Objective: This article addresses the evidence basis for treating acute multiple sclerosis (MS) relapses and choosing disease-modifying therapies in patients with relapsing MS, radiologically isolated syndrome, and progressive MS.

Latest developments: Symptoms related to MS relapses occur as a result of new acute focal inflammatory demyelination and may improve more quickly with the use of high-dose corticosteroids. However, these treatments must not be given when symptoms are instead due to systemic issues (eg, non-neurologic illness, sleep deprivation, infection) that lead to transient worsening of symptoms attributed to old areas of MS-related damage. While trials are ongoing to establish whether an optimal treatment strategy exists for newly diagnosed, active, or relapsing MS, clinicians and people with MS must currently use shared decision-making to select a higher-efficacy therapy or embark on an escalation approach. Screening for specific contraindications to various MS therapies must occur before beginning therapy, and ongoing monitoring for effectiveness and safety concerns is indicated. Emerging data indicate that, on average, MS therapy is beneficial for people identified in the presymptomatic phase of MS. However, people with slowly worsening progressive MS may not experience as much benefit from currently approved MS therapies in the absence of active disease (relapses or new lesions on MRI).

Essential points: There are many treatment options for people with relapsing MS. Patients should be carefully monitored to assess treatment response, and a change in treatment approach should be considered if safety concerns emerge.