Management

Patients with MS may present with symptom changes due to:

• Another illness (eg. infection)
• Further relapse
• Change of disease of status

To manage patients with MS, a Coordinated multidisciplinary approach is recommended and should consist of:

• Consultant neurologists
• MS nurses
• Physiotherapists and occupational therapists
• Speech and language therapists, psychologists, dietitians, social care and continence specialists
• GPs

A single point of contact should be designated to coordinate care & help access services for MS patients and they should be informed when MS patients present with symptom changes.

It is recommended that an agreed care plan to manage significant symptom changes in MS patients should be in place.

The goals of medical management of MS are to:

• Delay onset of further symptoms
• Slow disease progression
• Relieve symptoms of the presenting features
• Reduce complications associated with an acute exacerbation

Relieving symptoms and reducing complications are the focus of management of MS in the ED.

Management of initial presentations

disseminating acute encephalitis

The focus is to stabilise acute life-threatening conditions, initiate supportive care and seizure precautions and monitor for increasing intracranial pressure (ICP).

Other presentations

Acute MS episodes are thought to be secondary to an episode of demyelination. Therefore, treatments that modify the inflammatory process and immune system are used in an attempt to minimise this demyelination.

Any individual who experiences an acute episode (including optic neuritis) sufficient to cause distressing symptoms or a limitation of activity should be offered a course of high-dose corticosteroids [9].

Relapse (Attack/ exacerbation)

A clinical episode with patient reported symptoms and objective findings typical of MS reflecting a focal or multifocal demyelination in the CNS, developing acutely or subacutely, with a duration of atleast 24 hours, with or without recovery and in the absence of fever or infections. When it is the first episode it is Clinically Isolated Syndrome.

Treating acute relapse of MS

1. Under guidance of professionals with expertise in treating MS, since not all relapses need steroids.
2. Oral methylprednisolone 0.5 g daily for 5 days should be offered to patients with relapse.
3. Intravenous methylprednisolone 1 g daily for 3-5 days is an alternative if:
   • oral steroids have failed or not tolerated.
   • Patients requiring admission for a severe relapse or monitoring of medical or psychological conditions such as diabetes or depression.
4. Steroids should not be prescribed at lower doses than methylprednisolone 0.5 g daily for 5 days to treat an acute relapse of MS.
5. Patients with MS should not be a supply with steroids to self-administer at home for future relapses.
6. High-dose steroid prescription should be done after explaining possible temporary effects on mental health (such as depression, confusion and agitation) and worsening of blood glucose control in people with diabetes.

Other treatment options might be considered by specialists which may include diet modification, beta interferon, glatiramer acetate, azathioprine, mitoxantrone, IV IG, plasma exchange, intermittent pulsed methylprednisolone etc.

Management of the complications of MS

Fever: Fever must be reduced to minimise the increased weakness caused by even a small elevation of core temperature. Aim to normalise body temperature with surface cooling and antipyretics.

Infection: Aggressively seek and treat any cause of infection. Urinary tract infections and pyelonephritis must be excluded in any acute exacerbation of MS. A microscopy culture and sensitivities (MC&S) must be sent and antibiotics started if screening dipstick testing suggests a urinary tract infection (UTI).

Urinary retention: Especially in patients with symptoms of UTI, a post-voiding residual volume determination should be made with sterile catheterisation if indicated. Patients may need to be referred for advice on intermittent sterile catheterisation to avoid a long-term indwelling catheter.

Respiratory function: Respiratory infections must be managed aggressively. Endotracheal intubation may be complicated by a higher risk of aspiration.

Autonomic lability: MS patients are at higher risk of hypotension at induction of anaesthesia. Spontaneous ventilation may be disrupted.

Seizures: Seizures should be treated according to the usual algorithms.

Other therapies

Advocates of medical marijuana believe that MS symptoms, especially spasticity, can be improved with the use of cannabis.

However, in randomized trials, cannabinoids have failed to provide consistent improvement in MS-related outcomes [15,16].

New treatments for MS

• Fingolimod (Gilenya) was the first FDA-approved oral DMT. In The TRANSFORMS trial the annualized relapse rate was significantly reduced in fingolimod groups compared with the interferon beta-1a group.
• Dimethyl fumarate another oral treatment, In the CONFIRM and DEFINE trials, an oral formulation of dimethyl fumarate(BG-12) significantly reduced relapse rates and the development of new brain lesions on MRI in patients with active MS.
• Ponesimod was approved by the FDA in March 2021 for the treatment of adults with relapsing forms of MS.