Multiple Sclerosis (MS): Disease monitoring
How to recognize MS relapse
Relapse in MS, also called exacerbation, attack or flare-up, is a deterioration in the patient’s symptom status – either through occurrence of new symptoms or exacerbation of pre- existing symptoms1.
Clinically defined, a relapse must1:
- Persist for ≥24 hours
- Occur ≥30 days from a previous relapse
- Occur in the absence of infection or other causes
Heterogeneity in both type and severity of symptom presentation makes a comprehensive overview of symptoms related to relapse difficult to obtain1. Symptoms of a relapse may be mild (e.g. fatigue) or debilitating (e.g. optic neuritis). Isolated symptoms may indicate a relapse in a single central nervous system (CNS) region, while co-occurring diverse symptoms may suggest relapse across disparate regions of inflammation. Inflammation underlies the disease process in MS and relapses are a direct result of the immune system attacking the CNS, promoting inflammation-induced myelin degradation1. Degradation of myelin, which normally protects our nerve fibers, prevents effective transmission of nerve signals – resulting in MS symptoms1.
Indicators of MS disease activity
Disease activity should be monitored both clinically and sub-clinically2. Neurological reserve can be affected by any damage to the CNS, even when it does not lead directly to visible symptoms such as disability progression or a relapse. Therefore, it is important to consider all indicators of disease activity, not only the visible ones. Examples of sub-clinical parameters for disease activity are new lesions on magnetic resonance imaging (MRI) or brain atrophy2.
Demyelination - The neuron on the left shows a healthy myelinated axon, while the neuron on the right shows an axon with damaged or missing myelin sheaths
Patient–physician partnership
Discussions between patient and physician should include patient views on treatment options and their personal treatment goals2. Patients may not always report symptom appearance or exacerbations; 46% of patients in a UK survey did not report a relapse3, mainly because they deemed the symptoms too mild to inform their clinician or felt that it would be futile to do so. On the other hand, studies have consistently shown a correlation between relapses in the first few years of MS and later levels of disability, demonstrating the importance of effective monitoring and reporting of symptoms and relapses2.
Consider the importance of in-depth evaluation of patient status to inform treatment plans and translate research evidence into effective clinical care in this video ‘First do no harm – The gap between what we know and what we do’.
The gap between what we know and what we do
Consider the importance of in-depth evaluation of patient status to inform treatment plans and translate research evidence into effective clinical care in this video
References
- Managing relapses in multiple sclerosis. Accessed at: https://www.nationalmssociety.org/managing-ms/treating-ms/managing-relapses
- Giovannoni G, Butzkueven H, Dhib-Jalbut S, Hobart J, Kobelt G, Pepper G, Sormani MP, Thalheim C, Traboulsee A, Vollmer T. Brain health: Time matters in multiple sclerosis. Accessed at: https://www.msbrainhealth.org/recommendations/brain-health-report/
- Duddy M, Lee M, Pearson O, Nikfekr E, Chaudhuri A, Percival F, Roberts M, Whitlock C. The UK patient experience of relapse in multiple sclerosis treated with first disease modifying therapies. Mult Scler Relat Disord 2014; 3(4): 450–456. doi: 10.1016/j.msard.2014.02.0
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