When to Go to the Hospital for MS.

For many with multiple sclerosis, relapses can turn serious. We asked the experts when a flare merits a trip to the hospital..

If you have multiple sclerosis (MS), you know that symptoms can flare suddenly. Maybe it’s a feeling of numbness in your arms, or muscle stiffness that makes it difficult to work; or it could be partial vision loss. No matter what you’re experiencing, one key question applies to all those changes: Is this an emergency that warrants a hospital visit?

Although some symptoms of an MS relapse can be minor and temporary, others are serious enough that they should be addressed quickly, says Tirisham Gyang, M.D., a neurologist at The Ohio State University Wexner Medical Center in Columbus. In these cases, “prompt evaluation and management are essential for addressing relapse effects and preventing complications,” she notes.

So how do you know when a symptom flare warrants a trip to the ER vs. a watch and wait approach? We asked our experts to break it down.

MS is an autoimmune condition in which the body’s immune system mistakenly attacks the myelin sheath, a protective coating of fatty tissue over nerves in your brain and spinal cord. Eventually, this leads to scarring. When this happens, it can cause a range of symptoms, from poor bladder control to tremors to partial paralysis. The most common form of MS is relapsing-remitting MS, or RRMS, in which you experience relapses of symptoms—also called flares, attacks, or exacerbations—followed by periods of remission in which you experience few to no symptoms. RRMS accounts for about 85% of MS cases, according to the National Multiple Sclerosis Society. “Relapses can occur even when someone is on disease-modifying therapies for MS,” Dr. Gyang points out.

Per the National MS Society, no two people with MS have exactly the same set of symptoms, and symptoms can change over time. The most common, per the organization, are:

• Bladder dysfunction

• Bowel issues

• Cognitive changes such as difficulty processing information or making decisions

• Depression, which is one of the most common symptoms of MS

• Emotional changes such as irritability, fear, anxiety, and grief

• Fatigue

• itching

• “MS hug,” which is a squeezing sensation around the torso

• Muscle weakness

• Numbness or tingling in the face, body, arms, or legs

• Pain

• Sexual dysfunction

• Spasticity, which includes muscle stiffness or involuntary contractions

• Vertigo and dizziness

• Vision problems

• Walking difficulties, often due to loss of balance, fatigue, and muscle weakness

Less commonly, MS can cause other symptoms such as loss of hearing or taste, seizures, tremors, speech issues, and difficulty swallowing. You may also experience breathing problems since MS can weaken muscles that support the lungs..

“A relapse is the appearance of new neurologic symptoms or a recurrence of previous symptoms that last at least 24 hours and are not due to the person having an infection or from an issue like a fever,” says Barbara Giesser, M.D., a neurologist and MS specialist at Pacific Neuroscience Institute at Providence Saint John’s Health Center in Santa Monica, CA. “A relapse is thought to occur when there is increased inflammation in the central nervous system, either at the site of an old area of damage or in the formation of a new area of damage.”.

Of the symptoms that might occur in the midst of a relapse, some are more important to address immediately by calling your doctor or going straight to the ER if symptoms are severe and worsening, Dr. Gyang says. These more urgent symptoms include:

• Balance or coordination problems that come on suddenly

• Facial pain on one side

• Vision changes

• Weakness or numbness in one or more limbs

Symptoms like these, especially if they’re intense and you haven’t experienced them in the past, could indicate your MS is in a flare, Dr. Gyang says. That can merit new imaging and might lead to a change in your treatment regimen. You may also need immediate intervention like IV medications or hydration.

Another reason to address these particular symptoms sooner rather than later is that they are all associated with cardiovascular events like a stroke or heart attack. According to a systematic review and meta-analysis in BMC Neurology, people with MS have an increased risk of stroke—nearly three times higher than the general population—so it’s extra important to know the signs of stroke and get prompt medical attention if you experience them..

A pseudo-relapse refers to the recurrence or worsening of previously improved or resolved MS symptoms due to exposure to certain triggers, rather than new disease activity, according to Dr. Gyang.

“These symptoms often mirror those experienced during prior relapses,” she says. “Common precipitating factors include infections, physical or emotional stress, increased body temperature or heat, and medication changes.”

Unlike true relapses, pseudo-relapses do not indicate new damage or inflammation but are due to a temporary aggravation due to external or internal stressors, she adds. Even though they may not be a “true relapse,” physical challenges brought on during a pseudo-relapse can sometimes be serious enough to require hospitalization to resolve symptoms, she says..

Determining whether your acute symptoms are due to an MS relapse typically involves diagnostic imaging. This may be done in the ER, or as an inpatient if you’ve been admitted to the hospital by your neurologist, Dr. Gyang says.

“Depending on the symptoms, MRI scans of the eyes, brain, and spinal cord can be performed to identify new or active lesions,” she says. “Additional tests may be performed to rule out certain triggers of a pseudo-relapse such as infection or acute illness. These diagnostic steps help confirm relapses and guide appropriate treatment.”

Once an MS relapse is confirmed, treatment often involves a three- to five-day course of high-dose oral or intravenous steroids which can ease inflammation, thereby reducing the duration and severity of symptoms, she adds. Whether you receive treatment at home or stay in the hospital depends on the severity of your symptoms.

“It’s important to note that steroids can increase risk of infections, which can prolong hospitalization or, in some cases, lead to readmission,” Dr. Gyang says.

High-dose steroids can also cause other side effects, including allergic reaction and gastrointestinal issues, according to the National Library of Medicine.

Ironically, some of the very drugs used to treat MS and prevent relapses long-term might also increase your chances of hospitalization, says Shailesh Rajguru, D.O., the chair of the American Osteopathic Board of Neurology and Psychiatry and a practicing neurologist at Bond Clinic in Winter Haven, FL.

“The goal in prescribing disease-modifying therapies (DMTs) is to reduce the risk of relapse and hospitalization,” he says. “However, DMTs can suppress the immune response, and that might lead to infection.”

A study in JAMA Neurology found that rates of serious infections were lower among people with MS who were taking interferon beta, an older DMT, versus those taking the newer DMTs such as Rituxan (rituximab,) Tysabri (natalizumab), and Gilyena (fingolimod). The researchers noted that more studies need to be done to pinpoint why this happens, but it’s possible that the newer DMTs deplete B-cells—a component of the immune system that is overactive in people with MS—more than interferon beta. While this is beneficial for MS management overall, it could contribute to higher infection incidence, according to the researchers.

If you’re on a DMT, Dr. Rajguru suggests talking with your neurologist about strategies to mitigate the risk of infection.