Effect of Vitamin D Supplements on Relapse Rate and Expanded Disability Status Scale (EDSS) in Multiple Sclerosis (MS): A Systematic Review and Meta-Analysis

Vitamin D in Multiple Sclerosis: A Comprehensive Umbrella Review

BACKGROUND

Multiple sclerosis (MS) is an inflammatory neuroimmune disease with a multifaceted etiology and long-lasting adverse effects. Several studies have explored the role of 25-hydroxyvitamin D (25(OH)D) serum levels, vitamin D receptor (VDR) gene polymorphisms, and vitamin D supplementation (VDS) in individuals with MS.

OBJECTIVES

The aim of this study was to evaluate the relationship of MS with 25(OH)D serum levels, VDR gene polymorphisms, and VDS.

METHODS

We assessed relevant articles published in PubMed, Scopus, and Web of Science from the inception up to 24 February, 2024. Meta-analyses that investigated the link of 25(OH)D serum levels, VDR gene polymorphisms including Apal (rs7975232), BsmI (rs1544410), Taql (rs731236), and Fokl (rs10735810), and VDS with the risk and clinical manifestations of MS were included. The methodological quality of selected articles was assessed by the Assessment of Multiple Systematic Reviews version 2. The statistical analysis of this umbrella review was carried out using RStudio version 2023.03.1 and R version 4.3.2, simultaneously.

RESULTS

A total of 23 of 304 records were entered into this umbrella review with a pooled sample size of 37,567 participants. Eleven articles were rated as high quality, 1 was moderate quality, 1 was low quality, and 10 were critically low quality. The homozygote model of FokI (FF+ff compared with Ff) was significantly associated with an 8% reduction of MS risk (odds ratio: 0.92, 95% confidence interval: 0.86, 0.98; I2 = 0%, P > 0.99).

CONCLUSION

According to existing clinical evidence, the risk of MS may be associated with VDR gene polymorphism. Further studies are needed to explore the association of MS and vitamin D.

TRIAL REGISTRATION NUMBER

This trial was registered at International Prospective Register of Systematic Reviews (PROSPERO) as registration number CRD42024521541.

Effects of robotic rehabilitation on fatigue experience, disability, and quality of life in patients with multiple sclerosis (MS): A systematic review and meta-analysis

Background

Rehabilitation plays an important role in improving symptoms in patients with multiple sclerosis (MS). There are studies evaluating the effects of robotic rehabilitation in patients with MS, but the results varied between the studies. So, we designed this systematic review and meta-analysis to estimate pooled effects of robotic rehabilitation on fatigue, disability, and quality of life in subjects with MS.

Methods

We systematically searched PubMed, Scopus, EMBASE, Web of Science, Google Scholar, and also gray literature including references of the included studies, and also conference abstracts on October 1th 2022. Data regarding the total number of participants, first author, publication year, country of origin, mean age, EDSS, and results of fatigue and quality of life were recorded.

Results

The first literature search revealed 6878 results, after deleting duplicates, 5019 studies remained. Two researchers, evaluated the titles and abstracts, and finally 77 full texts were assessed. For meta-analysis, we included 11 studies. The pooled Standardized Mean Difference (SMD) of Kurtzke Expanded Disability Status Scale (EDSS) (after-before) estimated as -0.56 (95%CI: -0.89,-0.23). The pooled SMD of Fatigue Severity Scale (FSS) estimated as -0.54(95%CI: -1.06, -0.01) (I2=66.7%, P=0.01). The pooled SMD of physical health subscale of multiple sclerosis quality of life (MSQOL-54) estimated as 0.36(95%CI:-0.23, 0.96) (I2=51.4%, P=0.1). The pooled SMD of mental health subscale of MSQOL54 estimated as 0.48 (95%CI: 0.07, 0.88) (I2=0%, P=0.6).

Conclusions

The results of this systematic review and meta-analysis show that robotic rehabilitation has positive effects on fatigue, and disability in patients with MS.

Investigating the effects of 25-hydroxyvitamin D3 on clinical outcomes in multiple sclerosis patients: A randomized, double-blind clinical trial- a pilot study

BACKGROUND

The primary objective of this clinical trial was to assess whether administrating oral calcifediol (25(OH)D3) could enhance the clinical outcomes of patients diagnosed with multiple sclerosis.

METHODS

This clinical trial was designed as a randomized, double-blind, two-arm study, with 25 participants receiving daily 50 μg of calcifediol and 25 people receiving daily 50 μg of cholecalciferol. The primary outcomes were serum levels of 25(OH)D3, number of relapses, changes in Kurtzke Expanded Disability Status Scale (EDSS), the 25-foot walk, and cognitive function.

RESULTS

At the end of the trial, delta serum concentrations of 25(OH)D3 were 85.32±40.94 ng/ml in the calcifediol group compared to 13.72±11.56 ng/ml in the cholecalciferol group; 84 % of the calcifediol group and none of the cholecalciferol group had circulating 25(OH)D3 concentrations exceeding 70 ng/ml. While both groups showed an overall trend towards improved cognitive function at the end of the study, the calcifediol group exhibited greater improvements in most cognitive tests. However, the trial had no significant beneficial effects on MS relapse, EDSS score, quality of life, or fatigue in either group, the calcifediol or cholecalciferol.

CONCLUSIONS

The trial shows that calcifediol is more effective in rapidly increasing 25(OH)D3 levels in MS patients compared to cholecalciferol when administrated at a similar dosage.

The Effects of Aquatic Therapy on Depression, Fatigue, and Balance in Patients with Multiple Sclerosis (MS): a Systematic Review and Meta-Analysis

Background: Fatigue, depression, and balance impairment are common in patients with multiple sclerosis (MS). Aquatic therapy is an exercise program which is effective in improving the well-being of patients with MS. So, we designed this systematic review to estimate the pooled effects of aquatic therapy on depression, fatigue and balance in subjects with MS. Methods:Two independent researchers did a systematic and comprehensive search of PubMed, Scopus, EMBASE, Web of Science, Google Scholar as well as gray literature, including references of the included studies, and conference abstracts. The search was done on October 31st 2022. We extracted data regarding the total number of participants, first author, publication year, country of origin, mean age, EDSS, and results of fatigue, depression and balance. Results:The first search identified 6403 studies. After deleting duplicates, 3347 studies remained, and 86 full texts were evaluated. Ten studies remained for meta-analysis. The pooled standardized mean difference (SMD) of BBS (after-before) was 0.67 (95% CI 0.19-1.16) (I²=11.6%, P=0.3). The pooled SMD of MFIS (after-before) was -0.4 (95% CI -0.71 to -0.09) (I2=21%, P=0.2). The pooled SMD of FSS (after-before) was -1.13 (95% CI -1.95 to -0.3) (I²=82.5%, P=0.003). The pooled SMD of BDI (after-before) was -1.83 (95% CI -2.31 to -1.35) (I²=30.1%, P=0.2). Conclusion:The results of the present systematic review and meta-analysis show that aquatic therapy is effective for depression, fatigue, and balance improvement in subjects with MS.

Exploring factors to interpretation of targeted nutrition messages for people living with multiple sclerosis

OBJECTIVES

Current dietary recommendations for MS suggest following national dietary guidelines developed for the general population. The aim of this study was to explore the interpretation of MS-targeted nutrition messages.

METHODS

Using the Elaboration Likelihood Model of persuasion, three nutrition messages were developed targeting the strongest evidence for MS: vitamin D, dietary fat, and dietary diversity. Semi-structured interviews including the cognitive 'thinking-aloud' technique were used to test the messages with adults living with MS. Data were transcribed and coded thematically.

RESULTS

Theoretical saturation was reached by 15 interviews. The data corpus indicated three themes and seven subthemes. The data revealed that people living with MS changed their diet after MS diagnosis. Dietary change was due to uncertainty, fear of disease progression and risk of relapse. The admiration and scepticism of extremist MS diets depended on personal vulnerability and support from health care professionals. The unique MS journey appeared influential to message interpretation; driven by engagement, practicality, and credibility.

CONCLUSION

The interpretation of targeted nutrition messages revealed that dietary changes made after diagnosis are a coping mechanism to improve sense of control and self-management.

PRACTICAL IMPLICATIONS

The potential psychological benefit of dietary change for MS management must be prioritised using person-centred care.

Vitamin D3 as an add-on treatment for multiple sclerosis: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Vitamin D deficiency has been linked to a higher risk of multiple sclerosis (MS) and disease progression. However, the efficacy of vitamin D3 as an adjuvant therapy for MS remains a controversial topic.

OBJECTIVE

To perform a systematic review and meta-analysis of randomized controlled trials to assess the impact of adjunct high-dose vitamin D3 on clinical and radiological outcomes.

METHODS

PubMed, Embase, and Cochrane Library were searched for trials published until December 18th, 2022. Authors independently selected randomized controlled trials involving patients with MS, with an intervention group receiving high dose (≥ 1000 IU/day) cholecalciferol and reporting clinical or radiological outcomes. Authors independently extracted data and assessed the risk of bias using a standardized, pilot-tested form. The meta-analysis was conducted using RStudio for EDSS at the last follow-up, ARR, and new T2 lesion count.

RESULTS

We included 9 studies with 867 participants. No significant reduction of EDSS (MD = 0.02, CI 95 % [-0.37; 0.41], p = 0.91), ARR (MD -0.03, CI 95 % [-0.08; 0.02], p = 0.26), or new T2 lesions (MD -0.59, CI 95 % [-1.24;0.07], p = 0.08) was observed at 6-24 months. We found no evidence of publication bias.

CONCLUSION

The findings of this meta-analysis strengthen current evidence that vitamin D3 supplementation has no significant impact on clinical outcomes in patients with MS. However, the non-significant reduction of new T2 lesions could precede long-term clinical benefits and should be validated in additional studies.

The Efficacy of Fingolimod and Interferons in Controlling Disability and Relapse Rate in Patients with Multiple Sclerosis: A Systematic Review and Meta-Analysis

Background

Fingolimod and interferons are used in the relapse form of multiple sclerosis (MS). The goal of this systematic review and meta-analysis was to evaluate the efficacy of fingolimod versus interferon in patients with MS. The systematic search was done in PubMed, Scopus, Embase, Web of Science, and Google Scholar.

Methods

The references of included studies as well as conference abstracts were searched up to July 2021. The literature search revealed 8211 articles, and after deleting duplicates 5594 remained. For the meta-analysis, four studies were included. The standardized mean difference (SMD) of the Expanded Disability Status Scale (EDSS) after treatment (interferon vs fingolimod) was -0.06 (95% CI: -0.28, 0.17) (I2 = 80.2%, P = 0.002).

Results

The SMD of the annual relapse rate (ARR) after treatment (interferon - fingolimod) was -0.08 (95% CI: -0.53, 0.36) (I2 = 95.5%, P < 0.001). The SMD of the ARR after treatment and before treatment in the interferon group was - 1.45, (95% CI: -1.55, -1.36) (I2 = 0, P = 0.3). The SMD of ARR after treatment and before treatment in the fingolimod group was - 1.3, (95% CI: -1.94, -0.65) (I2 = 97.4%, P < 0.001). Conclusions: The results of this systematic review show that efficacy of interferon and fingolimod in controlling relapse rate and disability is similar.

Impact of menopause on relapse rate and disability level in patients with multiple sclerosis (MS): a systematic review and meta-analysis

BACKGROUND

Menopause is a physiologic phase in women's lives. Findings regarding multiple sclerosis (MS) course through menopause are diverse. So, we designed this systematic review and meta-analysis to estimate the impact of menopause on relapse rate, and disability status in women with MS.

METHODS

PubMed, Scopus, EMBASE, Web of Science, and google scholar were systematically searched by two independent researchers on January 1st, 2023. They also evaluated conference abstracts, and references of the included studies. In addition, data regarding the total number of participants, name of the first author of the publication, publication year, country of origin, disease duration, disease type, annual relapse rate, and Expanded Disability Status Scale (EDSS) before and after menopause were recorded.

RESULTS

A literature search revealed 1024 records. Twenty-one full texts were evaluated, and finally, four studies were included for meta-analysis. Mean ARR before menopause ranged between 0.21 and 0.37, and after menopause ranged between 0.13 and 0.08. The SMD of mean ARR ranged between - 1.04, and - 0.29, while the pooled SMD was estimated as -0.52(95% CI: -0.88, -0.15) (I2 = 73.6%, P = 0.02). The mean EDSS before menopause ranged between 1.5 and 2, and after menopause ranged between 2 and 3.1. The SMD of EDSS ranged between 0.46, and 0.71. The pooled SMD of EDSS change (after menopause-before menopause) estimated as 0.56(95% CI: 0.38, 0.73)(I2 = 0, P = 0.4).

CONCLUSION

The result of this systematic review and meta-analysis show that menopause can be associated with relapse rate reduction, unlike increase in disease-related disability in women with MS.

Effect of Vitamin D Supplementation on Fatigue in Multiple Sclerosis: A Systematic Review and Meta-Analysis

Vitamin D supplementation has been considered a possible treatment to reduce the risk of disease activity and progression in people with multiple sclerosis (MS). However, its effect on disease symptoms remains unclear. The aim of this meta-analysis was to conduct a systematic review to assess the effect of vitamin D on fatigue in this population. The systematic review was conducted using the MEDLINE, Cochrane Library, Embase and Web of Science databases from inception to May 2023. Randomized controlled trials (RCTs) reporting pre-post changes in fatigue after vitamin D supplementation were included. Pooled effect sizes and 95% confidence intervals (95% CIs) were calculated by applying a random effects model with Stata/SE (Version 16.0; StataCorp., College Station, TX, USA). The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. A total of five studies with 345 individuals (271 females; age range: 25.4-41.1 years) were included. A significant reduction in fatigue was perceived when vitamin D supplementation was compared with a control group: -0.18 (95% CI: -0.36 to -0.01; I² = 0%). Thus, our findings show that the therapeutic use of vitamin D on fatigue in people with MS could be considered. Nevertheless, due to the lack of agreement on the dose to be applied, it is recommended to use it under medical prescription.

Clinical and Imaging Outcomes after Vitamin D Supplementation in Patients with Multiple Sclerosis: A Systematic Review

The link between vitamin D and multiple sclerosis (MS) has been suggested in epidemiological, genetic, immunological, and clinical studies. The aim of the present systematic review of the literature was to assess the effects of vitamin D supplementation on clinical and imaging outcomes in patients with MS. The outcomes we assessed included relapse events, disability progression, and magnetic resonance imaging (MRI) lesions. The search was conducted using PubMed, ClinicalTrials.gov, and EudraCT databases, and it included records published up until 28 February 2023. The systematic review was reported according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) 2020 guidelines. Nineteen independent clinical studies (corresponding to 24 records) were included in the systematic review. The risk of bias in randomized controlled trials (RCTs) was analyzed using the Cochrane risk-of-bias tool. Fifteen trials investigated relapse events, and most of them reported no significant effect of vitamin D supplementation. Eight of 13 RCTs found that vitamin D supplementation had no effect on disability [assessed by Expanded Disability Status Scale (EDSS) scores] compared to controls. Interestingly, recent RCTs reported a significant reduction in new MRI lesions in the central nervous system of MS patients during supplementation with vitamin D3.

Radiological Benefits of Vitamin D Status and Supplementation in Patients with MS—A Two-Year Prospective Observational Cohort Study

Current data emphasize the immunomodulating role of vitamin D in enhancing the anti-inflammatory response. Vitamin D deficiency is an established risk factor for developing multiple sclerosis—the autoimmune demyelinating and degenerative disease of the central nervous system. Several studies confirmed that higher vitamin D serum level is associated with better clinical and radiological outcomes in patients with multiple sclerosis, whereas vitamin D supplementation benefits in multiple sclerosis remain inconclusive. Despite that, many experts suggest regular measurements of vitamin D serum levels and supplementation in patients with multiple sclerosis. In this study, 133 patients with multiple sclerosis (relapsing–remitting subtype) were prospectively observed in a 0-, 12- and 24-month time span in a clinical setting. The study group consisted of 71.4% of patients (95 out of 133) supplementing vitamin D. The associations between vitamin D serum levels, clinical outcomes (disability status expressed by EDSS, number of relapses and time to relapse) and radiological outcomes (new T2-weighted lesions and number of gadolinium-enhanced lesions) were evaluated. There were no statistically significant correlations between clinical outcomes and vitamin D serum levels or supplementations. Fewer new T2-weighted lesions were observed in patients with vitamin D supplementations (p = 0.034) in 24 months of observation. Moreover, an optimal or higher level of vitamin D (>30 ng/mL) maintained throughout the entire observation period was associated with a lower number of new T2-weighted lesions in 24 months of observation (p = 0.045). These results support vitamin D implementation commencement and amelioration in patients with multiple sclerosis.

Efficacy of Diet on Fatigue and Quality of Life in Multiple Sclerosis: A Systematic Review and Network Meta-analysis of Randomized Trials

BACKGROUND AND OBJECTIVE

Emerging evidence suggests a role for diet in multiple sclerosis (MS) care; however, owing to methodological issues and heterogeneity of dietary interventions in preliminary trials, the current state of evidence does not support dietary recommendations for MS. The objective of this study was to assess the efficacy of different dietary approaches on MS-related fatigue and quality of life (QoL) through a systematic review of the literature and network meta-analysis (NMA).

METHODS

Electronic database searches were performed in May 2021. Inclusion criteria were (1) randomized trial with a dietary intervention, (2) adults with definitive MS based on McDonald criteria, (3) patient-reported outcomes for fatigue and/or QoL, and (4) minimum intervention period of 4 weeks. For each outcome, standardized mean differences (SMDs) were calculated and included in random effects NMA to determine the pooled effect of each dietary intervention relative to each of the other dietary interventions. The protocol was registered at PROSPERO (CRD42021262648).

RESULTS

Twelve trials comparing 8 dietary interventions (low-fat, Mediterranean, ketogenic, anti-inflammatory, Paleolithic, fasting, calorie restriction, and control [usual diet]), enrolling 608 participants, were included in the primary analysis. The Paleolithic (SMD -1.27; 95% CI -1.81 to -0.74), low-fat (SMD -0.90; 95% CI -1.39 to -0.42), and Mediterranean (SMD -0.89; 95% CI -1.15 to -0.64) diets showed greater reductions in fatigue compared with control. The Paleolithic (SMD 1.01; 95% CI 0.40-1.63) and Mediterranean (SMD 0.47; 95% CI 0.08-0.86) diets showed greater improvements in physical QoL compared with control. For improving mental QoL, the Paleolithic (SMD 0.81; 95% CI 0.26-1.37) and Mediterranean (SMD 0.36; 95% CI 0.06-0.65) diets were more effective compared with control. However, the NutriGRADE credibility of evidence for all direct comparisons is very low because of most of the included trials having high or moderate risk of bias, small sample sizes, and the limited number of studies included in this NMA.

DISCUSSION

Several dietary interventions may reduce MS-related fatigue and improve physical and mental QoL; however, because of the limitations of this NMA, which are driven by the low quality of the included trials, these findings must be confirmed in high-quality, randomized, controlled trials.

Vitamin D Supplementation Practices among Multiple Sclerosis Patients and Professionals

Vitamin D serum level increase is associated with a reduction in clinical relapse rate, gadolinium-enhancing lesions, new or enlarging T2 lesions and new active lesions in the MRI in MS patients. However, current RCTs assessing the vitamin D supplementation therapeutic effect in MS provide inconclusive results. Experts recommend vitamin D measurements and implementations among patients with MS. This article discusses an observational study, performed without any intervention to evaluate the vitamin D status and practices among MS patients and professionals in the clinical setting. A total of 139 patients with MS treated by disease-modifying therapy were recruited and fulfilled the standardized questionnaire assessing the vitamin D supplementation practices and vitamin D level influencing factors such as education, insolation, smoking, obesity and current treatment. The collected data were then compared to the patients' vitamin D serum levels available in medical records at the baseline and after 12 months of observation. Professionals' practices and recommendations were also assessed. A total of 74.1% patients confirmed vitamin D supplementation, and all patients were administered cholecalciferol, taken orally. However, only 43.69% of the patients achieved an optimal vitamin D concentration (30-50 ng/mL). The lack of a doctor's recommendation was the most frequent reason for the absence of vitamin D supplementation. The most often recommended vitamin D daily dose was 4000 IU. There was no adverse effect of supplementation observed. Vitamin D status in patients with MS is currently better than in the general population, but still, a significant percentage of patients do not implement vitamin D.

Vitamin D and Depressive Symptoms in Adults with Multiple Sclerosis: A Scoping Review

BACKGROUND

Vitamin D deficiency has been correlated with Multiple Sclerosis (MS) risk and disease activity. There is some controversy as to whether vitamin D could have an impact on depressive symptoms in people with MS (pwMS). The aim of this scoping review was to evaluate the association between vitamin D status and depressive symptoms in pwMS.

METHODS

We searched databases to include studies published up to March 2021 to provide an overview of the available evidence on the correlation between vitamin D status and depressive symptoms in pwMS. The eligibility criteria were as follows: studies evaluating the use of vitamin D measurement on depressive symptoms in patients suffering from MS, including randomized and non-randomized studies; studies written in English; and studies exploring an adult population over the age of 18.

RESULTS

Eleven studies met our inclusion criteria: two of them were abstracts only; the majority were cross-sectional studies; two were prospective longitudinal studies; one was a retrospective cohort study; and one was a randomized placebo-controlled trial (RCT). Of the eleven studies selected, seven showed a potential correlation between low vitamin D levels and depressive symptoms.

CONCLUSION

Future RCT studies should include patients with greater severity of depressive symptoms and should consider confounding factors such as sun exposure and seasonal variation of vitamin D.

Impact of Vitamin D Supplementation on Multiple Sclerosis

Multiple sclerosis (MS) is an autoimmune disease affecting a large number of people every year. The exact causal factor for this disease is unclear, but it commonly affects middle-aged women, with known triggers like stress, childbirth, infections, poor diet, lack of sleep, etc.

Many epidemiological studies have indicated that various genetic abnormalities are also critical drivers of the onset of MS. The major risk factors of MS identified include hypovitaminosis D while environmental protective factors include allele HLA DRB1 1501, obesity, Epstein-Barr virus infection, sexual hormones, and smoking.

Our article explores the correlation between the deficiency of vitamin D and the onset and progression of MS. The study uses a systematic review methodology by researching and reviewing scholarly articles exploring the topic. We conducted online searches of literature on Google Scholar and PubMed using the keywords "vitamin D deficiency" and "multiple sclerosis" and accessed the relevant secondary literature sources for review. The variables under study included vitamin D insufficiency as the dependent variable while MS was the independent variable. Causal variables included environmental, genetic, and protective factors.

We hypothesized that there is indeed a correlation between vitamin D deficiency and MS. The findings from our review indicate a strong correlation between the insufficiency of vitamin D and the onset and progression of MS. These results are essential in devising interventions to accomplish primary and secondary prevention of MS, as well as integrating vitamin D supplementation in current treatment protocols for MS.