MS Center, Department of Neurology, University of California, 675 Nelson Rising Lane, Box 3206, San Francisco, CA, 94158-3206, USA.
Curr Treat Options Neurol. 2015 Apr;17(4):345. doi: 10.1007/s11940-015-0345-6.
While not all multiple sclerosis (MS) relapses require treatment, relapses that are bothersome or that impair function should prompt consideration of timely treatment to restore function and minimize disability. Patients with suspected MS relapses should be evaluated to confirm the diagnosis, exclude other causes of neurological dysfunction, and identify potential triggers for relapse or pseudo-relapse, such as urinary tract infections, fever, or metabolic derangements. The diagnosis of an MS relapse is clinical, but MRI may be useful for confirmation and to evaluate for multifocal disease activity. High-dose oral or intravenous glucocorticoids, with or without an oral taper, are first-line therapy for MS relapses. Adrenocorticotropic hormone (ACTH) provides an alternative to glucocorticoid treatment but is currently much more expensive and does not have proven superiority. If the acute neurological deficits remain severe after steroid treatment, and particularly if there is persistent abnormal contrast-enhancement of the symptomatic lesion on repeat MRI, plasma exchange (PLEX) should be considered as an acute rescue therapy for relapse. In exceptional cases, particularly fulminant or tumefactive disease that fails to improve following treatment with steroids and PLEX, cytoxic agents such as cyclophosphamide or B cell-depleting regimens such as rituximab may be considered, although risk must be carefully weighed and the kinetics of such regimens indicate that they probably serve more to accelerate remission of disease activity than as an immediate relapse remedy. A single dose of natalizumab given as acute therapy for MS relapse was shown not to improve clinical outcomes in a randomized controlled trial. Attention to symptom management and promotion of neurorehabilitation are important aspects of MS relapse care. Neuroprotective and neuroreparative therapies remain under investigation, but are likely to become important complementary elements of relapse therapy in the future. Relapses serve as important indicators of MS disease activity. In the context of the emerging treatment paradigm of targeting freedom from evidence of MS disease activity, relapses should prompt consideration of transitioning to a disease-modifying treatment that may offer better efficacy.
虽然并非所有多发性硬化症 (MS) 复发都需要治疗，但令人困扰或导致功能受损的复发应促使及时考虑治疗，以恢复功能并最大程度减少残疾。疑似 MS 复发的患者应进行评估以确认诊断，排除其他神经功能障碍的原因，并识别复发或假性复发的潜在触发因素，如尿路感染、发热或代谢紊乱。MS 复发的诊断是临床诊断，但 MRI 可能有助于确认和评估多发病灶活动。高剂量口服或静脉内糖皮质激素，无论是否口服减量，都是 MS 复发的一线治疗方法。促肾上腺皮质激素 (ACTH) 提供了一种替代糖皮质激素治疗的方法，但目前价格昂贵，且没有证明其优越性。如果类固醇治疗后急性神经功能缺损仍然严重，特别是如果重复 MRI 上症状性病变的对比增强持续异常，则应考虑血浆置换 (PLEX) 作为急性复发的抢救治疗。在特殊情况下，特别是类固醇和 PLEX 治疗后仍未改善的暴发性或肿块样疾病，可能需要考虑细胞毒性药物，如环磷酰胺，或 B 细胞耗竭方案，如利妥昔单抗，尽管必须仔细权衡风险，并且这些方案的动力学表明，它们可能更有助于加速疾病活动的缓解，而不是作为急性复发的补救措施。一项随机对照试验表明，在多发性硬化症复发的急性治疗中单次给予那他珠单抗并不能改善临床结局。关注症状管理和促进神经康复是 MS 复发护理的重要方面。神经保护和神经修复治疗仍在研究中，但在未来可能成为复发治疗的重要补充元素。复发是 MS 疾病活动的重要指标。在针对 MS 疾病活动无证据的新兴治疗模式背景下，复发应促使考虑转为可能更有效治疗疾病的疾病修饰治疗。
