Complementary MS treatment requires ‘patient-by-patient approach’

ByStephanie C. Viguers

Disease-modifying therapies for multiple sclerosis have limited efficacy and are associated with adverse events, so patients may require additional treatment strategies, according to research published in The Journal of Alternative and Complementary Medicine. Many patients with MS turn to complementary treatment to help alleviate their symptoms. The National MS Society states that most patients in the United States incorporate complementary treatment as part of their disease management.

There is limited research on the safety and efficacy of these interventions, as well as their potential impact on disease-modifying therapy. Herbal supplements in particular have biologically active ingredients that could have negative health effects when taken alone or in combination with other medications. Because of this risk, the NIH’s National Institute of Neurological Disorders and Stroke stresses the importance of discussing all therapies — prescription and nonprescription — with patients.

Andrew R. Romeo, MD

Although more research is needed on certain complementary treatments, generic strategies like healthy diet and exercise are encouraged, according to Andrew R. Romeo, MD, neurologist at Michigan Medicine, University of Michigan.

“In most cases, I don’t have any concerns and support the desire of people with MS to seek out those complementary strategies,” Romeo told Healio Primary Care. “But symptom management has to be individualized, so I try to take a patient-by-patient approach. Some people will benefit from various complementary therapies more than others.”

To learn more, Healio spoke with Romeo about the role of complementary treatment in MS and what strategies he recommends for patients.

Diet and supplementation

Currently, there are no special diets that are recommended for patients with MS, according to Romeo.

“That’s a question my patients frequently ask,” he said. “There is a lot of information circulating about different anti-inflammatory diets, but we need more research on those topics and ideas.”

A research review paper by Pavan Bhargava, MD, assistant professor of neurology at Johns Hopkins Medicine, identified several common themes among popular dietary strategies in MS. Almost all these diets avoid foods that are highly processed, have a high glycemic index and are high in saturated fat. Most of these diets also recommend reducing fatty red meat consumption and eating more fruit and vegetables. Still, more research is needed to identify the optimal diet strategy.

“As of right now, I’m recommending to my patients a standard, healthy balanced diet based on USDA guidelines,” Romeo said. “We think that having a healthy, balanced diet can make a difference for patients, but at this time, we don’t have the data to endorse any type of diet plan.”

Supplements

In addition to the lack of research on diets, there is also limited evidence to support the benefit of nutritional supplements in MS. Some studies have shown that vitamin D supplementation may decrease the severity of symptoms, but overall the evidence remains inconclusive.

“I’ll often recommend vitamin D supplementation to my patients who have low vitamin D levels,” Romeo said. “It hasn’t been definitively demonstrated that vitamin D supplementation is helpful, but there does seem to be a link with vitamin D and disease or inflammatory activity.”

Herbal supplements are not regulated by the FDA for MS and could interact with other medications, according to the NIH. In its recommendations on complementary medicine in MS, the American Academy of Neurology (AAN) stated that there was only enough evidence to draw conclusions on one herbal supplement: ginkgo biloba (GB). Although GB was not effective against most MS symptoms, AAN issued a “level C” recommendation for GB as a potential strategy for reducing fatigue.

Research published in the Journal of Neurology in 2011 showed that 26.6% of patients with MS in the United States reported using herbal supplements for at least 1 month. The most commonly used herbal supplement was evening primrose oil (40.4%) followed by cranberry fruit extract (35.2%).

Evening primrose oil contains large amounts of the essential fatty acids gamma-linolenic acid and linoleic acid, according to the Multiple Sclerosis Trust. The benefits of evening primrose oil have not been confirmed, but trials in newly diagnosed patients indicated that linoleic acid reduced the severity but not the number of MS relapses. Further, a small study published by researchers in Iran in 2018 revealed that evening primrose oil improved cognition, vitality and life satisfaction while reducing pain and fatigue, but there was no significant impact on quality of life, and the supplement did not prevent disease progression.

A systematic review published by Australian researchers in Multiple Sclerosis and Related Disorders in November 2019 revealed that several nutraceutical interventions show promise in MS. The analysis — which included results from 37 randomized controlled trials investigating different nutraceuticals — indicated that alpha lipoic acid, GB, vitamin A, biotin, carnitine, green tea, coenzyme Q10, probiotics, curcumin, Andrographis paniculata, ginseng and lemon verbena improved biological outcomes such as MRI brain volume change and antioxidant capacity, as well as clinical outcomes such as fatigue, depression and disability scores, compared with control groups. Still, more “sufficiently powered, long-term trials” are needed to confirm the results.

“The results of this review provide preliminary evidence for the emerging use of nutraceutical interventions in the MS setting,” researchers wrote. “However, due to the small sample sizes and lack of replication or validation studies using the same agent and outcome measures, recommendations for clinical use are premature.”

Physical activity

Physical therapy is used in MS to maintain optimal functioning and prevent complications such as deconditioning, muscle weakness and muscle contractures related to spasticity, according to the National MS Society. Additionally, pelvic floor exercises can also be used to improve urinary and bladder issues in MS.

In some patients, physical activity can trigger Uhthoff’s phenomenon, a condition in which elevated body temperature can temporarily worsen or induce symptoms of MS, according to Romeo.

“Once patients cool off, those symptoms will subside. It does not cause damage,” he said.

The benefits of physical activity have wide implications for cardiovascular health, strength, mobility, balance sleep mood and fatigue, according to Romeo. A study published in the Journal of Manipulative and Physiological Therapeutics demonstrated that rehabilitation and resistance training had a large impact on functionality. Despite these benefits, previous research has shown that at least two-thirds of patients with MS do not participate in regular physical activity.

A study published in October 2019 by researchers from McMaster University showed that patients with MS were twice as likely to adhere to physical activity if they received a direct physician referral instead of only information about physical activity, suggesting that “physicians play a role in prescribing it to their patients,” they wrote.

When recommending physical exercises, Romeo said it is important to use an individualized approach.

“Some patients need to work with a physical therapist to come up with specific exercises or routines that are going to be beneficial,” he added. “For others, it can be things that all of us should be doing anyway, such as combinations of aerobics and strength training two to three times a week.”

Medical Marijuana

Medical marijuana has been legalized in 33 states, but the United States Drug Enforcement Administration still considers marijuana as an illicit substance “with no currently accepted medical use and a high potential for abuse.” Results of an online survey hosted by the National MS Society and the Michael J. Fox Foundation revealed that 66% of patients with MS currently use marijuana for symptom treatment.

Nabiximols (Sativex, GW Pharmaceuticals), an oral mucosal spray containing THC and cannabidiol, is approved in Canada and the United Kingdom for MS symptoms of neuropathic pain, spasticity and overactive bladder, according to research published in the International Journal of MS Care. However, the spray is not approved in the United States. Data from two phase 3 trials evaluating the medical benefits of nabiximols among patients with cancer did not demonstrate an improvement in self-reported pain scores.

Although there are no marijuana treatments approved by the FDA for MS, AAN recommendations list nabiximols as a “level B” effective agent for reducing symptoms of spasticity, pain and urinary frequency, but also state that nabiximols is probably unable to improve objective spasticity measures or the number of urinary incontinence episodes. Oral cannabis extracts are categorized as “level A” effective treatments under the AAN recommendations for spasticity and pain (excluding central neuropathic pain) but are likely ineffective against objective spasticity measures (short-term) and tremor. There is level B evidence that synthetic THC is effective against symptoms of spasticity and pain, with the exception of central neuropathic pain.

Although medical marijuana may alleviate certain symptoms of MS, Romeo said it is important to weigh those benefits against the potential adverse events, which include mental confusion, cognitive impairment, anxiety and/or paranoia, nausea, vomiting, dry mouth, dry eyes, sedation, increased appetite, headache, impaired balance and coordination and elevated heart rate, according to the National MS Society. Studies evaluating smoked marijuana have not produced enough evidence to confirm its safety or efficacy for treating MS symptoms, and the long-term safety of medical marijuana for MS remains unknown.

“I certainly have patients who have found [medical marijuana] beneficial, even in comparison to some prescription medications that they’ve been on in the past,” Romeo said. “It’s also important to realize there are different regulations across state lines. Availability and options vary.”

References

Sources/Disclosures

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Source: Healio Interview

Disclosures: Romeo reports no relevant financial disclosures.

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