A relapse (also known as a flare up or exacerbation) is treated with the primary goal of reducing inflammation and speeding up the recovery process. In clinical practice, not every relapse requires medical intervention; mild sensory changes like tingling or minor fatigue are often monitored to see if they resolve on their own. However, if a relapse impacts your daily functioning, such as affecting your vision or mobility, medical treatment becomes necessary. The current clinical standard focuses on high dose corticosteroids as the first line of defence. While these treatments do not change the long term course of the disease, they are effective at shortening the duration of an attack and helping you return to your baseline function more quickly.
What we will discuss in this article
- Distinguishing a true relapse from a pseudo relapse
- The role of high dose corticosteroids in acute treatment
- Alternative therapies like plasma exchange and ACTH
- Rehabilitation strategies to restore functional independence
- Monitoring for infections before starting treatment
- Modern updates on natalizumab biosimilars for relapse prevention
- Emergency guidance for severe or life threatening relapses
Confirming a true relapse
Before treatment begins, a clinician must ensure that the symptoms represent a true new inflammatory event.
A true relapse is defined as the appearance of new neurological symptoms or the worsening of old ones that last for at least 24 hours and occur at least 30 days after any previous attack. Clinicians must first rule out a pseudo relapse, which is a temporary worsening of symptoms caused by external factors like heat, stress, or an underlying infection (such as a urinary tract infection). It is standard procedure to screen for infections via blood or urine tests before starting any anti-inflammatory treatment, as steroids can worsen an existing infection.
High dose corticosteroids: The first line
Corticosteroids are the mainstay of acute relapse management, used to rapidly calm the immune system and close a leaky blood brain barrier.
The standard treatment involves a short course (typically 3 to 5 days) of high dose steroids. Two primary methods are used:
- Intravenous (IV) Infusion: Usually 1,000 mg of methylprednisolone administered daily in a hospital or clinic setting.
- High Dose Oral Tablets: Clinical research has shown that a high dose of oral steroids (such as 500 mg to 1,250 mg daily) is clinically equivalent to IV treatment in terms of recovery speed and safety.
These medications reduce the swelling around the nerve fibres, allowing signals to pass through more effectively. Common temporary side effects include metallic taste, difficulty sleeping, mood changes, and increased appetite.
Treatments for severe or resistant relapses
If a relapse is particularly severe or does not respond to initial steroid treatment, specialized alternatives are available.
Plasma Exchange (Plasmapheresis)
For relapses that cause significant disability (such as loss of vision or inability to walk) and do not improve with steroids, plasma exchange may be used. This process involves a machine that filters your blood to remove the specific antibodies thought to be attacking the nervous system. The cleaned blood is then returned to your body.
ACTH (Adrenocorticotropic Hormone)
This is an injectable medication that stimulates the body’s own adrenal glands to produce natural steroid hormones. While less common than synthetic steroids, it remains an option for patients who cannot tolerate or do not respond to traditional corticosteroid therapy.
Rehabilitation and long term follow up
The treatment of a relapse does not end when the medication course is finished; rehabilitation is a vital part of the recovery phase.
Once the acute inflammation is controlled, a multidisciplinary team (including physiotherapists and occupational therapists) works with the patient to restore lost strength and balance. There is a strong clinical focus on the use of personalised exercise programs and cognitive rehabilitation to address the lingering effects of an attack. Additionally, experiencing a relapse often prompts a neurology review to see if your current long-term disease-modifying therapy (DMT) needs to be changed to a higher efficacy option, such as a natalizumab biosimilar, to prevent future flares.
Emergency guidance
Most relapses can be managed in an outpatient setting, but some situations require immediate emergency care.
Seek immediate medical assessment if you experience a sudden and total loss of vision in both eyes, a rapid onset of severe weakness that prevents breathing or swallowing, or a sudden change in mental status.
Seek urgent medical advice if you notice:
- A total inability to walk that develops over a few hours
- A sudden loss of bladder or bowel control
- High fever or signs of a severe infection while experiencing neurological changes
- Severe psychiatric symptoms, such as mania or suicidal thoughts, after starting steroids
- Extreme, sharp pain in the spine or limbs that prevents all movement
To summarise
Relapses of Multiple Sclerosis are primarily treated with high dose corticosteroids, either through an IV drip or oral tablets, to speed up recovery and reduce inflammation. For severe cases that do not respond to steroids, plasma exchange offers a powerful alternative to reset the immune environment. A critical part of the process is ruling out pseudo relapses caused by infection and utilising rehabilitation to regain functional independence. While the treatment of a relapse focuses on the immediate event, it also serves as a catalyst for reviewing long term management plans to ensure you are on the most effective therapy to protect your future health.
Will steroids fix the damage permanently?
Steroids help you recover from a relapse faster, but they do not change the underlying long term damage or prevent future attacks.
Why did my doctor say I do not need treatment for my relapse?
If your symptoms are mild (like slight numbness) and not affecting your daily safety or work, the risks and side effects of high dose steroids may outweigh the benefits.
How many times a year can I have steroids?
To protect your bone health and reduce the risk of cataracts or diabetes, clinicians generally advise no more than 2 or 3 courses of high dose steroids per year.
What is a pseudo relapse?
This is a temporary flare of old symptoms caused by things like a fever, hot weather, or an infection. Once the trigger is removed (e.g., the infection is treated), the symptoms usually improve.
Can I have treatment at home?
Yes. Many health systems offer services where an MS nurse can administer IV steroids or provide high dose oral tablets for you to take at home.
Does a relapse mean my medication is not working?
Not necessarily, but it is a sign that should be discussed with your neurologist. One relapse might be a blip, but repeated flares often mean it is time to switch to a more potent therapy.
How long does it take to recover from a relapse?
Recovery is different for everyone. While the initial flare might last a few days, the full recovery process through rehabilitation can take several weeks or even months.
Authority Snapshot
This article was reviewed by Dr. Stefan Petrov, a UK trained physician with an MBBS and extensive experience in general medicine, surgery, and emergency care. Dr. Petrov has worked in intensive care units and has a strong background in performing diagnostic and therapeutic procedures. He is dedicated to medical education and providing evidence based health content to help patients navigate and manage acute neurological events with confidence.
