Management of MS relapses discussed

Relapses associated with multiple sclerosis (MS) should not be relied upon to monitor disease activity, according to a presentation at the recent Neurology Update meeting.

Consultant Neurologist in the Royal Victoria Hospital (RVH), Belfast, Dr Stella Hughes conveyed this message during her talk, which was entitled “MS Relapses – Dos and Don’ts”.

While she said that relapses can be a useful marker of disease, there should be limits to how this marker is employed.

In terms of “Don’ts”, Dr Hughes said consultants should not: Assume that relapses are not costly to patients; accept or ignore relapses; discount relapses due to age or disease duration; or ignore lifestyle factors.

In terms of “Dos”, she said it was important to: Educate patients; confirm relapses clinically; repeat MR imaging; have disease modifying treatment multi-disciplinary meetings; and consider the prognostic value of the relapse.

“Relapses are indicative of acute and possibly chronic disease activity and can indicate later disease severity early on,” according to Dr Hughes.

With increasing disease duration, she said, however, that the effect of relapses was “unclear”.

While the use of corticosteroids can accelerate recovery, their long-term benefit has not been established.

It was important to abide by guidelines, which state patients with MS should not be given a “supply to steroids to self-administer at home for future relapses”.

For severe, steroid-unresponsive relapses options include: Plasma exchange; IVIG immunoglobulin; and rituximab.

Dr Hughes also pointed to the Association of British Neurologists revised (2015) guidelines for prescribing disease-modifying treatments in MS, which state: “It is not yet clear whether treatment should aim for a target such as ‘no evidence of disease activity – either clinical or radiological’ and ‘whether a single relapse should trigger an immediate treatment escalation is not known’.”

In an earlier presentation, Consultant Neurosugeon in RVH, Belfast, Mr Neil Simms delivered a talk on ‘Subarachnoid Haemorrhage (SAH) – diagnosis, investigation, and treatment’. According to Mr Simms, the incidence of SAH is falling, while the mortality from SAH in patients who reach hospital is  now 33 per cent.

“More elderly SAH patients are being transferred/treated, which has an impact on bed days,” Mr Simms told delegates.

In relation to flow diversion, he said the procedure “appears to be a safe treatment option in the management of selected acutely ruptured aneurysms”.

He also said there is a need to explore the anecdotal observation that patients who have had acute shunt and antiplatelets are better clinically at three-month review.

Other talks at the update meeting related to neurogenetics; hereditary cerebral amyloid angiopathy; and evidence-based management of status epilepticus.