Ch 15: Multiple Sclerosis Flashcards
most common subtype of MS
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
4 Theories of Etiology of MS
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
Diagnosis of MS
- 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)
Most important modifiable risk factor for people with MS
Smoking
why people were initially cautious about exercise in MS
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)
mind-body therapies beneficial for MS
- Yoga
- Mindfulness meditation
Tai Chi and contemplative practices, as well as psychotherapy (high risk of suicide) are important
Diets for MS
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.
Specific dietary things to consume for MS
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
elimination diets for MS
Case reports of gluten sentsitivity manifesting as optic neuritis
Increased frequency of gliadin and gluten IgA antibodies in MS
Vitamin D in MS
- 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!
Thiol-based antioxidants
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.
magnesium
Needed for Vitamin D levels to maintain in circulation
Mild help with spasticity in MS
Why would Bcomplex help in MS
- 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
Melatonin in MS
- 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
Omega supplementaiton in MS
- studies are inconclusive
