neuro.ms-flare.core.v1PRODUCTION

neuro.ms-flare.core.v1

Multiple Sclerosis Flare

neurologysubacuteadult

Hard-required inputs

0 / 7

Care setting:

Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Confirm true relapse (≥24h, no fever/infection) vs pseudo-relapse (AAN 2024)

Inputs

Actions

Advance rule

Set

Advance when

pseudo-relapse triggers excluded

Patient inputs (13)

age*demographic • CONTEXT

Younger relapses respond better; pregnancy alters DMT choice (AAN 2024)

temperature*vital • CONTEXT

Fever / Uhthoff phenomenon = pseudo-relapse, not true flare (AAN 2024)

ms_subtype*history • DIFFERENTIAL

not present

RRMS / SPMS / PPMS — only RRMS/active SPMS respond to immunomodulation (AAN 2024)

mri_brain_spine_with_contrast*imaging • INITIAL_WORKUP

not present

Active gadolinium-enhancing lesion confirms relapse vs pseudo-relapse; long cord lesion ≥3 segments pivots to NMOSD (Wingerchuk 2015 PMID 26092914)

urinalysis*lab • INITIAL_WORKUP

Rule out UTI as pseudo-relapse trigger (Uhthoff) (AAN 2024)

current_dmt*history • TREATMENT

not present

Existing DMT informs escalation (anti-CD20, S1P, natalizumab) vs switch decision (AAN 2024)

pregnancy_status*history • TREATMENT

Pregnancy excludes most DMTs; methylprednisolone OK after first trimester (AAN 2024)

aqp4_igglab • BRANCHING_WORKUP

AQP4-IgG positive → NMOSD (different management — eculizumab/satralizumab/inebilizumab/rituximab) (Wingerchuk 2015 PMID 26092914; Pittock 2019 PREVENT PMID 31050279)

mog_igglab • BRANCHING_WORKUP

MOG-IgG positive → MOGAD (often monophasic; bilateral optic neuritis; cortical encephalitis) (Banwell 2023 PMID 36706773)

edss_at_baselinesymptom • RISK_STRATIFICATION

EDSS pre-flare anchors recovery target (AAN 2024)

last_relapse_datehistory • TREATMENT

not present

Relapse frequency drives DMT escalation per ECTRIMS 2024

glucoselab • TREATMENT

Steroid pulse raises glucose; baseline before methylprednisolone (AAN 2024)

jc_virus_indexlab • TREATMENT

JCV+ on natalizumab → PML risk; gates DMT switch (AAN 2024)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (10)

10 need judgement

informationallife_threateningsteroid_refractory_severe
MS phenotype: severe flare unresponsive to IV methylprednisolone 1 g × 3–5 d by day 7–14; high-disability flare (high EDSS change, transverse myelitis, severe optic neuritis with no light perception) — plasmapheresis 5 cycles q48h (Apoly DS Magaña Neurology 2011 PMID 11309833 NEEDS_SOURCE_REVIEW)
Trigger could not be auto-evaluated — needs clinician judgement.
informationalsevereoptic_neuritis
MS phenotype: acute monocular vision loss + RAPD + pain on eye movement; MRI orbit ± brain shows optic-nerve enhancement; high-dose IV methylprednisolone 1 g × 3–5 d per ONTT (Beck NEJM 1992 PMID 1734247)
Trigger could not be auto-evaluated — needs clinician judgement.
informationalseveretransverse_myelitis
MS phenotype: spinal-cord band-like deficit + sensory level + motor level + bowel/bladder dysfunction; MRI cord shows T2-hyperintense lesion; if ≥3 vertebral segments → NMOSD-suspected pivot (AAN 2024; Wingerchuk 2015 PMID 26092914)
Trigger could not be auto-evaluated — needs clinician judgement.
informationalseverebrainstem_syndrome
MS phenotype: INO + ataxia + vertigo + dysarthria + dysphagia; MRI brainstem shows T2/gad-enhancing lesion; CAUTION — pivot for NMOSD area-postrema syndrome with intractable hiccups/vomiting (Wingerchuk 2015 PMID 26092914)
Trigger could not be auto-evaluated — needs clinician judgement.
informationalseverenmosd_suspected
AQP4-IgG positive (live cell-based assay preferred) OR longitudinally extensive transverse myelitis ≥3 vertebral segments OR bilateral simultaneous optic neuritis OR area-postrema syndrome with intractable hiccups/vomiting (Wingerchuk 2015 PMID 26092914) — DIFFERENT MANAGEMENT
Trigger could not be auto-evaluated — needs clinician judgement.
informationalseveremogad_suspected
MOG-IgG positive (live cell-based assay preferred) OR bilateral optic neuritis with optic-nerve-head swelling OR cerebral cortical encephalitis with seizures OR ADEM-like presentation (Banwell 2023 PMID 36706773) — often monophasic
Trigger could not be auto-evaluated — needs clinician judgement.
informationalseverejcv_high_index_natalizumab
On natalizumab + JCV index >1.5 + >24 mo on therapy — PML risk > 1:1000 (AAN 2024)
Trigger could not be auto-evaluated — needs clinician judgement.
informationalmoderatecerebellar_hemispheric_attack
MS phenotype: large MRI plaque with gad-enhancement in cerebellum or hemisphere; ataxia, hemiparesis, hemisensory, language deficit (AAN 2024)
Trigger could not be auto-evaluated — needs clinician judgement.
informationalmoderatebreakthrough_relapse_on_dmt
New relapse despite ≥6 months on adequate DMT (AAN 2024)
Trigger could not be auto-evaluated — needs clinician judgement.
informationalmilduhthoff_pseudoflare
MS phenotype: worsening symptoms with fever / UTI / heat exposure; NO new lesion on MRI; supportive only — treat infection + cool patient (AAN 2024)
Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

This dossier does not reference any calculators.

Recommended regimen

MS flare — acute relapse treatment (AAN 2024)

axis: ms_flare_acutestep 1 - Step 1 — IV methylprednisolone pulse

Selected step "Step 1 — IV methylprednisolone pulse" — Confirmed MS relapse (deficit ≥24 h, gad-enhancing lesion, no fever/infection)

methylprednisolone
first line
corticosteroid_pulse
1 g IV daily × 3–5 d • IV • daily × 3–5 d (max: 5 g cumulative)
triggers: confirmed_relapse
ONTT (Beck NEJM 1992 PMID 1734247) — IV methylprednisolone shortens optic-neuritis recovery; oral prednisone alone increases recurrence
rxcui 6902
prednisone
first line
corticosteroid_oral
1250 mg PO daily × 3–5 d • PO • daily × 3–5 d (max: 5 d course)
triggers: outpatient_no_IV_access
Le Page (Lancet 2015) — oral methylprednisolone-equivalent 1250 mg/d non-inferior to IV (AAN 2024)
rxcui 8640

outpatient playbook — drug actions (4)

1. DMT initiation / escalation
Per axis (ocrelizumab 600 mg IV q6 mo; ofatumumab 20 mg SC monthly; natalizumab 300 mg IV q4 wk; fingolimod 0.5 mg PO daily; siponimod 2 mg PO daily; cladribine pulsed; DMF 240 mg BID; glatiramer 20 mg SC daily) • per DMT • per DMT
trigger: Active RRMS / breakthrough relapse / new diagnosis
OPERA Hauser 2017 PMID 28002679; HERMES Hauser 2008 PMID 18272891; CLARITY Giovannoni 2010 PMID 20089960; DEFINE Gold 2012 PMID 22992073 + CONFIRM Fox 2012 PMID 22992072
2. fingolimod first-dose monitoring
6-hour cardiac monitor at first dose; ECG + BP • PO • first dose only
trigger: Initiation
Bradycardia risk (AAN 2024)
3. symptomatic medications
Baclofen / tizanidine spasticity; oxybutynin / mirabegron bladder; amantadine / modafinil fatigue; SSRI mood; gabapentin pain • PO • per indication
trigger: Persistent symptoms
Quality-of-life management (AAN 2024)
4. vitamin D3
2000–4000 IU PO daily • PO • daily
trigger: Deficiency or maintenance
Disease activity association (AAN 2024)

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: New neurological deficit in known MS lasting ≥24h (AAN 2024); Acute monocular vision loss with painful eye movement + RAPD (ONTT 1992 PMID 1734247); Sensory level / motor level / bowel-bladder dysfunction (AAN 2024).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Multiple Sclerosis Flare** (neuro.ms-flare.core.v1).
Phenotype framing: True relapse vs pseudo-relapse vs NMOSD/MOGAD vs PML on natalizumab vs ADEM (AAN 2024)
Scope: Confirm true relapse (≥24h, no fever/infection) vs pseudo-relapse (AAN 2024)

No severity triggers fired against current inputs.

Plan

Regimen axis: **MS flare — acute relapse treatment (AAN 2024)** — step "Step 1 — IV methylprednisolone pulse".
1. methylprednisolone 1 g IV daily × 3–5 d IV daily × 3–5 d (corticosteroid_pulse, first line) — ONTT (Beck NEJM 1992 PMID 1734247) — IV methylprednisolone shortens optic-neuritis recovery; oral prednisone alone increases recurrence
2. prednisone 1250 mg PO daily × 3–5 d PO daily × 3–5 d (corticosteroid_oral, first line) — Le Page (Lancet 2015) — oral methylprednisolone-equivalent 1250 mg/d non-inferior to IV (AAN 2024)

Setting playbook (outpatient) — Post-relapse: DMT-escalation discussion (with future companion engine `neuro.ms-dmt-escalation.v1`), MRI surveillance q6–12 mo with NEDA-3 target, JCV-Ab q6 mo on natalizumab, CBC + LFT per DMT, AQP4/MOG result follow-up (re-classify if positive), EDSS q6 mo, fatigue + spasticity + bladder management, mood/SUDEP-equivalent screen, vaccination planning, pregnancy counseling (AAN 2024)
3. DMT initiation / escalation Per axis (ocrelizumab 600 mg IV q6 mo; ofatumumab 20 mg SC monthly; natalizumab 300 mg IV q4 wk; fingolimod 0.5 mg PO daily; siponimod 2 mg PO daily; cladribine pulsed; DMF 240 mg BID; glatiramer 20 mg SC daily) per DMT per DMT — Active RRMS / breakthrough relapse / new diagnosis (OPERA Hauser 2017 PMID 28002679; HERMES Hauser 2008 PMID 18272891; CLARITY Giovannoni 2010 PMID 20089960; DEFINE Gold 2012 PMID 22992073 + CONFIRM Fox 2012 PMID 22992072)
4. fingolimod first-dose monitoring 6-hour cardiac monitor at first dose; ECG + BP PO first dose only — Initiation (Bradycardia risk (AAN 2024))
5. symptomatic medications Baclofen / tizanidine spasticity; oxybutynin / mirabegron bladder; amantadine / modafinil fatigue; SSRI mood; gabapentin pain PO per indication — Persistent symptoms (Quality-of-life management (AAN 2024))
6. vitamin D3 2000–4000 IU PO daily PO daily — Deficiency or maintenance (Disease activity association (AAN 2024))

Non-pharmacologic actions:
- PT/OT + symptom-specific rehab continued (AAN 2024)
- Driving assessment if visual or cognitive impairment (AAN 2024)
- Vocational counselling — return-to-work planning (AAN 2024)
- Heat-avoidance education (Uhthoff) (AAN 2024)
- Smoking cessation — accelerates disability (AAN 2024)
- Exercise programme — aerobic + resistance (AAN 2024)
- Sleep hygiene + OSA screen (STOP-BANG) (AAN 2024)
- Vaccinations — annual influenza, pneumococcal, COVID; live vaccines before DMT (AAN 2024)
- Pregnancy counselling — DMT washout timing (AAN 2024)

AVOID / contraindication checks:
- Exclude_pseudo_relapse_fever_UTI_first (AAN 2024)
- Rule_out_NMOSD_AQP4_before_DMT (Wingerchuk 2015 PMID 26092914)
- Rule_out_MOGAD_MOG_IgG_before_DMT (Banwell 2023 PMID 36706773)
- JCV_index_check_before_natalizumab (AAN 2024)
- Varicella_vaccine_before_S1P_modulator (AAN 2024)
- CYP2C9_genotype_for_siponimod (AAN 2024)
- Vaccinations_before_anti_CD20 (AAN 2024)
- Meningococcal_for_eculizumab (PREVENT Pittock 2019 PMID 31050279)
- NMOSD_AQP4_positive_NO_interferon_NO_natalizumab (Wingerchuk 2015 PMID 26092914)

Monitoring

Regimen monitoring:
- recovery at 4 and 12 weeks (AAN 2024)
- EDSS change pre post (schema-blocked — see depth bundle)
- glucose during steroid (AAN 2024)
- mood sleep during steroid (AAN 2024)
- DMT specific labs CBC LFT JCV IgG (AAN 2024)
- annual brain MRI with NEDA 3 target (AAN 2024)
- AQP4 MOG send out result follow up (Wingerchuk 2015 PMID 26092914; Banwell 2023 PMID 36706773)

Setting (outpatient) monitoring:
- EDSS q6 mo (schema-blocked) (AAN 2024)
- MRI brain ± cord annually with NEDA-3 (AAN 2024)
- JCV-Ab q6 mo on natalizumab (AAN 2024)
- CBC + LFT + IgG per DMT schedule (AAN 2024)
- AQP4 + MOG send-out result follow-up — re-classify if positive (Wingerchuk 2015 PMID 26092914; Banwell 2023 PMID 36706773)
- Mood + cognitive + fatigue screens q6–12 mo (AAN 2024)

Follow-up plan: MS clinic at 4–6 wk; rehab/PT/OT; symptomatic Rx (spasticity, fatigue, bladder); annual MRI brain ± cord; vaccine planning before B-cell depletion (AAN 2024)
- Close-out criterion: MS clinic + rehab follow-up scheduled

Monitoring phase: Glucose during steroid course, mood/sleep, recovery trajectory at 4 + 12 wk; DMT-specific labs (CBC, JCV, IgG) (AAN 2024)

Disposition

Current setting: outpatient — Post-relapse: DMT-escalation discussion (with future companion engine `neuro.ms-dmt-escalation.v1`), MRI surveillance q6–12 mo with NEDA-3 target, JCV-Ab q6 mo on natalizumab, CBC + LFT per DMT, AQP4/MOG result follow-up (re-classify if positive), EDSS q6 mo, fatigue + spasticity + bladder management, mood/SUDEP-equivalent screen, vaccination planning, pregnancy counseling (AAN 2024)

Disposition criteria:
- MS clinic q6 mo if stable (AAN 2024)
- MS clinic q3 mo if active disease or DMT initiation (AAN 2024)
- Re-route to NMOSD/MOGAD engines if antibody-positive (Wingerchuk 2015 PMID 26092914; Banwell 2023 PMID 36706773)

Escalation triggers (move to higher acuity):
- New relapse despite DMT → DMT escalation (companion engine `neuro.ms-dmt-escalation.v1`) (AAN 2024)
- JCV index rising on natalizumab → switch (AAN 2024)
- AQP4-IgG positive → NMOSD pathway (future `neuro.nmosd.v1` engine) (Wingerchuk 2015 PMID 26092914)
- MOG-IgG positive → MOGAD pathway (future `neuro.mogad.v1` engine) (Banwell 2023 PMID 36706773)
- New disability progression independent of relapse → SPMS transition workup (AAN 2024)

Patient Action Plan

**MS relapse action plan (AAN 2024)**
Personalised values: baseline_EDSS (AAN 2024), current_DMT (AAN 2024), common_relapse_pattern (AAN 2024), MS_clinic_contact (AAN 2024).

**Stable baseline (AAN 2024)** (green):
Triggers:
- No new neurologic symptoms
- Function at baseline
- No fever/infection
Actions:
- Take DMT as prescribed
- Heat avoidance (Uhthoff)
- Hydration + sleep + exercise
- Vitamin D supplementation if deficient
- Annual MRI per MS clinic

**Possible relapse — new symptom <24 h or with fever (AAN 2024)** (yellow):
Triggers:
- New neurologic symptom <24 h
- Fever or infection (UTI, viral) — pseudo-relapse risk
- Heat exposure with transient worsening (Uhthoff)
Actions:
- Check temperature; if febrile, treat infection (avoid worsening triggers)
- Hydrate, cool environment
- Wait 24 h while monitoring
- Contact MS clinic if symptoms persist >24 h or worsen
Contact provider when:
- Symptom persists >24 h afebrile
- Symptom worsens despite cooling/treatment
- New severe symptom

**Relapse signs — call MS clinic / ED (AAN 2024)** (red):
Triggers:
- New visual loss (especially with painful eye movement) (ONTT PMID 1734247)
- New limb weakness
- New sensory level / bowel-bladder symptoms (transverse myelitis)
- New brainstem symptoms (double vision, dysphagia, dysarthria, vertigo)
- Symptoms persisting >24 h without fever
Actions:
- Contact MS clinic urgently; if severe → ED
- Bring DMT name + last dose
- For severe optic neuritis (no light perception) or transverse myelitis: ED for STAT MRI + steroid pulse ± PLEX
Contact provider when:
- Any red zone trigger — call MS clinic / ED

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] MS phenotype: severe flare unresponsive to IV methylprednisolone 1 g × 3–5 d by day 7–14; high-disability flare (high EDSS change, transverse myelitis, severe optic neuritis with no light perception) — plasmapheresis 5 cycles q48h (Apoly DS Magaña Neurology 2011 PMID 11309833 NEEDS_SOURCE_REVIEW)
- [SEVERE] MS phenotype: acute monocular vision loss + RAPD + pain on eye movement; MRI orbit ± brain shows optic-nerve enhancement; high-dose IV methylprednisolone 1 g × 3–5 d per ONTT (Beck NEJM 1992 PMID 1734247)
- [SEVERE] MS phenotype: spinal-cord band-like deficit + sensory level + motor level + bowel/bladder dysfunction; MRI cord shows T2-hyperintense lesion; if ≥3 vertebral segments → NMOSD-suspected pivot (AAN 2024; Wingerchuk 2015 PMID 26092914)

Citations

- ECTRIMS 2024 Consensus on DMT Selection + AAN 2018 DMT Practice Guideline + 2017 McDonald Criteria (PMID 29275977; 2024 revision pending publication) + ONTT (Beck NEJM 1992 PMID 1734247) + Apoly DS (Magaña Neurology 2011 PMID 11309833 NEEDS_SOURCE_REVIEW) + NMOSD criteria 2015 (Wingerchuk Neurology 2015 PMID 26092914) + MOGAD criteria 2023 (Banwell Lancet Neurol 2023 PMID 36706773) [PMID:29275977](https://pubmed.ncbi.nlm.nih.gov/29275977/)
- Cited evidence (PMID 1734247) [PMID:1734247](https://pubmed.ncbi.nlm.nih.gov/1734247/)
- Cited evidence (PMID 11309833) [PMID:11309833](https://pubmed.ncbi.nlm.nih.gov/11309833/)
- Cited evidence (PMID 28002679) [PMID:28002679](https://pubmed.ncbi.nlm.nih.gov/28002679/)
- Cited evidence (PMID 29545067) [PMID:29545067](https://pubmed.ncbi.nlm.nih.gov/29545067/)

Last reconciled with current guidelines: 2026-05-14.

References

ECTRIMS 2024 Consensus on DMT Selection + AAN 2018 DMT Practice Guideline + 2017 McDonald Criteria (PMID 29275977; 2024 revision pending publication) + ONTT (Beck NEJM 1992 PMID 1734247) + Apoly DS (Magaña Neurology 2011 PMID 11309833 NEEDS_SOURCE_REVIEW) + NMOSD criteria 2015 (Wingerchuk Neurology 2015 PMID 26092914) + MOGAD criteria 2023 (Banwell Lancet Neurol 2023 PMID 36706773) — PMID:29275977
Cited evidence (PMID 1734247) — PMID:1734247
Cited evidence (PMID 11309833) — PMID:11309833
Cited evidence (PMID 28002679) — PMID:28002679
Cited evidence (PMID 29545067) — PMID:29545067