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What Are the Relapsing Forms of MS?

Posted on July 23, 2021
Medically reviewed by
Evelyn O. Berman, M.D.
Article written by
Brooke Dulka, Ph.D.

  • The three relapsing forms of multiple sclerosis are clinically isolated syndrome (CIS), relapsing-remitting MS (RRMS), and active secondary progressive MS (SPMS).
  • Relapsing forms of MS can transition to more progressive forms of the disease.
  • Long-term treatment with disease-modifying therapies (DMTs) is the most effective way to delay MS progression.

Multiple sclerosis can take different disease courses, and each represents a different type of MS. Only certain types of MS have a risk for relapses — also known as flares, exacerbations, or attacks. Relapses are periods of new or worsening MS symptoms. Doctors sometimes disagree about the exact nature of MS, but relapsing forms of MS are often treated using the same medication options.

Understanding the Relapsing Forms of MS

There are three types of relapsing MS: clinically isolated syndrome, relapsing-remitting MS, and active secondary progressive MS.

Clinically Isolated Syndrome

Clinically isolated syndrome is often the first episode of symptoms that eventually lead to a diagnosis of MS. CIS is diagnosed after neurological symptoms present for at least 24 hours. These symptoms must be due to demyelination (damage to the myelin that sheathes nerves) or inflammation in the central nervous system.

CIS is a condition that can convert (or progress) to MS. The risk for conversion is often predicted based on the quantity and size of brain lesions, as seen on initial baseline magnetic resonance imaging (MRI) scans. CIS is usually diagnosed in people between the ages of 20 and 40. Effective treatment soon after a diagnosis of CIS is important to delay the conversion to MS.

Relapsing-Remitting MS

Relapsing-remitting MS is the most common form of MS. However, no two people experience RRMS the same way. This is because lesions can occur in different locations within the central nervous system, affecting different functions.

RRMS is characterized by defined attacks of new or increasing neurological symptoms. There are several risk factors for RRMS. Women are approximately two to three times more likely than men to be diagnosed with RRMS. The age of onset for RRMS is similar to that of CIS — between ages 20 and 40. However, children can also be diagnosed with RRMS. Genetics pose another risk factor, as RRMS can run in families.

Active Secondary Progressive MS

After a period of time living with RRMS, this form can progress to secondary progressive MS. In people with SPMS, neurological symptoms continue to get worse without clear periods of remission. SPMS is considered active if relapses continue to occur, and inactive if there have been no relapses for a period of time. According to the National Multiple Sclerosis Society, without the use of approved disease-modifying therapies, 50 percent of those diagnosed with RRMS will likely transition to SPMS within 10 years, and 90 percent tend to transition within 25 years.

Although CIS, RRMS, and SPMS are distinctive forms of relapsing MS, they are often grouped together and share similar treatment options.

Treatment Options for Relapsing Forms of MS

Disease-modifying therapies are the primary defense against progression in relapsing forms of MS. There are approximately 20 medications currently approved for the treatment of relapsing forms of MS. Research suggests DMTs can:

  • Reduce the frequency of MS relapses
  • Limit new MS activity, such as lesions or plaques on the brain and spinal cord, as shown on MRI scans
  • Slow disease progression, including conversion from CIS to RRMS or from RRMS to active SPMS

Those diagnosed with any type of relapsing MS should discuss disease-modifying therapies with a doctor as soon as possible. Early treatment can make a positive difference in slowing the progression of MS.

Classes of DMTs for Relapsing Forms of MS

Different classes of medications are used as disease-modifying therapies in cases of relapsing MS. Each class works in a different way, and your neurologist can help you decide on the best treatment option for you.

Classes of drugs used as DMTs for MS include:

  • Interferons, such as Avonex (interferon beta 1a) and Betaseron (interferon beta 1b)
  • Monoclonal antibodies, such as Ocrevus (ocrelizumab) and Tysabri (natalizumab)
  • Fumarates, such as Tecfidera (dimethyl fumarate) and Vumerity (diroximel fumarate)
  • Sphingosine-1-phosphate receptor modulators, such as Gilenya (fingolimod) and Mayzent (siponimod)
  • Pyrimidine synthesis inhibitors, such as Aubagio (teriflunomide)

Read What Are S1P Receptor Modulators?

First-Line Drugs for Relapsing Forms of MS

First-line DMTs are the initial treatments most commonly prescribed when a person is recently diagnosed with MS. Any FDA-approved DMT can technically be prescribed as a first-line drug. Generally speaking, first-line DMTs include:

  • Aubagio (teriflunomide)
  • Avonex (interferon beta 1a)
  • Betaseron (interferon beta 1b)
  • Copaxone (glatiramer acetate)
  • Extavia (interferon beta 1b)
  • Glatopa (glatiramer acetate)
  • Ocrevus (ocrelizumab)
  • Plegridy (peginterferon beta 1a)
  • Rebif (interferon beta 1a)
  • Tecfidera (dimethyl fumarate)
  • Vumerity (diroximel fumarate)

Second-Line Drugs for Relapsing Forms of MS

If first-line drugs fail to reduce your rate of flares or slow the progression of MS, your doctor may suggest switching to a second-line drug. A neurologist might also recommend switching to a second-line DMT if you don’t have access to the first-line drug anymore, or you cannot tolerate the side effects of the first-line drug.

Second-line DMTs may include:

  • Gilenya (fingolimod)
  • Lemtrada (alemtuzumab)
  • Mavenclad (cladribine)
  • Mayzent (siponimod)
  • Novantrone (mitoxantrone)
  • Tysabri (natalizumab)

Learn more about what to expect when starting an S1P receptor modulator.

Delaying MS Progression

MS is a debilitating disease that will progres — or continue to get worse — as time goes by. There is not yet a cure for MS. However, beginning a DMT treatment as early as possible following diagnosis can help delay the progression to more debilitating forms of MS.

There are many new MS drugs. At present, it is largely unknown how these medications might delay or lower the risk for MS progression in the long term. Long-term treatment with a DMT is the single most important factor in delaying MS progression.

Talk With Others Who Understand

MyMSTeam is the social network for people with multiple sclerosis and their loved ones. On MyMSTeam, more than 170,000 members come together to ask questions, give advice, and share their stories with others who understand life with multiple sclerosis.

Are you living with a relapsing form of multiple sclerosis? Do you worry about progression? Share your experience in the comments below, or start a conversation by posting on your Activities page.

References
  1. Types of MS — National Multiple Sclerosis Society
  2. Will the Real Multiple Sclerosis Please Stand Up? — Nature Reviews Neuroscience
  3. Inflammation in Multiple Sclerosis: The Good, the Bad, and the Complex — The Lancet Neurology
  4. Multiple Sclerosis: An Immune or Neurodegenerative Disorder? — Annual Review of Neuroscience
  5. The Prevalence of MS in the United States: A Population-Based Estimate Using Health Claims Data — Neurology
  6. Clinically Isolated Syndrome (CIS) — National Multiple Sclerosis Society
  7. Conversion From Clinically Isolated Syndrome to Multiple Sclerosis: A Large Multicentre Study — Multiple Sclerosis Journal
  8. Updates on Clinically Isolated Syndrome and Diagnostic Criteria for Multiple Sclerosis — The Neurohospitalist
  9. Relapsing-Remitting MS (RRMS) — National Multiple Sclerosis Society
  10. Heterogeneity of Multiple Sclerosis Lesions: Implications for the Pathogenesis of Demyelination — Annals of Neurology
  11. Multiple Sclerosis — Symptoms and Causes — Mayo Clinic
  12. Modest Familial Risks for Multiple Sclerosis: A Registry-Based Study of the Population of Sweden — Brain
  13. Secondary Progressive MS (SPMS) — National Multiple Sclerosis Society
  14. Treating RRMS — National Multiple Sclerosis Society
  15. Advances in the Treatment of Multiple Sclerosis (PDF) — Neurologic Clinics
  16. Treatment Strategies for Multiple Sclerosis: When To Start, When To Change, When To Stop? — World Journal of Clinical Cases
  17. Treatment for MS — MS Focus
  18. Sphingosine 1-Phosphate Receptor Modulators in Multiple Sclerosis — CNS Drugs
  19. The Effect of Immunomodulatory Treatment on Multiple Sclerosis Fatigue — Journal of Neurology, Neurosurgery & Psychiatry
  20. Immunosuppressive Agents in Multiple Sclerosis — Neurotherapeutics
  21. Transition to Secondary Progression in Relapsing-Onset Multiple Sclerosis: Definitions and Risk Factors — Multiple Sclerosis Journal
Evelyn O. Berman, M.D. is a neurology and pediatric specialist and treats disorders of the brain in children. Review provided by VeriMed Healthcare Network. Learn more about her here.
Brooke Dulka, Ph.D. is a freelance writer at MyHealthTeams. Learn more about her here.

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