When you receive a call from a patient with MS with worsening of their neurological symptoms or having new neurological deficits developing over few hours to days, consider a relapse.
It is important that you exclude infections particularly urinary tract infections as they are relatively common in patients with MS and can mimic the symptoms of a relapse (pseudo-relapse). The patient can drop off a urine sample at the surgery for testing and then treat if necessary. You might find it useful if you have already prescribed Multistix tests to your MS patients for home testing.
If they test negative and their symptoms are distressing and/or impacting on their activities of daily living consider Methylprednisolone (Medrone, 100mg tablets), 500mg daily for 5 days, taken in the morning with food with PPI cover (for those at risk from peptic ulcer disease, gastritis or who are taking regular NSAIDs or Warfarin).
Remember that not every relapse requires active treatment. Steroids reduce the duration of the relapse by an average of 13 days and may reduce the severity. They do not alter the long-term outcome. Therefore minor and sensory relapses do not require steroid treatment.
Admission to hospital is not required unless the relapse is sufficiently severe that your patient is unable to manage at home with the maximum support available. In this situation they will need to be referred to the on-call medical team.
A second course of steroids for the same relapse is usually not required, however if your patient’s condition continues to deteriorate, consider a discussion with your local neurologist for further management.
Avoid frequent (more than three per year) or prolonged courses of steroids. If your patient required large cumulative doses of steroids their risk of osteoporosis should be considered. For diabetics on Insulin, encourage them to closely monitor their blood sugar during the steroid treatment. Those with brittle diabetes might need admission to hospital so consider a discussion with your local on duty medical team. Steroid therapy should be avoided during the first trimester of pregnancy. If treatment is needed, again consider a discussion with your local neurologist or obstetrician.
Encourage your patient to contact their MS nurse if available otherwise update their neurologist about the relapse. The patient will benefit from having their treatment reviewed to try to prevent further relapses and progression of their disease.
I suggest arranging a virtual follow up in a week or so to check on them, assess their needs and consider referral to social services and further rehabilitation if required. Reassure your patient reminding them that significant recovery can be expected within 2-3 months but some residual disability can occur following 30-50% of all relapses.
Key Points:
- MS Relapse usually occurs over few hours to days and lasts for weeks to months
- Exclude infection and treat, prior to considering steroids
- Methylprednisolone 500mg daily for 5 days regardless of weight is considered early if the relapse is distressing and/or severe enough to impact on ADL
- Always seek advice from secondary care colleagues if required
- Follow up patients to manage further needs
Other resources:
- www.nice.org.uk/guidance/cg186
- www.mssociety.org.uk/about-ms/types-of-ms/relapsing-remitting-ms/managing-relapses
- www.nhs.uk/conditions/multiple-sclerosis
Dr Nassif Mansour is a GPwER in neurology and chair of the Primary Care and Community Neurology Society
