-relapse is eliminated, symptoms will resolve.

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Cross Currents is an independent supplementary service offered by Parkhurst Exchange, property of Parkhurst Publishing Ltd. It is designed to provide physicians and other readers with practical information on approaches to patient treatment. The opinions expressed reflect those of the authors, and any statements or recommendations made are not necessarily held by and do not imply endorsement of the Editorial Advisory Board of Parkhurst Exchange, the publisher nor the sponsor funding the distribution. Distribution of this editorial supplement is funded by an educational grant from Teva Neuroscience.

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