Patterns of dietary and herbal supplement use by multiple sclerosis patients

Exploratory 5-year follow-up study of retinol, tocopherols, and carotenoids in multiple sclerosis

BACKGROUND

Retinol, tocopherols, and carotenoids (RTC) have physiological roles as vitamins, pro-vitamins, and antioxidants, and provide biomarkers of dietary vegetable and fruit intake. The goal was to investigate RTC in multiple sclerosis (MS).

METHODS

This exploratory study included 106 people with MS (71 relapsing-remitting MS or RR-MS; and 35 progressive MS or PMS) and 31 healthy controls (HC) at baseline and 5-year follow-up (5YFU). Serum retinol, α-carotene, β-carotene, α-tocopherol, δ-tocopherol, γ-tocopherol, β-cryptoxanthin, lutein/zeaxanthin, and lycopene were measured using high performance liquid chromatography. Serum neurofilament light chain (sNfL) levels were measured using the single molecule array method. Expanded Disability Status Scale (EDSS) and low contrast letter acuity (LCLA) were used as disability measures.

RESULTS

Retinol in MS was positively correlated with α-carotene, β-carotene, β-cryptoxanthin, lutein/zeaxanthin, and α-tocopherol but negatively correlated with δ-tocopherol. EDSS was associated with α-tocopherol, δ-tocopherol, and lycopene. Greater retinol levels were associated with greater LCLA in RR-MS and PMS; high contrast visual acuity was not associated. Greater γ-tocopherol levels were associated with lower LCLA and high contrast visual acuity in PMS.

CONCLUSIONS

RTC exhibit distinctive associations with LCLA and EDSS in MS.

Shining a Light on Selenium: a Meta-analysis of Supplementation in Multiple Sclerosis

Multiple sclerosis (MS) is a chronic immune-mediated demyelinating disease of the central nervous system. Selenium is a trace element with significant antioxidant activity. This study aimed to seek evidence concerning selenium supplementation in MS. A systematic search was performed on PubMed, Web of Science, Scopus, and Embase databases to identify the studies assessing the consumption rate, efficacy, and safety of selenium and selenium-containing supplementations in MS patients. The meta-analysis was performed using the Comprehensive Meta-Analysis and the risk of bias was evaluated using the Joanna Briggs Institute's critical appraisal tools. A total of 9 studies were included, which consisted of six studies regarding the rate of selenium supplement consumption in MS patients, with a total sample size of 2381 patients. Based on the quantitative synthesis, 14.3% (95% CI, 12.8-16.0%; I2, 3.58%) of MS patients had current selenium supplements usage, and 11.3% (95% CI, 7.6-16.6%; I2, 81.40%) of patients had used selenium supplements previously. Although there is no evidence regarding supplementation with selenium alone, three RCT studies reported the safety of selenium-containing supplementation use in MS with improved inflammation and oxidative stress conditions. The findings of this study show that over 10% of patients with MS used selenium supplements, with no clinical significance supporting the benefits. There is a lack of evidence regarding the safety and efficacy of selenium supplements in MS patients. Due to the limited number of included studies and the lack of comprehensive and specific studies regarding selenium supplements in MS, the results must be interpreted with caution, and future clinical trials are required.

Do dietary interventions improve health outcomes in people with multiple sclerosis? A Cochrane Review summary with commentary

BACKGROUND: A broad range of complementary and alternative medicine (CAM) approaches, including different dietary interventions, alone or in conjunction with conventional medicine are currently trailed in people with multiple sclerosis (MS). Published clinical and experimental data suggest that certain dietary interventions may improve MS-related health outcomes. OBJECTIVE: To assess the effectiveness of dietary interventions to improve MS-related health outcomes. METHODS: To summarize the updated Cochrane Review “Dietary interventions for multiple sclerosis-related outcomes” conducted by Parks et al. Best available evidence was discussed from the rehabilitation perspective. RESULTS: Overall 30 RCTs (with 2335 participants) evaluated a range of dietary interventions: polyunsaturated fatty acids, antioxidant supplements, dietary programmes and other dietary supplements. All included trials had one or more methodological issues leading to an unknown or high risk of bias. The findings suggest that the evidence is uncertain about the effect of dietary interventions on MS-related health outcomes. CONCLUSIONS: The evidence for dietary interventions in people with MS is sparse and uncertain, and more robust studies are needed.

Assessing multiple sclerosis-related quality of life among Iranian patients using the MSQOL-54 tool: a cross-sectional study

BACKGROUND

Multiple sclerosis (MS) is a chronic autoimmune disease and is one of the most costly medical conditions that imposed families with catastrophic health expenditures. There is an increasing trend in using alternative medicines including, dietary supplements, herbs, vitamins, and minerals. To date, the association between dietary as well as herbal supplements and QoL in MS patients is under researched; thus, this study aimed to assess the association between the self-reported supplement used and QoL between MS patients.

METHODS

This cross-sectional study was conducted on patients with MS referring to Shahid Kazemi Pharmacy, based in the city of Tehran, Iran, as a national pharmacy providing specialized pharmaceutical products and pharmaceutical care to patients. The Multiple Sclerosis Quality of Life-54 (MSQoL-54) tools was performed to evaluate MS patients QoL.

RESULTS

A total number of 382 patients with MS participated in this study. They include 89 (23.3%) men and 293 (76.7%) women, aged 40 ± 10.9 years old. The overall score of the MSQoL-54 questionnaire was 41.58 out of 100. Physical health composite (PHC) and mental health composite (MHC) were 69.60 and 62.99 from 100, respectively. This study revealed that 76.4% of patients used at least one vitamin daily; 92.4% of patients do not receive any herbal product. Vitamin D is the most widely used supplement, followed by calcium, while vitamin C is the least consumed. No correlation was observed regarding supplement use and overall QoL, PHC, or MHC. There were no significant differences between QoL's dimensions score in patients who used supplements. The results showed that increasing the number of supplements used did not relate to overall QoL, PHC, or MHC. In addition, there was not any correlation between the duration used of supplements and QoL's dimensions score in MS patients (p-value> 0.05).

CONCLUSIONS

The dietary supplement appears to be popular among MS patients. The study results showed that the number of supplementations and their long-term use in patients with MS were not associated with higher QoL. Similarly, the herbal supplements have failed to improve QoL.

"I need personal experiences or some sort of documentation": a qualitative study on where people with multiple sclerosis seek information on dietary and herbal supplements

Background

The use of dietary and herbal supplements (DIHES) is widespread among people with multiple sclerosis (PwMS). PwMS are a highly informed patient group, and they use several types of sources to seek information on subjects related to their disease. However, it is still unknown where PwMS seek information about DIHES. It is important that PwMS make decisions about DIHES based on accurate, useful and accessible information. Therefore, the aim of this study was to explore where PwMS seek information on DIHES and how they experience and engage with this information.

Methods

Semi-structured interviews were conducted with eighteen PwMS using DIHES. Participants were selected from a cross-sectional survey. Diversity sampling was used, based on relevant characteristics such as gender and number of DIHES used during the past 12 months. The interviews were conducted face-to-face or over the telephone and lasted between 30 min and 1 hour. The interviews were recorded, transcribed verbatim, and analyzed using thematic network analysis in NVivo 12 Pro software.

Results

Three main themes emerged in the analysis: i) engaging with healthcare professionals (HCPs) regarding DIHES, ii) social networks as a source of information regarding DIHES, and iii) reliance on bodily sensations. Most participants navigated all three types of sources. All participants had at some point discussed DIHES with an HCP. Information from HCPs was considered reliable and valuable, but HCPs were viewed as uncommitted to the dialogue about DIHES. Recommendations from others were often the driver of decisions regarding use of DIHES. However, the information from PwMS’ networks could be overwhelming and difficult to navigate. Finally, PwMS relied on their own experiences regarding DIHES and let their bodily sensations guide their use of DIHES.

Conclusions

Participants often rely on all three types of information sources to create a nuanced and comprehensive information base. However, PwMS may feel overwhelmed or confused with all the information they have gathered. These findings indicate the need for better guidance for PwMS concerning DIHES and an openness among HCPs to engage in dialogue.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12906-021-03377-0.

Use of natural medicine and dietary supplements concomitant with conventional medicine among people with Multiple Sclerosis

BACKGROUND

The use of complementary and alternative medicine (CAM) are widespread among people with Multiple Sclerosis (PwMS) and are often used concomitant with conventional treatment. Natural medicine and dietary supplements (NADS) are the most frequently used CAM modality and among other patient groups use of NADS concomitant with conventional medicine has been reported as a potential risk to patients' safety due to risk of drug interactions. The use of NADS concomitant with conventional medicine has, however, not been investigated among PwMS. This study's aim was to investigate the prevalence of NADS and conventional MS-related medicine use among PwMS, specific types of NADS and conventional MS-related medicine used, the prevalence of NADS used concomitant with conventional MS-related medicine, and to characterize PwMS who use NADS and PwMS who use NADS concomitant with conventional MS-related medicine in a Danish context.

METHODS

The study was a cross-sectional study conducted as an interviewer-administered survey via phone in April 2019. The questionnaire includes questions about the use of NADS and conventional MS medicine as well as sociodemographic and health-related factors. In total 384 PwMS answered the questionnaire. Both descriptive and logistic analyses were used to analyze the data.

RESULTS

The results show that the majority of PwMS use conventional MS-related medicine. In total, 85 % (n=322) had used at least one NADS within the last 12 months including vitamin D. When excluding vitamin D, the use of NADS within the last 12 months was 78.4% (n=298). Beside vitamin D the most reported types of NADS used were fatty acids (37%), Multivitamins (37%), and Calcium (35%). A total of 75.8% (n=288) reported using NADS concomitant with conventional MS medicine, and the products most often combined with conventional MS medicine were Vitamin D, Multivitamin, Calcium, Magnesium, and fatty acids. The results suggest that PwMS using NADS concomitant with conventional MS-related medicine are characterized by a high prevalence of young and newly diagnosed patients with a high education level.

CONCLUSION

The study contributes to a better understanding of NADS used among PwMS. The study shows that the majority of PwMS use NADS and that they use it concomitant with conventional MS-medicine. Furthermore, the detailed mapping of the specific types of NADS used gives a nuanced insight into the specific products of NADS used among PwMS, including different kinds of vitamins, minerals, and herbal remedies.

Dietary interventions for multiple sclerosis-related outcomes

BACKGROUND

Multiple sclerosis (MS) is a common demyelinating disease of the central nervous system. Although the exact pathogenesis remains unknown, the leading theory is that it results from immune system dysregulation. Approved disease-modifying therapy appears to modulate the immune system to improve MS-related outcomes. There is substantial interest in the ability of dietary interventions to influence MS-related outcomes. This is an update of the Cochrane Review 'Dietary interventions for multiple sclerosis' (Farinotti 2003; Farinotti 2007; Farinotti 2012).

OBJECTIVES

To assess the effects of dietary interventions (including dietary plans with recommendations for specific whole foods, macronutrients, and natural health products) compared to placebo or another intervention on health outcomes (including MS-related outcomes and serious adverse events) in people with MS.

SEARCH METHODS

On 30 May 2019, we searched CENTRAL, MEDLINE, Embase, and Web of Science. We also searched ClinicalTrials.gov, World Health Organization International Clinical Trials Registry Platform (ICTRP), and Networked Digital Library of Theses and Dissertations (NDLTD). We checked reference lists in identified trials and requested information from trial authors to identify any additional published or unpublished data.

SELECTION CRITERIA

We included any randomized controlled trial (RCT) or controlled clinical trial (CCT) examining the effect of a dietary intervention versus placebo or another intervention among participants with MS on MS-related outcomes, including relapses, disability progression, and magnetic resonance imaging (MRI) measures.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. Planned primary outcomes were number of participants experiencing relapse and change in disability progression, according to a validated disability scale at the last reported follow-up. Secondary outcomes included MRI activity, safety, and patient-reported outcomes. We entered and analysed data in Review Manager 5.

MAIN RESULTS

We found 41 full-text articles examining 30 trials following full-text review. Participants were adults with MS, defined by established criteria, presenting to MS clinics in Europe, North America, and the Middle East. Study design varied considerably, although all trials had at least one methodological issue leading to unknown or high risk of bias. Trials examined: supplementation to increase polyunsaturated fatty acids (PUFAs) (11 trials); a variety of antioxidant supplements (10 trials); dietary programmes (3 trials); and other dietary supplements (e.g. acetyl L-carnitine, biotin, creatine, palmitoylethanolamide, probiotic, riboflavin) (6 trials). In three trials comparing PUFAs with monounsaturated fatty acids (MUFAs), the evidence was very uncertain concerning difference in relapses (risk ratio (RR) 1.02, 95% confidence interval (CI) 0.88 to 1.20; 3 studies, 217 participants; 75% in the PUFA group versus 74% in the MUFA group; very low-certainty evidence). Among four trials comparing PUFAs with MUFAs, there may be little to no difference in global impression of deterioration (RR 0.85, 95% CI 0.71 to 1.03; 4 studies, 542 participants; 40% in the PUFA group versus 47% in the MUFA group; low-certainty evidence). In two trials comparing PUFAs with MUFAs (102 participants), there was very low-certainty evidence for change in disability progression. None of the PUFA versus MUFA trials examined MRI outcomes. In one trial comparing PUFAs with MUFAs (40 participants), there were no serious adverse events; based on low-certainty evidence. In two trials comparing different PUFAs (omega-3 versus omega-6), there may be little to no difference in relapses (RR 1.02, 95% CI 0.62 to 1.66; 2 studies, 129 participants; 30% in the omega-3 versus 29% in the omega-6 group; low-certainty evidence). Among three trials comparing omega-3 with omega-6, there may be little to no difference in change in disability progression, measured as mean change in Expanded Disability Status Scale (EDSS) (mean difference (MD) 0.00, 95% CI -0.30 to 0.30; 3 studies, 166 participants; low-certainty evidence). In one trial comparing omega-3 with omega-6, there was likely no difference in global impression of deterioration (RR 0.99, 95% CI 0.51 to 1.91; 1 study, 86 participants; 29% in omega-3 versus 29% in omega-6 group; moderate-certainty evidence). In one trial comparing omega-3 with omega-6 (86 participants), there was likely no difference in number of new T1- weighted gadolinium-enhancing lesions, based on moderate-certainty evidence. In four trials comparing omega-3 with omega-6, there may be little to no difference in serious adverse events (RR 1.12, 95% CI 0.38 to 3.31; 4 studies, 230 participants; 6% in omega-3 versus 5% in omega-6 group; low-certainty evidence). In four trials examining antioxidant supplementation with placebo, there may be little to no difference in relapses (RR 0.98, 95% CI 0.59 to 1.64; 4 studies, 345 participants; 17% in the antioxidant group versus 17% in the placebo group; low-certainty evidence). In six trials examining antioxidant supplementation with placebo, the evidence was very uncertain concerning change in disability progression, measured as mean change of EDSS (MD -0.19, 95% CI -0.49 to 0.11; 6 studies, 490 participants; very low-certainty evidence). In two trials examining antioxidant supplementation with placebo, there may be little to no difference in global impression of deterioration (RR 0.99, 95% 0.50 to 1.93; 2 studies, 190 participants; 15% in the antioxidant group versus 15% in the placebo group; low-certainty evidence). In two trials examining antioxidant supplementation with placebo, the evidence was very uncertain concerning difference in gadolinium-enhancing lesions (RR 0.67, 95% CI 0.09 to 4.88; 2 studies, 131 participants; 11% in the antioxidant group versus 16% in the placebo group; very low-certainty evidence). In three trials examining antioxidant supplementation versus placebo, there may be little to no difference in serious adverse events (RR. 0.72, 95% CI 0.17 to 3.08; 3 studies, 222 participants; 3% in the antioxidant group versus 4% in the placebo group; low-certainty evidence).

AUTHORS' CONCLUSIONS

There are a variety of controlled trials addressing the effects of dietary interventions for MS with substantial variation in active treatment, comparator, and outcomes of interest. PUFA administration may not differ when compared to alternatives with regards to relapse rate, disability worsening, or overall clinical status in people with MS, but evidence is uncertain. Similarly, at present, there is insufficient evidence to determine whether supplementation with antioxidants or other dietary interventions have any impact on MS-related outcomes.

Dietary Supplement Use is High among Individuals with Parkinson Disease

OBJECTIVES

To assess the present use of dietary supplements among the Parkinson disease (PD) population and to determine which dietary supplements are most commonly taken.

METHODS

This cross-sectional study used an online questionnaire that was administered to individuals with PD via support group Web sites. Dietary supplement users also were asked whether they spoke with a healthcare professional about their supplement use.

RESULTS

Of the 205 respondents, 83.4% reported taking at least 1 dietary supplement. Although 94 different types of dietary supplements were identified, >50% of participants taking dietary supplements took multivitamins, vitamin D, and vitamin B₁₂ (52.6%, 74.3%, and 56.1%, respectively). Respondents reported taking coenzyme Q10, Mucuna pruriens, folate, vitamin B₁₂, vitamin B₆, melatonin, and N-acetylcysteine most commonly for PD. Among supplement users, 29.2% did not discuss their supplement use with a healthcare practitioner.

CONCLUSIONS

The results of this study demonstrate a high prevalence of dietary supplement use among individuals with PD, in addition to a wide variety of supplements being taken. This study's findings also indicate the need for better dialog between patients and healthcare practitioners regarding the use of dietary supplements.

The effect of emerging nutraceutical interventions for clinical and biological outcomes in multiple sclerosis: A systematic review

BACKGROUND

Due to the considerable burden of multiple sclerosis (MS)-related symptoms and the need to identify effective interventions to prevent disease progression, various nutraceutical interventions have been trialed as adjunctive treatments. The aim of this review was to investigate the efficacy and safety of nutraceutical interventions for clinical and biological outcomes in people with MS.

METHODS

In accordance with PRISMA reporting guidelines, a systematic literature search was conducted using three electronic literature databases. Risk of bias was assessed using the Jadad scale.

RESULTS

Thirty-seven randomized controlled trials, investigating fourteen nutraceuticals, were included in the review. Trials that investigated alpha lipoic acid (n = 4/6), ginkgo biloba (n = 3/5), vitamin A (n = 2/2), biotin (n = 1/2), carnitine (n = 1/2), green tea (n = 1/2), coenzyme Q10 (n = 1/1), probiotics (n = 1/1), curcumin (n = 1/1), Andrographis paniculata (n = 1/1), ginseng (n = 1/1), and lemon verbena (n = 1/1) were reported to improve biological (e.g. MRI brain volume change, antioxidant capacity) and/or clinical (e.g. fatigue, depression, Expanded Disability Status Scale) outcomes in multiple sclerosis compared to control. However, most trials were relatively small (average study sample size across included studies, n = 55) and there were few replicate studies per nutraceutical to validate the reported results. Furthermore, some nutraceuticals (e.g. green tea and inosine) should be used with caution due to reported adverse events. Risk of bias across most studies was low, with 31 studies receiving a score between 4 and 5 (out of 5) on the Jadad Scale.

CONCLUSION

The existing literature provides preliminary support for the use of a number of nutraceutical interventions in MS. However, sufficiently powered long-term trials are required to expand the currently limited literature and to investigate unexplored nutraceuticals that may target relevant pathways involved in MS such as the gut microbiome and mitochondrial dysfunction. Prospero ID: CRD42018111736.

Polypharmacy in outpatients with relapsing-remitting multiple sclerosis: A single-center study

Background

Multiple sclerosis (MS) is an immune-mediated disease of the central nervous system. Given the chronic and heterogenous nature of the disease, treatment with various therapies is a frequent scenario in clinical practice. In persons with chronic morbidity such as MS patients, polypharmacy can give rise to considerable health problems.

Objectives

The aim of the present study was to examine the frequency of polypharmacy among relapsing-remitting (RR) MS patients as well as to analyse sociodemographic and clinical factors, which might be associated with polypharmacy (use of five or more medications). Differences in medication between MS patients with and without secondary illnesses (PwSI and Pw/oSI), between men and women and between patients with and without polypharmacy (PwP and Pw/oP) were examined.

Methods

For 145 RRMS outpatients, we prospectively collected data by means of anamnesis, patient records, clinical examination and a structured patient interview. This was followed by comparative analyses of various patient subgroups (PwP vs. Pw/oP, PwSI vs. Pw/oSI, men vs. women).

Results

The proportion of included MS patients with polypharmacy (use of ≥5 medications) was 30.3%. PwP were significantly older than Pw/oP (45.9 vs. 41.7 years), had a lower level of education and showed a significantly higher median EDSS score (3.0 vs. 2.0). Comorbidities (p<0.001; odds ratio [OR] = 6.293) and higher EDSS scores (p = 0.029; OR = 1.440) were associated with a higher risk of polypharmacy. The proportion of polypharmacy among PwSI was approximately four times higher than among Pw/oSI (46.8% vs. 11.8%). Particularly in the use of antihypertensives, gastrointestinal drugs and dietary supplements, there were differences between Pw/oP and PwP.

Conclusion

We found a high burden of polypharmacy in patients with RRMS. This particularly applies to more severely disabled MS patients who suffer from comorbidities.

Dietary factors and pediatric multiple sclerosis: A case-control study

BACKGROUND

The role of diet in multiple sclerosis (MS) is largely uncharacterized, particularly as it pertains to pediatric-onset disease.

OBJECTIVE

To determine the association between dietary factors and MS in children.

METHODS

Pediatric MS patients and controls were recruited from 16 US centers (MS or clinically isolated syndrome onset before age 18, <4 years from symptom onset and at least 2 silent lesions on magnetic resonance imaging). The validated Block Kids Food Screener questionnaire was administered 2011-2016. Chi-squared test compared categorical variables, Kruskal-Wallis test compared continuous variables, and multivariable logistic regression analysis was performed.

RESULTS

In total, 312 cases and 456 controls were included (mean ages 15.1 and 14.4 years). In unadjusted analyses, there was no difference in intake of fats, proteins, carbohydrates, sugars, fruits, or vegetables. Dietary iron was lower in cases ( p = 0.04), and cases were more likely to consume below recommended guidelines of iron (77.2% of cases vs 62.9% of controls, p < 0.001). In multivariable analysis, iron consumption below recommended guidelines was associated with MS (odds ratio = 1.80, p < 0.01).

CONCLUSION

Pediatric MS cases may be less likely to consume sufficient iron compared to controls, and this warrants broader study to characterize a temporal relationship. No other significant difference in intake of most dietary factors was found.

Complementary and Alternative Medicine Usage by Multiple Sclerosis Patients: Results from a Prospective Clinical Study

OBJECTIVES

To investigate the factors associated with complementary and alternative medicine (CAM) usage by multiple sclerosis (MS) patients. Design, Setting/Location: Single-center, prospective clinical study at an academic MS center in the northeastern United States.

METHODS

This study included CAM data from 524 MS patients and 304 healthy controls (HC) enrolled in a prospective study of clinical, neuroimaging, and environmental risk factors in MS at an academic MS Center. Clinical, neuroimaging, and disease-modifying treatment data were obtained. In addition, data on usage of CAM modalities, including acupuncture, aromatherapy, Ayurveda, Chinese herbal medicine, chiropractor, electromagnetic therapy, homeopathy, hypnosis, massage, naturopathy, Qi gong, Reiki, therapeutic touch, and bee stings were collected in an in-person interview.

RESULTS

The percentages of HC reporting usage of any CAM (32%) was similar to that in MS patients after diagnosis (30.5%). The usage of any CAM was higher in MS patients after MS diagnosis compared to before MS diagnosis (p < 0.001). The three most frequently used CAM for MS patients after MS diagnosis and HC were chiropractor, massage, and acupuncture. The most frequent reasons for CAM use were MS symptom relief, back problems, and pain. In multivariate analysis, female gender, higher education level, MS disease course, and not currently on disease-modifying therapies (DMT) treatment status were associated with CAM usage.

CONCLUSIONS

Gender, education level, DMT treatment status, and MS disease course are associated with CAM usage in MS patients. Ever-CAM usage patterns in MS patients are similar to those in HC.

Reserve-related activities and MRI metrics in multiple sclerosis patients and healthy controls: an observational study

BACKGROUND

To examine whether past and current reserve-related activities make the brain less susceptible to MS pathology (i.e., lesions or disease-related atrophy).

METHODS

This secondary analysis of a cohort study included 276 healthy controls (HC), and 65 clinically isolated syndrome (CIS), 352 relapsing-remitting MS (RR) and 109 secondary- progressive MS (SPMS) patients. Past reserve-related activities comprised educational and occupational attainment. Current reserve-related activities comprised strenuous and non-strenuous activities. MRI was performed on 3 T scanner. Regression and non-parametric analysis examined relationships between MRI metrics and reserve-related activities.

RESULTS

Multivariate models (HC as referent) revealed significant interactions in predicting strenuous reserve-related activities with chronic lesion burden (for CIS), brain- (for RR & SPMS), subcortical- (for CIS, RR, & SPMS) and amygdala- (for RR) volumes. Maximal Lifetime Brain Growth was higher for RR patients who engaged in running before and after diagnosis, rather than only before or never. Residual Brain Volume was higher in RR patients who did weights-exercise before and after diagnosis, as compared to only before.

CONCLUSIONS

Reserve-related activities are related to brain health cross-sectionally in all MS subgroups, and longitudinally in RR patients. Consistent with reserve theory, RR patients who maintained strenuous activities had higher Maximal Lifetime Brain Growth and Residual Brain Volume. The study's limitations are discussed, including the potential for recall bias and design limitations that preclude causal inference.

Iranian consensus on use of vitamin D in patients with multiple sclerosis

Background

Accumulating evidences from experimental, epidemiologic and clinical studies support the potential linkage between poor vitamin D status and the risk of developing Multiple Sclerosis (MS), as well as, an adverse disease course. However, the results of the trials on the clinical outcomes of vitamin D supplementation in MS patients are less consistent which brought many discrepancies in routine practice. In this article we presented a summary of a symposium on vitamin D and MS. In this symposium we aim to review the current data about the relationship between vitamin D and MS, and suggest management guides for practicing neurologists.

Discussion

Generally, supplementation seems to be reasonable for all MS and clinically isolated syndrome (Rinaldi et al., Toxins 7:129–37, 2015) patients with serum 25(OH)D level below 40 ng/ml. In patients with vitamin D insufficiency or deficiency, a large replacing dose (e.g. 50,000 IU capsules of D per week for 8–12 week) is recommended. Panel also suggested: the checking of the serum vitamin D, and calcium level, as well as, patients’ compliance after the initial phase; a maintenance treatment of 1500–2000 IU daily or equivalent intermittent (weekly, biweekly or monthly) Dose, considering the patient’s compliance; routine check of serum vitamin D level at least two times a year especially at the beginning of spring and autumn; Serum vitamin D evaluation for first degree relatives of MS patients at high risk age and supplementation in case of insufficiency (25(OH)D less than 40 ng/ml); correction of vitamin D deficiency and insufficiency before pregnancy, as well as, a daily dose of 1500–2000 IU or equivalent biweekly intake in 2nd and 3rd trimesters; stopping supplementation if 25(OH)D serum level exceeds 100 ng/ml.

Summary

Although the results of high power studies are not available, correcting vitamin D status seems plausible in all MS and CIS patients. Maintaining the serum 25(OH)D level between 40 and 100 ng/ml is not known to exert adverse effect. More ever, it might be associated with lower disease activity.

Managing Disability in Progressive Multiple Sclerosis

OPINION STATEMENT

Patients with progressive forms of multiple sclerosis have various symptoms which affect their quality of life significantly including depression, cognitive decline, sleep changes, bladder dysfunction, sexual dysfunction, and spasticity. Despite recent promising results on the effects of ocrelizumab on neurological disability in patients with PPMS, currently none of the immunomodulatory therapies are approved for progressive forms of multiple sclerosis. Therefore, clinicians currently mostly focus on management of well-recognized comorbidities of this disease phenotype in order to improve patients' quality of life. There are very few studies evaluating strategies of symptomatic management on progressive forms of multiple sclerosis and most of the data is derived from studies on relapsing forms of multiple sclerosis. Understanding of the risks, benefits, and limitations of these therapies can significantly affect patient care. In this article, we review common comorbidities associated with progressive forms of multiple sclerosis and outline important strategies for their symptomatic management.

Use of herbal remedies by multiple sclerosis patients: a nation-wide survey in Italy

Though recent progress in multiple sclerosis (MS) treatment is remarkable, numerous unmet needs remain to be addressed often inducing patients to look for complementary and alternative medicines (CAM), especially herbal remedies (HR). HR use, scarcely investigated in MS, may cause adverse reactions (AR) and interfere with conventional treatment. We performed a survey aimed at evaluating use and attitudes towards HR and factor associated to HR use. Other CAM use and attitudes have been investigated as well. Multiple-choice questionnaires were distributed to MS out patients attending 14 Italian referral Centers. Multivariable logistic regression was used to identify HR use determinants. Present/past HR use for either MS or other diseases was reported in 35.6 % of 2419 cases (95 % CI 36.0-40.0 %). CAM use was reported in 42.5 % of cases. Independent predictors of HR use were represented by higher education, geographic area, dissatisfaction with conventional treatment of diseases other than MS and benefit perception from CAM use. Both HR and CAM use were not always disclosed to the healthcare professional. In conclusion, HR and other CAM appear to be popular among MS patients. The involvement of the healthcare professionals appears to be scarce with potential risk of AR or interference with conventional treatments.

Cardiovascular risk factors are associated with increased lesion burden and brain atrophy in multiple sclerosis

BACKGROUND

Cardiovascular (CV) risk factors have been associated with changes in clinical outcomes in patients with multiple sclerosis (MS).

OBJECTIVES

To investigate the frequency of CV risks in patients with MS and their association with MRI outcomes.

METHODS

In a prospective study, 326 patients with relapsing-remitting MS and 163 patients with progressive MS, 61 patients with clinically isolated syndrome (CIS) and 175 healthy controls (HCs) were screened for CV risks and scanned on a 3T MRI scanner. Examined CV risks included hypertension, heart disease, smoking, overweight/obesity and type 1 diabetes. MRI measures assessed lesion volumes (LVs) and brain atrophy. Association between individual or multiple CV risks and MRI outcomes was examined adjusting for age, sex, race, disease duration and treatment status.

RESULTS

Patients with MS showed increased frequency of smoking (51.7% vs 36.5%, p = 0.001) and hypertension (33.9% vs 24.7%, p=0.035) compared with HCs. In total, 49.9% of patients with MS and 36% of HCs showed ≥ 2 CV risks (p = 0.003), while the frequency of ≥ 3 CV risks was 18.8% in the MS group and 8.6% in the HCs group (p = 0.002). In patients with MS, hypertension and heart disease were associated with decreased grey matter (GM) and cortical volumes (p < 0.05), while overweight/obesity was associated with increased T1-LV (p < 0.39) and smoking with decreased whole brain volume (p = 0.049). Increased lateral ventricle volume was associated with heart disease (p = 0.029) in CIS.

CONCLUSIONS

Patients with MS with one or more CV risks showed increased lesion burden and more advanced brain atrophy.

Reserve-building activities in multiple sclerosis patients and healthy controls: a descriptive study

BACKGROUND

Cognitive reserve has been implicated as a possible protective factor in multiple sclerosis (MS) but to date no study has compared reserve-building activities across disease course or to healthy controls. This study aims to describe differences in reserve-building activities across the MS disease course and healthy controls.

METHODS

Secondary analysis of a cross-sectional cohort study that included 276 healthy controls, and subjects with clinically isolated syndrome (CIS; n = 67), relapsing-remitting MS (RRMS; n = 358) and secondary progressive MS (PMS; n = 109). Past reserve-building activities were operationalized as occupational attainment and education. Current activities comprised 6 strenuous and 6 non-strenuous activities, including 5 reserve-building activities and television-watching. Multivariate Analysis of Variance models examined group differences in past and current activities, after adjusting for covariates.

RESULTS

There were group differences in past and current reserve-building activities. SPMS patients had lower past reserve-building activities than healthy controls. All forms of MS engaged in fewer strenuous current reserve-building pursuits than healthy controls. RRMS read less than healthy controls. SPMS engaged in fewer job-related non-strenuous activities. All MS groups watched more television than healthy controls.

CONCLUSIONS

MS patients show significantly fewer past and present reserve-building activities. Although it is difficult to establish causality without future prospective studies, lifestyle-modifying interventions should prioritize expanding MS patients' repertoire of strenuous and non-strenuous activities.

Increased contrast enhancing lesion activity in relapsing-remitting multiple sclerosis migraine patients

Background and objectives

While the literature supports the idea that multiple sclerosis (MS) and migraine are related, the exact mechanism(s) of this association is not well understood. Observations of increased contrast enhancing (CE) lesion activity in individual MS patients suffering from migraine prompted us to determine a relationship between migraine and MRI outcomes in a large cohort of MS patients.

Methods

We included 509 MS and 64 clinically isolated syndrome (CIS) patients and 251 age- and sex-matched healthy individuals (HIs) who obtained 3 T MRI and were assessed for history of migraine. Number and volume of T2, T1 and CE lesions and brain volume measures were determined. The MRI findings were analyzed adjusting for key covariates and correcting for multiple comparisons.

Results

More MS (22.2%) and CIS (17.2%) patients had migraine, compared to HIs (14.6%, p = 0.067). More MS patients with migraine presented with CE lesions compared to those without (35.4% vs. 23.7%, p = 0.013). MS migraine patients had significantly increased number (p = 0.019) and volume (p = 0.022) of CE lesions compared to those without. In the regression analysis, MS migraine patients had an increased number of CE lesions (B = 1.242, p = 0.001), specifically those with relapsing–remitting disease course (B = 1.377, p = 0.001). No significant association of other MRI measures and migraine was found in MS and CIS patients or in HIs.

Conclusions

Our findings suggest an increased inflammatory pathobiology in MS patients with migraine headaches requiring possibly more frequent MRIs and also more efficient anti-inflammatory treatment.

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We examined 509 MS and 64 CIS patients and 251 healthy individuals.

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Subjects were assessed with 3 T MRI and for history of migraine.

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More MS and CIS patients had migraine, compared to healthy controls.

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More MS migraine patients presented with enhancing brain lesions compared to those without.

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MS migraine patients had an increased number and volume of enhancing lesions.

Cost effectiveness of fingolimod, teriflunomide, dimethyl fumarate and intramuscular interferon-β1a in relapsing-remitting multiple sclerosis

OBJECTIVE

The aim of the study was to compare the cost effectiveness of fingolimod, teriflunomide, dimethyl fumarate, and intramuscular (IM) interferon (IFN)-β(1a) as first-line therapies in the treatment of patients with relapsing-remitting multiple sclerosis (RRMS).

METHODS

A Markov model was developed to evaluate the cost effectiveness of disease-modifying drugs (DMDs) from a US societal perspective. The time horizon in the base case was 5 years. The primary outcome was incremental net monetary benefit (INMB), and the secondary outcome was incremental cost-effectiveness ratio (ICER). The base case INMB willingness-to-pay (WTP) threshold was assumed to be US$150,000 per quality-adjusted life year (QALY), and the costs were in 2012 US dollars. One-way sensitivity analyses and probabilistic sensitivity analysis were conducted to test the robustness of the model results.

RESULTS

Dimethyl fumarate dominated all other therapies over the range of WTPs, from US$0 to US$180,000. Compared with IM IFN-β(1a), at a WTP of US$150,000, INMBs were estimated at US$36,567, US$49,780, and US$80,611 for fingolimod, teriflunomide, and dimethyl fumarate, respectively. The ICER of fingolimod versus teriflunomide was US$3,201,672. One-way sensitivity analyses demonstrated the model results were sensitive to the acquisition costs of DMDs and the time horizon, but in most scenarios, cost-effectiveness rankings remained stable. Probabilistic sensitivity analysis showed that for more than 90% of the simulations, dimethyl fumarate was the optimal therapy across all WTP values.

CONCLUSION

The three oral therapies were favored in the cost-effectiveness analysis. Of the four DMDs, dimethyl fumarate was a dominant therapy to manage RRMS. Apart from dimethyl fumarate, teriflunomide was the most cost-effective therapy compared with IM IFN-β(1a), with an ICER of US$7,115.

Phase white matter signal abnormalities in patients with clinically isolated syndrome and other neurologic disorders

BACKGROUND AND PURPOSE

Identifying MRI biomarkers that can differentiate multiple sclerosis patients from other neurological disorders is a subject of intense research. Our aim was to investigate phase WM signal abnormalities for their presence, prevalence, location, and diagnostic value among patients with clinically isolated syndrome and other neurologic disorders and age-, sex-, and group-matched healthy controls.

MATERIALS AND METHODS

Forty-eight patients with clinically isolated syndrome and 30 patients with other neurologic diseases and a healthy control group (n = 47) were included in the study. Subjects were scanned at 3T by using SWI-filtered phase and T2WI, with WM signal abnormalities ≥3 mm being classified.

RESULTS

Patients with clinically isolated syndrome had significantly more phase and T2 WM signal abnormalities than healthy controls (P < .001). Phase WM signal abnormalities were more prevalent among patients with clinically isolated syndrome compared with patients with other neurologic disorders (4:1 ratio), whereas T2 WM signal abnormalities were more ubiquitous with a 2:1 ratio. The presence of phase WM signal abnormalities was sensitive for clinically isolated syndrome (70.8%) and achieved a moderate-to-high specificity for differentiating patients with clinically isolated syndrome and healthy controls, patients with other neurologic disorders, and patients with other neurologic disorders of other autoimmune origin (specificity, 70%-76.7%). Combining the presence of ≥2 phase lesions with the McDonald 2005 and 2010 criteria for dissemination in space improved the specificity (90%), but not the accuracy, in differentiating patients with clinically isolated syndrome from those with other neurologic disorders. In subanalyses among patients with clinically isolated syndrome who converted to clinically definite multiple sclerosis versus those who did not within a 3-year follow-up period, converters had significantly more phase (P = .008) but not T2 or T1 WM signal abnormalities.

CONCLUSIONS

Phase WM signal abnormalities are prevalent among patients with clinically isolated syndrome. The presence of (multiple) phase WM signal abnormalities tended to be more predictive of conversion to clinically definite multiple sclerosis and was specific in differentiating patients with clinically isolated syndrome and other neurologic disorders, compared with T2 WM signal abnormalities; however, the accuracy remains similar to that of the current McDonald criteria.

Vitamin D supplementation and monitoring in multiple sclerosis: who, when and wherefore

OBJECTIVES

Observational studies suggest that increasing the serum concentration of 25-hydroxyvitamin D with 50 nm could halve the relapse risk in relapsing-remitting multiple sclerosis (MS). Assuming that the association between disease activity and vitamin D status is entirely causal may however exaggerate the potential benefit. The aim of this paper is to address whether and how vitamin D should be monitored in patients with MS.

METHODS

Possible benefits of vitamin D supplementation were assessed from observational, experimental and clinical studies. Based on repeated measurements of 25-hydroxyvitamin D in Norwegian patients with MS , we estimate the effect of different supplementation regimes.

RESULTS

Serum levels of 25-hydroxyvitamin in the upper physiological range are associated with lower risk of relapses and magnetic resonance imaging disease activity, but the causality is uncertain. Osteoporosis develops early in patients with MS , and 25-hydroxyvitamin vitamin should therefore at least be 50 nm throughout the year. Levels between 75 and 125 nmol may offer some additional benefit for bone health, are not toxic and are associated with low disease activity. Adding 400 IU (10 μg) vitamin D daily would only bring 56% of the patients >50 nm and 11% >75 nm throughout the year, whereas 800 IU (20 μg) would maintain 97% >50 nm and 67% >75 nm.

CONCLUSION

We recommend that MS patients are supplemented with 800 IU of vitamin D at least from autumn to spring. Alternatively, 25-hydroxyvitamin D should be measured and the nadir level estimated and supplementation given to a target level between approximately 75 and 125 nm.

Dietary interventions for multiple sclerosis

BACKGROUND

Clinical and experimental data suggest that certain dietary regimens, particularly those including polyunsaturated fatty acids (PUFAs) and vitamins, might improve outcomes in people with multiple sclerosis (MS). Diets and dietary supplements are much used by people with MS in the belief that they might improve disease outcomes and overcome the effectiveness limits of conventional treatments.This is an update of the Cochrane review "Dietary intervention for multiple sclerosis" (first published on The Cochrane Library 2007, Issue 1).

OBJECTIVES

To answer MS patients' questions regarding the efficacy and safety of dietary regimens for MS. Can changes in dietary habits be an effective intervention for MS patients? Are the potential side effects of these interventions known, and have they been measured? Are potential interactions between dietary interventions and other curative or symptomatic treatments known and have they been studied?

SEARCH METHODS

We searched the Cochrane Multiple Sclerosis and Rare Diseases of the Central Nervous System Group Specialised Register (November 2011), CENTRAL (The Cochrane Library 2011, Issue 4), MEDLINE (PubMed) (1966 to November 2011), EMBASE (embase.com) (1974 to November 2011) and reference lists of papers found.

SELECTION CRITERIA

All controlled trials (randomised controlled trials (RCTs) and controlled clinical trials (CCTs)) on a specific dietary intervention, diet plan or dietary supplementation, except for vitamin D supplementation, compared to no dietary modification or placebo were eligible.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected articles, assessed trial quality and extracted data. Data were entered and analysed in RevMan.Dichotomous data were summarised as relative risks (RR) with 95% confidence intervals (95% CI) using a random-effects model in the presence of heterogeneity (I² > 60%). Continuous data were analysed using weighted mean differences, determined by the difference between the pre- and post-intervention changes in the treatment and control groups.

MAIN RESULTS

Six RCTs that investigated PUFAs emerged from the search strategy, accounting for 794 randomised patients.PUFAs did not have a significant effect on disease progression at 24 months. Omega-6 fatty acids (11 to 23 g/day linoleic acid) didn't show any benefit in 144 MS patients (RR 1.04, 95% CI 0.66 to 1.63). Linoleic acid (2.9 to 3.4 g/day) had no benefit in 65 chronic progressive MS patients (RR 0.78, 95% CI 0.43 to 1.42). Omega-3 fatty acids had no benefit in 292 relapsing remitting MS patients (RR 0.82, 95% CI 0.65 to 1.03, P = 0.08).Slight potential benefits in relapse outcomes were associated with omega-6 fatty acids in some studies, however these findings were limited by the reduced validity of the endpoints. No judgements about safety or patient-reported outcomes were possible. In general, trial quality was poor.No studies on vitamin supplementation and allergen-free diets were analysed as none met the eligibility criteria, mainly due to lack of clinical outcomes.

AUTHORS' CONCLUSIONS

PUFAs seem to have no major effect on the main clinical outcome in MS (disease progression), but they may tend to reduce the frequency of relapses over two years. However, the data that are available are insufficient to assess a real benefit or harm from PUFA supplementation because of their uncertain quality.Evidence on the possible benefits and risks of vitamin supplementation and antioxidant supplements in MS is lacking. More research is required to assess the effectiveness of dietary interventions in MS.