Ch 15: Multiple Sclerosis Flashcards

1
Q

most common subtype of MS

A

Relapsing-remitting (80%). Acute attacks with a steady baseline in between.

About 50% of people with RR do later get a progressive phase called secondary progressive

The minority have primary progressive. A small subset of these do have some relapses in parallel with their progression and are called progressive-relapsing

4 subtypes in total

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1
Q

4 Theories of Etiology of MS

A

1) Immunologic
* Autoimmune hypothesis is widely accepted
* Exposure to infections may help immune system. Some studies treating people with MS with helminths reduced disease severity!
* Gut microbiome may play a role

2) Environmental
* Incidence of MS increases as you go further from the equator (genetic? dietary? Vit D?)
* insufficient evidence for mercury dental fillings to be associated
* smoking is a clear risk factor
* air pollution may be a risk factor

3) Infectious agents
* many infectious agents are implicated but none definitively associated
* HHV-6, Chlamydia pneumoniae, Borrelia burgdorferi, and EBV getting most attention

4) Genetics
* most cases are sporadic. But susceptibility is linked to genetics
* Certain HLA types are more suseptible
* monozygotic twins who both have MS have very different clinical expression, so most of the disease expression is likely from post-germline events

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2
Q

Diagnosis of MS

A
  • Clinical: neurologic dysfunction disseminated in space and time
  • MRI shows demyelinated placques in periventricular white matter, optic nerves, brainstsem, cerebellum, and spinal cord
  • McDonald Criteria is used
  • Eval also includes CSF testing and evoked potential testing (measure brain response to sensory stimulation - can lead to quicker diagnosis and quicker access to DMARDS)
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3
Q

Most important modifiable risk factor for people with MS

A

Smoking

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4
Q

why people were initially cautious about exercise in MS

A

Worry that clinical status would worsen when they get overheated

In fact exercise is well tolerated and associated with improved strength, spasticiy, cognitionm, pain, fatigue, neuroprotective.

Mix of aerobic, strentgh, flexibility, and balance training

Attention needs to be given to safety and individualized modifications (avoid heat intolerance, exercise-related fatigue, and falls)

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5
Q

mind-body therapies beneficial for MS

A
  • Yoga
  • Mindfulness meditation

Tai Chi and contemplative practices, as well as psychotherapy (high risk of suicide) are important

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6
Q

Diets for MS

A

Multiple diets have been studied:
* Modified Paleolithic (Wahls): some benefit in fatigue and hand function
* Low-saturated fat (Swank): improved hand function
* Very low fat vegan (McDougall): no benefit in MS or disability but did show improvement in fatigue BMI, metabolic markers
* Keto: improved BMI, fatigue, depression
* Mediterranean diet: may decrease risk of developing MS. Given lack of consensus on diets, maybe this is best one to follow given improved CV profile
* Intermittent fasting: slower progession

May be best to just follow dietary practices to reduce inflammation.

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7
Q

Specific dietary things to consume for MS

A

Get enough Omega-3s.

Get enough Fiber (at least 25g / day) to help gut microbiome fermentation to make short-chain fatty acids acetates, propionate, and butyrate. Consider

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8
Q

elimination diets for MS

A

Case reports of gluten sentsitivity manifesting as optic neuritis

Increased frequency of gliadin and gluten IgA antibodies in MS

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9
Q

Vitamin D in MS

A
  • lower levels associated with higher disease disability and disease activity
  • HOWEVER trials on supplementing are largely inconclusive, but some are promising
  • Although results unclear, it is reasonable to correct deficiency and target a level of around 40.

case studies show that sunlight actually affects reduced risk of MS diagnosis and mortality!

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10
Q

Thiol-based antioxidants

A

ALA, NAC, and GSH
(alpha lipoic acid, N-acetylcysteine, and glutathione)

  • Reduced levels of GSH found in patients with MS
  • mixed results in studies about supplementing with ALA
  • NAC supplementaiton may improve glucose metabolism
  • ALA supplementation over 2 years in one study showed reduced brain volume loss

Glutathione is not absorbed orally!
Cautions:
- ALA: In general, quite well tolerated and safe. At higher doses can infrequently cause nausea, vomiting, and skin irritation at the intravenous site when given intravenously.
- NAC: Infrequently causes nausea, vomiting, and diarrhea.
- GSH: Rapid infusion can provoke respiratory distress, coughing, rhinorrhea, and vertigo.

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11
Q

magnesium

A

Needed for Vitamin D levels to maintain in circulation

Mild help with spasticity in MS

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12
Q

Why would Bcomplex help in MS

A
  • Cognitive function and antioxidants
  • Correlation between homocysteine elevation and worsening MS disease progression
  • High doses of injectable B12 showed improve brainstem nerve function in chronic progressive MS
  • High dose biotin may prevent demyelination. Of note it can affect tests (Like TSH, U pregnanyc, and HCt) that rely on streptavidin-biotin technology
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13
Q

Melatonin in MS

A
  • important antinnflammatory role!
  • Suppresses helper-T17 cells and their cytokines IL-17 and GM-CSF.
  • No large clinical trials
  • Smaller trials wshowed lower markers of oxixative stress but no significant clinical outcomes
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14
Q

Omega supplementaiton in MS

A
  • studies are inconclusive
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15
Q

Curcumin in MS

A

human clinical data in MS is limited

Caution - can increase blood levels of sulfasalazine

16
Q

Ginkgo biloba

A

studies show lack of benefit

17
Q

cannabinoids

A

oral cannabis extract is modestly effective in reducing pain (excluding central neuropathic pain), spasticity symptoms, and bladder dysfunction and is not effective in improving tremor.

Insufficient research for inhaled cannabis

Dronabinol closely related to THC

18
Q

Epigallocatechin-Gallate

A

from green tea? A polyphenol

Avoid until more studies. Current studies show hepatotoxicity risk.

19
Q

estrogen and MS

A
  • Estrogen is protective
  • Pregnant patietns have reduced disease activity
  • Improved symptoms and MRIs in women wit hMS treated with estriol or high dose ethinylestradiol
  • More robust evidence needed before recommending estrogen replacement; reasonable to consider HRT in accordance with menopause guidelines
20
Q

testosterone and MS

A
  • low T levels in men with MS correlate with cognitive decline
  • T has immune and neuroprotective effects
  • More evidence is needed before recommending it
  • But if a patient has low T, and lifestyle changes dont provide benefit, can then supplement in accordance with national guidelines
  • Contraindications: polycythemia, BPH, prostate cancer
21
Q

Steroids and plasma exchanges

A
  • high-dose steroids helpful during relapses (oral and IV similar efficacy) but dont affect overall recovery or outcomes
  • plasma exchange given during severe attacks refractory to steroids

high dose steroids, among their known side effects, may be associated with defects in long term memory, and if given outside of a relapse in order to prevent progressions may actually contribute to worsening of progression when patients stop taking it

22
Q

who are DMARDs recommended for

A

those with a definite diagnosis with relapsing-remitting MS.

Note: the meds treat the signs and sx of MS and are not curative. Unclear effects on progression to disability.

Experts recommend commencing treatment at the time of the first episode of disease.

Oral vs. injectable. Aggressive robust treatment vs better tolerated. Many options available, need to figure out patient’s goals.

23
Q

MS in TCM

A
  • TCM views MS as a heterogenous group of causes and disease processes
  • Spleen, liver, or kidney deficiency
  • acupuncture is effective in treating MS symptoms
24
Q

MS in Ayurveda

A

Excess of pita (inflammation) burns up the kapha (myelin nand results in excess of vata

Reduce pita and replenish kapha.

25
Q

magnet therapy

A

can be delivered in many forms

probably effective for fatigue

probaby ineffective for depression
may improve paraesthesias