Relapsing-Remitting Multiple Sclerosis (RRMS) Disease Course:

Relapsing-remitting multiple sclerosis (RRMS) is the most common course of the disease.  It has been estimated that 80-85% of all MS cases diagnosed begin as the relapsing-remitting course of the disease.

This course of the disease has clearly defined attacks called “exacerbations” resulting in new symptoms and/or increases in severity of existing symptoms.   During periods of remission, symptoms may completely disappear, partially disappear or continue and become more permanent.  Periods of remission have no apparent progression of the disease.

Episodes of acute inflammation activity are known as “relapses.”  In reading online you may see these relapses referred to as “Flare-Ups” or “Attacks“.

A relapse is considered active when it lasts for more than 24 hours and the resulting symptoms are new and/or a worsening of existing symptoms.  Relapses can continue anywhere from a few days to several months.  A relapse may be fairly mild or severe enough to require hospitalization.  Following a relapse, there may or may not be a full recovery and return to baseline.  Certain symptoms may linger for a longer period of time or become permanent.

MSProgressionEach individuals experience with RRMS is unique to them depending on what areas of their central nervous system (CNS) are damaged during relapses.

It is advised that MS patients have a good grasp on knowing their symptoms and if a caregiver is also helping manage the disease that they be aware of the patient’s symptoms as well.  In doing so recognizing new symptoms or worsening of existing symptoms can be addressed rapidly should a relapse occur.

Medications called “Disease Modifying Therapies” or DMTs attempt to alter the course of RRMS.  It is important to note that DMTs are not a cure but instead attempt to alter the natural course of the disease.  The target of the DMTs is to stop relapses from occurring.

When people are diagnosed with RRMS and do not take a disease modifying medication the progression of the disease may transition to a new course called Secondary Progressive Multiple Sclerosis (SPMS).  It is estimated that about 50%-80% of RRMS patients who do not take a DMT will progress towards the SPMS course between 10-20 years after disease onset.  SPMS signals a more progressive course of the disease where more disability is accrued and less recovery from symptoms.

Females are two to three times more likely to have RRMS than males.

Neuron
Nerve Cells In The Brain

In 2006 the first highly effective DMT came to market, several more medications have since become available to patients.  Statistics towards transition times to secondary progressive MS for patients engaging these new treatments remains unknown.

Quick Summary:

  • RRMS is the most common course of the disease with 80-85% of all patients diagnosed at onset of the disease.
  • Females are two to three times more likely to have RRMS than males.
  • RRMS is characterized by disease activity or relapses followed by a time of no activity or remission.
  • Existing symptoms may or may not worsen during a relapse and new symptoms may or may not appear.
  • After a relapse symptoms may have complete, partial or no recovery from them.
  • A relapse is considered to be new symptoms and/or worsening existing symptoms that last more than 24 hours and/or signs of disease activity in MRI’s.
  • Each individuals experience with RRMS is unique.
  • Disease Modifying Treatments attempt to alter the natural course of the disease by staving off relapses.
  • Patients may transition to a new course of the disease known as Secondary Progressive Multiple Sclerosis.
  • Secondary Progressive MS is a more progressive course in the disease.

What is a Relapsing-Remitting Multiple Sclerosis Relapse?

NeuronRelapsing-remitting multiple sclerosis is defined by inflammatory attacks on myelin, a fatty, layered substance that surrounds nerve fibers in the central nervous system (CNS).  The CNS is comprised of the brain, spinal cord and optic nerves in a human being.  Inside the CNS are millions of nerve cells called “neurons.”  It has been speculated that the adult human brain may have between 100 million and as many as 1 trillion neurons.

Neurons are living cells complete with a nucleus, DNA and living cell functions.  Several different types of neurons exist.  Neurons connect together to form neural networks in the central nervous system.  Neurons have input terminals called dendrites, a cell body, an axon and synaptic output terminals.  Extending from the cell body the axon connects to the synaptic output terminals which in turn connect to other neuron’s dendrites.

Our central nervous system is responsible for controlling nearly all of our bodily functions including musculature control, processing of information, memory, mood, speech processing, feeling pain, urination and much more.

In relapsing-remitting multiple sclerosis cells from a person’s immunity system which normally protects the body from flu’s, bacterial infections and even cancers known as “antigens” attacks neurons in the CNS.  During these inflammatory attacks, activated immune cells cause small, localized areas of damage which produce the symptoms associated with MS. Because the location of the damage is so variable, no two people have exactly the same symptoms.

The axon of neurons is covered with myelin and is known as the “myelin sheath” which helps both protect the axon and helps conduct electrical signals across the length of the axon.  The axon conceptually can be thought of like a piece of wire and myelin the insulation over the wire.

Inflammation caused by the immune system cells attacking the myelin sheath results in swelling causing the myelin sheath to break apart.  When the myelin sheath is damaged it does not conduct electrical signals as efficiently.  The speed and strength of the electrical signal quality get impacted or even degraded to a point where the signal cannot traverse the length of the axon.  The axon itself may become severed resulting in conduction block.

Where the myelin has been damaged scar tissue appears which are known as “Plaques” or “Lesions.

The degradation or loss of signal quality results in the symptoms associated with relapsing-remitting multiple sclerosis.

Quick Summary:

  • The central nervous system encompasses the human brain, spinal cord and optic nerves.
  • The central nervous system controls a large share of our bodily functions. It is our “control center.”
  • Nerve cells called neurons are living cells that connect together to form neural networks in the central nervous system.
  • In relapsing-remitting multiple sclerosis (MS) immune system cells attack neuron cells and damage the myelin sheath.
  • The myelin sheath both protects the axon’s of neuron cells and helps conduct electrical signals down the length of the axon.
  • The axon extends from a neuron’s cell body and conveyors electrical signals down its length similar to electrical wire ending at synapses.
  • The synapses convey information to other neuron cells through input synapses called dendrites.
  • Inflammation caused by immune system cells attacking the myelin sheath results in inflammation causing the myeling sheath to break apart.
  • The degradation of the electrical signal quality or complete loss of signal results in the symptoms associated with relapsing-remitting MS.
  • Where myelin is damaged scar tissue is left behind.
  • The scarred tissue is often called plaques or lesions.

Monitoring of Relapsing-Remitting Multiple Sclerosis:

RRMS_SPMSRegular monitoring of any disease activity and/or progression should take place including a neurological examination and magnetic resonance imaging scan (MRI).  The ability to document the course of activity, progression and symptomatic disability can help your health care provider make determinations about management of the disease.

Your provider may see that the disease is getting worse and recommend a more aggressive approach to managing the disease.

If for example, no new symptoms have appeared but the MRI shows evidence of progression your care provider may recommend attempting to use a different DMT therapy as evidence of disease activity is known to result in disability even if no new symptoms have appeared.  If new symptoms have appeared or old symptoms appear to be worsening the health care provider may decide other options or additional options towards managing the disease course.  The target in treating relapsing-remitting MS is to have no evidence of disease progression in MRI’s and no worsening of old symptoms or appearance of new symptoms.

Disease activity and progression should be evaluated at regular intervals by neurologic examination and MRI. Being able to characterize the course of your disease at different points in time helps you and your MS care provider discuss your treatment options and expected outcomes. For example:

For example, if you have RRMS that is active and worsening, you and your MS care provider will likely want to consider a more aggressive treatment approach than if there were no evidence of activity or worsening. Together, you can weigh the potential risks and benefits of other treatment options.

If your symptoms have not worsened on the treatment you are currently taking, but you have evidence of new disease activity on your MRI, you and your healthcare provider may discuss switching to another treatment with a different mechanism of action in order to control the disease activity more effectively and help prevent worsening.

If your RRMS is stable without evidence of MRI activity or worsening, you and your healthcare provider can feel confident that the current treatment regimen is working effectively.

Many clinicians and patients believe that documenting your MS daily is important towards recognizing disease progression and understanding one’s specific symptoms.  Documenting aspects of the disease daily and bringing the record to neurologist visits can help them see the course of the disease in a more granular fashion allowing for more granular disease management.

Quick Summary:

  • Regular monitoring of RRMS is important generally every 3-6 months or when an exacerbation takes place.
  • Monitoring makes helps make sure that treatments are working and effective.
  • Monitoring helps project the future of the disease course in the patient.
  • Documenting your MS daily can be very helpful in knowing if treatment is effective and help with symptomatic management.
  • Documenting your MS daily can help your care provision team project the course of your MS.

Treatment of Relapses: 

It is important to recognize when a relapse is occurring and when in doubt see a neurologist as soon as possible.

If the neurologist in assessing the patient believes a relapse is taking place they will often prescribe corticosteroids such as Solumedrol, Acthar Gel and/or Prednisone.  The corticosteroids help ease the inflammation caused by the immune systems attack and in doing so attempts save nerve (neuron) cells from further damage.

A magnetic resonance imaging scan (MRI) may be prescribed to try and see where in the central nervous system new damage has been accrued and to confirm the activity as a relapse.

Assessment of the level of the exacerbation, disease progression, disability accrued if any will help make decisions towards better management of the current course of the disease.

Other medications may be prescribed to help cope with symptoms such as pain, mood, spasticity or other symptomatic issues.

Physical therapy, occupational therapy or other interventions may be recommended by the health care provider to further help manage symptoms or disability accrual.

Lifestyle alternations among large segments of the multiple sclerosis community has been shown for many patients to help manage symptoms.  If you are a tobacco smoker or use tobacco related products your care provider may suggest you cease as smoking has been shown in studies to worsen MS activity.  Dietary changes, weight loss, exercise regimens, cognitive therapies, sleep clinics are some of the recommendations that may occur from a health care provider.

It should be noted that it is important for the patient to explore existing options and ask about them with their health care provider.  While in theory it is your health care teams job to advise you towards your care all too often patients find that this is not happening.  Multiple Sclerosis is not a disease to be trifled with assuming your health care team has everything in hand and taken care of.  Self-advocacy can play a vital role in both quality of life and long-term best outcomes in multiple sclerosis.

Educate yourself about the disease and explore what options may best suit your life.

Before engaging in any changes in your treatment whether dietary, dietary supplements, exercise or other therapies it is advisable to contact your health care team to make sure that any changes are documented and approved of.

Quick Summary:

  • Relapses indicate new disease activity and are defined as worsening of existing symptoms and/or new symptoms.
  • To be a relapse the change in symptoms must last at least 24 hours and some neurologist suggest 48 hours without improvement back to baseline.
  • Relapses often are treated with corticosteroids to try reduce inflammation which results in damage to myelin sheaths.
  • Symptoms related to the relapse may require additional medications to manage, physical therapy or other lifestyle related alterations.
  • Exploring all options in respect to symptomatic management in MS and relapses is important.
  • Educating yourself about MS towards self-advocacy is imperative in managing MS.
  • Never make alterations in your lifestyle, diet, exercice, dietary supplements without first consulting your health care provider.

Disease-Modifying Drugs (DMDs) For Relapsing-Remitting Multiple Sclerosis:

Relapsing-remitting multiple sclerosis has many treatment options available known as “Disease-modifying treatments” or DMTs or “Disease-modifying Drugs” (DMDs).  Relapses and MRI scans showing disease activity may signify that the current DMT a patient is taking may need to be re-evaluated and perhaps a new treatment prescribed.  Relapsing-remitting DMTs have target staving off future relapses.  Many differ in the mechanisms of action in attempting to stop relapses.  Conceptually the DMTs work to stop relapses and thus save nerve cells in the patient’s central nervous system from damage.  DMTs are not a cure but instead they serve to change the natural course of the disease.

The treatments have delivery mechanisms including hypodermic injection, intervenous infusion, and oral pill medication formats.

Quick Summary:

  • DMD’s are not cures for the disease.
  • DMD’s attempt to alter the natural course of the disease.
  • DMD’s attempt to stop progression of the disease.
  • DMD’s have differing mechanisms of action.
  • DMD delivery mechanisms including hypodermic injection, intervenous infusion and oral pill’s.

How does Relapsing-Remitting Multiple Sclerosis Differ from Primary Progressive Multiple Sclerosis?

RRMS ImageProgressive courses of multiple sclerosis have much less of the inflammation associated with relapsing-remitting MS.  RRMS is defined by attacks resulting in inflammation (relapses) and progressive forms of MS involve much less of this type of inflammation.

Patients living with RRMS tend to have more scars known as “plaques” on MRI scans than people with primary-progressive multiple sclerosis (PPMS). Further, PPMS patients tend to have more plaques on their spinal cord and fewer inflammatory immune cells in the region.

RRMS patients tend statistically tend to be diagnosed in their 20s or 30s although it does occur both in childhood, middle-aged and even the elderly.  PPMS tends to be diagnosed when a patient is in their 40s or 50s.

RRMS patients tend to have episodes of numbness, pain, vision problems, fatigue, spasticity, thinking and cognition deficits, bladder, and bowel dysfunction.  PPMS patients are more likely to experience problems with walking and mobility and a more gradual but consistent progression of disability accrued and worsening of other symptoms they may have.

Quick Summary:

  • RRMS relapses result in more inflammation and damage to myelin sheath on neuron cells in the central nervous system then progressive MS disease courses.
  • RRMS patients statistically are diagnosed at a younger age than progressive MS patients.
  • RRMS patients tend to have more plaques (lesions) in the central nervous system than progressive patients.
  • Progressive MS patients are more likely to accrue walking and mobility symptoms .vs. RRMS patients.
  • RRMS patients are more likely to have vision problems, pain, fatigue, spasticity, cognitive and other symptoms than progressive patients.

Summary:

Relapsing-remitting multiple sclerosis is the most common course of the disease that patients are diagnosed with.  While a cure still remains elusive, life with RRMS thanks to research, medications, symptoms management can now be managed far more successfully that was the case only 15 years ago.

If you have been diagnosed with multiple sclerosis it is important to learn as much as you can about the disease towards self-advocacy of your health care.  Due to the symptoms that can result from multiple sclerosis information truly is power.