Enhancing Multiple Sclerosis Relapse Management Through an Evidence-Based Approach

Counseling Curriculum
Patient Compass

Multiple sclerosis (MS) is a chronic and unpredictable neurologic disorder affecting approximately 2.3 million people worldwide and approximately 900,000 people in the United States, with an average age of onset between 20 and 30 years.1,2 Among the various clinical courses of MS, relapsing-remitting MS (RRMS) is the most common, accounting for approximately 85% of initial diagnoses.1

Relapses, also known as exacerbations or flares, are a defining feature of RRMS and represent episodes of neurologic dysfunction that last for at least 24 hours and can last for as long as several months.3,4 These relapses can be distressing for patients, causing a sudden and often severe worsening of symptoms, impacting their quality of life and potentially leading to increased long-term disability.1,4

The use of disease-modifying therapy (DMT) has been effective in reducing the occurrence of relapses in patients with MS. However, it is crucial to note that DMT is not an acute treatment for managing relapses once they occur. Many patients do not promptly report relapse symptoms to their healthcare providers (HCPs), and studies have revealed that patients are more likely to contact their HCP during severe relapses but are less likely to report mild relapses.4

This article guides HCPs in patient counseling for MS relapse management. By emphasizing clear medical information, empathy, and evidence-based techniques, HCPs empower patients in open communication, better engagement, and improved relapse management.

Importance of Early Communication

Timely reporting of relapse symptoms is of paramount importance in effectively managing MS relapses. However, the Multiple Sclerosis in America 2017 survey revealed that only 47% of patients reported always or often contacting their HCP during a relapse.4 This delay in communication can lead to missed opportunities for early intervention, potentially resulting in prolonged recovery periods and increased risk for permanent neurologic damage.

HCPs must emphasize to their patients the urgency of reporting relapse symptoms promptly. By doing so, patients can benefit from early assessment, appropriate treatment initiation, and a higher likelihood of achieving full or partial recovery. Engaging in open dialogue and encouraging patients to maintain regular communication fosters a partnership in care, allowing HCPs to provide timely support and tailored treatment plans.4

Understanding Relapse Severity

Relapses in MS can vary significantly in their presentation and severity. In a recent study of adult patients with MS who currently use a DMT, patients characterized 38.3% of their relapses as mild, 45.1% as moderate, and 16.6% as severe.4 Each relapse category presents unique challenges for patients and HCPs alike.

HCPs should take the time to educate their patients about relapse severity to encourage them to reach out when a relapse occurs.4 The severity of relapses in MS can be defined as mild, which may involve only slight increases in disability; moderate, which is characterized by more noticeable and impactful symptoms; or severe, which can cause significant disability and functional impairment.5

By providing patients with clear guidelines for identifying and reporting symptoms based on their severity, HCPs can improve patient awareness and facilitate more accurate relapse reporting. Moreover, this empowers patients to actively participate in their care, aiding HCPs in making informed treatment decisions to address each relapse’s specific needs.

Treatment Strategies

Relapsing MS management involves the use of DMTs to reduce relapse occurrence and severity.2

Acute Therapy for Relapses

DMTs are not used to treat relapses directly. Instead, acute therapies such as intravenous corticosteroids or oral corticosteroids are used to manage severe relapses. Repository corticotropin injection can also be prescribed for patients who have not tolerated or responded well to corticosteroids.4

Long-Term Treatments

Injection Treatments

Modern therapies for MS first emerged during the 1990s, marked by the introduction of interferon beta and glatiramer acetate. Preparations of interferons used for the treatment of MS include interferon beta-1a (IFNβ-1a), interferon beta-1b (IFNβ-1b), and pegylated interferon beta-1a (pegylated IFNβ-1a).6,7

Monoclonal Therapies

Monoclonal antibody DMTs include natalizumab, alemtuzumab, ofatumumab, and ocrelizumab. Although monoclonal antibody treatments have higher efficacy than injectable and oral DMTs and have been found to reduce relapse rates, these therapies can cause infusion reactions characterized by headache, nausea, urticaria, pruritus, and flushing, although these side effects can be mitigated by premedications such as antihistamines, antipyretics, and steroids. It should be noted that patients with hepatitis B should not be prescribed ocrelizumab, cladribine, or alemtuzumab due to risk for reactivation.2

Oral DMTs

Fingolimod, teriflunomide, dimethyl fumarate, siponimod, diroximel fumarate, and ozanimod are oral medications that can reduce the incidence of relapses for patients with MS.2 They are reportedly more convenient than injections or infusions.8 Diroximel fumarate is a newer oral medication and has been shown to cause fewer gastrointestinal side effects compared with other medications in its class.9

Explaining Treatment Options and Counseling Techniques for MS Management

In the management of MS relapses, patients may have varying levels of familiarity with these treatment options and their potential benefits and side effects. The Multiple Sclerosis in America 2017 survey indicated that prior conversations between patients and HCPs about management of relapses were the strongest predictors of whether or not a patient would contact their HCP during a relapse.4

Addressing Gaps in Care

Knowledge Deficits

HCPs should identify and address patients’ knowledge gaps and provide sufficient and appropriate information to help patients make informed decisions regarding their care. This may not only improve patient knowledge, but may also improve their sense of control and psychologic well-being, thereby improving their quality of life.10

Treatment Decision Reluctance

Patients with RRMS often have difficulty deciding whether to change their treatments due to uncertainty regarding the effectiveness of new treatments and fears regarding disease progression. There remains a need for patient-centered decision aids that can help support patients with RRMS in making more reasoned and personalized healthcare decisions.11

Counseling Techniques

Having advance discussions with patients with MS regarding relapse management and treatment decisions may positively impact patients’ decision-making abilities and quality of life.4,10 Additionally, the use of a smartphone-based e-diary to collect patient-reported outcomes (PROs) may be helpful. In 1 study examining the use of an e-diary, adherence to the e-diary was high, and changes in e-diary-derived PROs over time predicted clinical MS relapses at the group level, suggesting this may have potential for clinical research and improved MS care in real-world settings.12


Effective patient counseling is essential for managing MS relapses. HCPs must ensure that patients receive comprehensive information about the available treatment options. By presenting evidence-based data about treatment outcomes, potential side effects, and any other relevant considerations, HCPs can empower patients to make informed decisions about their care. Engaging patients in shared decision making improves treatment adherence and fosters a sense of control over their health, leading to more proactive and positive healthcare experiences.4


What Are Multiple Sclerosis Relapses?

Multiple sclerosis (MS) relapses are sudden exacerbations of neurologic disability lasting more than 24 hours, followed by partial or complete remission. Understanding what relapses are and how they manifest helps patients recognize the importance of reporting new or worsening symptoms.

How Can Someone Recognize Relapse Severity?

Differentiate mild, moderate, and severe relapse symptoms and their impact on daily life. Recognizing the severity of a relapse allows patients to communicate effectively with their healthcare practitioner (HCP), enabling timely intervention and appropriate treatment.

Why Is Early Reporting Important?

Stress the importance of promptly reporting relapse symptoms to the HCP. Early reporting enables timely evaluation, intervention, and adjustment of treatment plans, potentially preventing further disability.

What Are Available Relapse Treatments?

Educate patients about common therapies for managing relapses. Knowing available treatment options empowers patients to make informed decisions about their care.

What Are the Risks and Benefits of Treatment Options?

Discuss the potential risks and benefits of different relapse treatments. Patients need to be informed about the possible side effects and the expected benefits in reducing relapse severity and duration to make treatment decisions aligned with their preferences and health goals. Patients should be encouraged to ask questions and express their concerns so that the HCP can provide tailored information that addresses individual needs and preferences.

What Can Be Done to Proactively Manage Relapses?

Emphasize the importance of keeping a symptom diary to track changes and new symptoms. Proactively managing relapses involves early identification and timely reporting, leading to better outcomes and effective disease management. HCPs can also recommend lifestyle changes (eg, stress management, exercise) to positively impact disease course and overall well-being.


1. Ramirez A, Keenan A, Kalau O, Worthington E, Cohen L, Singh S. Prevalence and burden of multiple sclerosis-related fatigue: a systematic literature review. BMC Neurol. 2021;21(1):468. doi:10.1186/s12883-021-02396-1

2. McGinley MP, Goldschmidt CH, Rae-Grant AD. Diagnosis and treatment of multiple sclerosis: a review. JAMA. 2021;325(8):765-779. doi:10.1001/jama.2020.26858.

3. Wang C, Ruiz A, Mao-Draayer Y. Assessment and treatment strategies for a multiple sclerosis relapse. J Immunol Clin Res. 2018;5(1):1032.

4. Waltrip RW, Mahler N, Ahsan A, Herbert LB. Effect of health care providers’ focused discussion and proactive education about relapse management on patient reporting of multiple sclerosis relapse. Int J MS Care. 2021;23(4):151-156. doi:10.7224/1537-2073.2020-018

5. Hosny HS, Shehata HS, Ahmed S, Ramadan I, Abdo SS, Fouad AM. Predictors of severity and outcome of multiple sclerosis relapses. BMC Neurol. 2023;23(1):67. doi:10.1186/s12883-023-03109-6

6. Goodin DS. The use of interferon Beta and glatiramer acetate in multiple sclerosis. Semin Neurol. 2013;33(1):13-25. doi:10.1055/s-0033-1343792

7. Freeman L, Longbrake EE, Coyle PK, Hendin B, Vollmer T. High-efficacy therapies for treatment-naïve individuals with relapsing-remitting multiple sclerosis. CNS Drugs. 2022;36(12):1285-1299. doi:10.1007/s40263-022-00965-7

8. Eagle T, Stuart F, Chua AS, et al. Treatment satisfaction across injectable, infusion, and oral disease-modifying therapies for multiple sclerosis. Mult Scler Relat Disord. 2017;18:196-201. doi:10.1016/j.msard.2017.10.002.

9. Paik J. Diroximel fumarate in relapsing forms of multiple sclerosis: a profile of its use. CNS Drugs. 2021;35(6):691-700. doi:10.1007/s40263-021-00830-z

10. Köpke S, Solari A, Rahn A, Khan F, Heesen C, Giordano A. Information provision for people with multiple sclerosis. Cochrane Database Syst Rev. 2018;10(10):CD008757. doi:10.1002/14651858.CD008757.pub3

11. Manzano A, Eskyté I, Ford HL, et al. Patient perspective on decisions to switch disease-modifying treatments in relapsing-remitting multiple sclerosis. Mult Scler Relat Disord. 2020;46:102507. doi:10.1016/j.msard.2020.102507

12. Golan D, Sagiv S, Glass-Marmor L, Miller A. Mobile-phone-based e-diary derived patient reported outcomes: association with clinical disease activity, psychological status and quality of life of patients with multiple sclerosis. PLoS One. 2021;16(5):e0250647. doi:10.1371/journal.pone.0250647

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Reviewed September 2023