Latest MS research – what I learned at ECTRIMS, part 2

xcel

Wow, what a full on 3 days for the brain! So inspiring to see a sea of research posters, a vast menu of presentations , and 8000 engaged delegates filling up on the latest research.

Bone marrow transplantation ( HSCT/stem cell) – is it a viable treatment for active relapsing remitting MS – debateimg_3970

Consensus was: safety is improving – from 2011 the mortality rate has been 0.3% rather than 1-2%. Due to impressive rates of NEDA ( no evidence of disease activity – relapses or on MRI) – 80% at 2 years and 70% at 4 years in one study;

Yes, but ONLY in cases of early/new, highly active/aggressive relapsing remitting MS, where person is young, still walking, and treatment with first & second line treatment have failed.

And now for something completely different, and please DO try this at home(!): Seriously, I will be

Lipoic acid for neuroprotection in secondary progressive multiple sclerosis: results of a randomised placebo-controlled pilot trial –  R.I. Spain (Portland, United States) lipoic-acid

This beautifully carried out RCT had people with progressive forms of MS taking 1,200mg of Lipoic Acid, a supplement often sold as an ‘anti-oxidant’, and also called ‘alpha-lipoic acid’ once a day. A control group took a placebo.

After 2 years, the group taking the lipoic acid had a whopping 66% less brain atrophy on MRI scan ( showing less loss of brain cells), taking them back to a normal rate of brain atrophy, and half the number of falls.

Love it when something so harmless is investigated properly and found effective. Especially good to have something positive for progressive MS!

Comparison of Beta Interferons, Fingolimon, Alemtuzemab (Lemtrada) and Natalizumab ( Tysabri)

showed that as we know, effectiveness in reducing relapses from lowest up goes: Interferons, then Fingolimod, then Alemtuzemab and Tysabri. The last 2 showed the same effectiveness in preventing relapses. Natalizumab also showed improvement in disability in the first year, but not after that. and as we now the side effect profile and the way you take it is very different. Tysabri also has a rebound effect if and when you stop taking it. 

Alemtuzemab

research was presented that showed this drug performing very well in ‘resetting’ the immune system. Around 60% of people did not need more than 2 infusions, and NEDA ( no evidence of disease activity) was very high., but only when used EARLY. Time to change from the ‘wait and see’ attitude? This is the push from leading MS experts. Maybe check in with the MS Brain Health campaign if your neurologist is dragging their feet.

Vitamin D vit D.jpg

very strong evidence coming through from numerous sources that notwithstanding previous medical controversies and uncertainties, all people with MS should be on high dose from diagnosis – 4-5000 IU daily at least, and testing ( backs up info already posted on this blog) MS Base ( a database with over 41,000 people with MS’s records) showed a clear seasonal peak in relapses around the world, at the end of winter; with a time lag, shorter in colder countries. Low vitamin D levels were the strongest risk for progression in another study, and added a further anti inflammatory effect to people already on a disease modifying treatment, in another.

One study found that  people with MS given 100,000 twice a month for 2 years had a 60% reduction in relapse rate, and a 78% reduction in new lesions, compared to placebo. Powerful stuff, hopefully enough to finally swing the doubters.

Siponimod for progressive MS

presented as promising new treatment but I missed that session so – investigate!

Scientific highlights presentation – was split into 3 sections ‘migration and CNS injury’, ‘Gut and Food’ and ‘remyelination and oligodendracytes’

At the end of the event, I was really surprised to see these slides in the highlights – I missed the full presentation but one slide went like this:

hb02Oxygen

MS from an energy perspective.

Q:Why are animals with experimental animal MS paralysed?

A: Axonal ( nerve) depolarisation ( can’t send messages)

Q Why are axons depolarised?

A: Hypoxia ( lack of oxygen)

Q: Why is the inflamed central nervous system hypoxic?

A: Reduced blood flow

Q Why is blood flow reduced?

A: Currently unclear , CNS specific ( ie we don’t know, but it’s just the central nervous system.)

Went on to describe how animals with this experimental model of MS respond very well to hyperbaric oxygen: Oxygen therapy reduces pattern 3 demyelination.

So maybe we will see some new research showing usefulness of hyperbaric oxygen? If you can access it, I always say that it’s worth trying, and observe the effects on yourself.

Diet and Gut in MS

Feels like finally, the importance of aspects of diet is being addressed and listened to in MS research. In fact all present were enjoined Not to ignore environmental factors. Hurrah! a strike for logical thinking!

This was a feature of quite a lot of research at ECTRIMS. Lots of research on the role of the Biome ( bacteria in the gut) and how it affects MS. Interesting, exciting, but we still haven’t nailed practical application yet, so best bet is Take a daily probiotic capsule or powder, with as many different strains in as possible. And do these things, discussed previously.

Being overweight was identified as a serious risk factor for both developing, and worsening with MS. If you’ve got pounds to lose, check out the excellent ‘Fast Diet/ 5:2 diet’, showcased by Micheal Moseley on the BBC -https://thefastdiet.co.uk/ fasting also has benefits for inflammatory conditions.

Salt:  

salt stored in the skin was posed as a driver for auto-immune neuroinflammation in one paper. People with MS were found to have higher levels of salt in the skin….so that too… we could all cut down our salt – most is found in processed foods… and as you do it, your tastebuds acclimatise so it won’t mean you won’t taste your food.

Ending on a high

Conference ended on a high note, celebrating the huge progress that has been made in preventing disability – progress that started even before the availability of the disease modifying drugs, but has in recent years added a further 15 years of non-disabled life to the average MS-er, and is still making leaps and bounds.

I hope I’ve made an accurate summary of the sessions that I attended – mistakes are possible, and they will be all  mine. If you spot one, please let me know!

That’s all for now, til the next time!

miranda

 

 

 

 

Advertisements

Latest vitamin d controversy discussed

thanks Professor Giovannonni, I’m sharing your blog post here from www.http://multiple-sclerosis-research.blogspot.co.uk/

Commentary is in italics. Keep taking the tablets! ( and going on the sunbed, without changing colour)

http://multiple-sclerosis-research.blogspot.co.uk/

Multiple Sclerosis Research


Doubt cast on vitamin D’s role against disease

Posted: 12 Dec 2013 01:53 AM PST

Vitamin controversy is not such a controversy if you ask the experts. #MSBlog #MSResearch“Some of you may have seen the BBC news from last week that covered the meta-analysis below. The press release and article is worth reading. They both question the health benefits of vD supplements and clinical outcome for a host of diseases including MS.”

 
“The difference between so called observational and intervention studies suggests that low vD levels are a marker of ill health, in our case MS. According this hypothesis inflammatory processes involved in pre-symptomatic MS and the clinical course of MS would reduce vD levels, which would then explain why low vD status is associated with MS. I have a problem with these conclusions regarding MS as they ignore the strong epidemiological data linking vD and/or sunshine to MS, for example latitude, migration studies, month of birth effect, parent-of-origin effects, difference in MS concordance rates between non-identical twins and siblings.”
 
“As I am not a vD expert I asked Bruce Hollis, one of the world’s preeminent vD experts for an opinion. This is what Bruce said: 
 
‘Same old story, not enough vitamin D and wrong dosing schedules. Please read my recent paper in JCEM online as it discusses these issues. Happy Holidays all.’
 
The abstract from Bruce Hollis’ review is below. He is simply making the point if you review a large number of studies that use the incorrect dose and dosing schedules of vD you get a result that suggest vD supplementation does not make a difference. In other words if you put crap in you get crap out. What Bruce and his colleagues are suggesting is that we need to properly designed vD intervention studies with adequate vD supplementation schedules that essentially keep your blood vD levels above 100 nmol/L all year round. Why this level? If you study populations that still live a hunter-gather existence in Africa, or people who work outdoor such as farmers and lifeguards, they all have blood levels above 100nmol/L.”
 
“Therefore this meta-analysis does not change our advice regarding levels of vD supplementation. We still support the vD Council’s recommendations of 5,000U of vD3 per day.”
 
Conversion units of vD
  1. 40U = 1μg
  2. 400U = 10μg
  3. 600U = 15μg
  4. 2,000U = 50μg
  5. 5,000U = 125μg
  6. 10,000U = 250μg
This blogs recommendations for levels of vD supplementation:
  1. Children less than 2 yrs of age: 600U per day
  2. Children 2-10 years of age: 2,000U per day
  3. Children above 10 years of age: 5,000U per day
  4. Adults: 5,000U per day
  5. Pregnant woman: 10,000U per day
“Please note that this is an average recommendation and some people may need more than this and other less than this to maintain a blood level between 100 and 200 nmol/L. In an ideal world you would start vD supplementation at this level and after 6-8 weeks you would have your levels checked and adjusted accordingly. There are many factors that control blood levels in an individual apart from the dose of vD. It is also important to note that you should not be taking any calcium supplements with vD. Calcium supplements are only necessary for bone health or if you have thin bones.”
 

Autier et al. Vitamin D status and ill health: a systematic review. The Lancet Diabetes & Endocrinology 2014; 2(1):76 – 89. 


Background: Low serum concentrations of 25-hydroxyvitamin D (25[OH]D) have been associated with many non-skeletal disorders. However, whether low 25(OH)D is the cause or result of ill health is not known. 
 
Methods: We did a systematic search of prospective and intervention studies that assessed the effect of 25(OH)D concentrations on non-skeletal health outcomes in individuals aged 18 years or older. We identified 290 prospective cohort studies (279 on disease occurrence or mortality, and 11 on cancer characteristics or survival), and 172 randomised trials of major health outcomes and of physiological parameters related to disease risk or inflammatory status. Investigators of most prospective studies reported moderate to strong inverse associations between 25(OH)D concentrations and cardiovascular diseases, serum lipid concentrations, inflammation, glucose metabolism disorders, weight gain, infectious diseases, multiple sclerosis, mood disorders, declining cognitive function, impaired physical functioning, and all-cause mortality. 
 
Results: High 25(OH)D concentrations were not associated with a lower risk of cancer, except colorectal cancer. Results from intervention studies did not show an effect of vitamin D supplementation on disease occurrence, including colorectal cancer. In 34 intervention studies including 2805 individuals with mean 25(OH)D concentration lower than 50 nmol/L at baseline supplementation with 50 μg per day or more did not show better results. Supplementation in elderly people (mainly women) with 20 μg vitamin D per day seemed to slightly reduce all-cause mortality. 
 
Conclusions: The discrepancy between observational and intervention studies suggests that low 25(OH)D is a marker of ill health. Inflammatory processes involved in disease occurrence and clinical course would reduce 25(OH)D, which would explain why low vitamin D status is reported in a wide range of disorders. In elderly people, restoration of vitamin D deficits due to ageing and lifestyle changes induced by ill health could explain why low-dose supplementation leads to slight gains in survival.Hollis and Wagner. The role of the parent compound vitamin d with respect to metabolism and function: why clinical dose intervals can affect clinical outcomes. J Clin Endocrinol Metab. 2013 Dec;98(12):4619-28.

Context: There is no doubt that vitamin D must be activated to the hormonal form 1,25-dihydroxyvitamin D to achieve full biological activity or that many tissues participate in this activation process-be it endocrine or autocrine. We believe that not only is 25-hydroxyvitamin D important to tissue delivery for this activation process, but also that intact vitamin D has a pivotal role in this process.

 
Objective: In this review, evidence on the vitamin D endocrine/autocrine system is presented and discussed in relation to vitamin D-binding protein affinity, circulating half-lives, and enzymatic transformations of vitamin D metabolites, and how these affect biological action in any given tissue. 
 
Conclusions: Circulating vitamin D, the parent compound, likely plays an important physiological role with respect to the vitamin D endocrine/autocrine system, as a substrate in many tissues, not originally thought to be important. Based on emerging data from the laboratory, clinical trials, and data on circulating 25-hydroxyvitamin D amassed during many decades, it is likely that for the optimal functioning of these systems, significant vitamin D should be available on a daily basis to ensure stable circulating concentrations, implying that variation in vitamin D dosing schedules could have profound effects on the outcomes of clinical trials because of the short circulating half-life of intact vitamin D.

Vitamin D in the MS media

Posted: 12 Dec 2013 01:54 AM PST

Grishkan IV, Fairchild AN, Calabresi PA, Gocke AR. 1,25-Dihydroxyvitamin D3 selectively and reversibly impairs T helper-cell CNS localization. Proc Natl Acad Sci U S A. 2013 Dec. [Epub ahead of print]
 
Pharmacologic targeting of T helper (TH) cell trafficking poses an attractive opportunity for amelioration of autoimmune diseases such as multiple sclerosis (MS). MS risk is associated with vitamin D deficiency, and its bioactive form, 1,25-dihydroxyvitamin D3 [1,25(OH)2D3], has been shown to prevent experimental autoimmune encephalomyelitis, a mouse model of MS, via an incompletely understood mechanism. Herein, we systematically examined 1,25(OH)2D3 effects on TH cells during their migration from the lymph nodes to the CNS. Our data demonstrate that myelin-reactive TH cells are successfully generated in the presence of 1,25(OH)2D3, secrete proinflammatory cytokines, and do not preferentially differentiate into suppressor T cells. These cells are able to leave the lymph node, enter the peripheral circulation, and migrate to the s.c. immunization sites. However, TH cells from 1,25(OH)2D3-treated mice are unable to enter the CNS parenchyma but are instead maintained in the periphery. Upon treatment cessation, mice rapidly develop experimental autoimmune encephalomyelitis, demonstrating that 1,25(OH)2D3 prevents the disease only temporarily likely by halting TH cell migration into the CNS.
We have had a topsy turvy week in the world of media and vitamin D. Last week the media was saying it is all a load of tosh following studies in non-MS cases published in the Lancet questioning whether vitamin D is all a myth and that vitamin D had  marginal effect on autoimmunity in humans and this week it is the bees knees. Is there any wonder why we do not really know what is going on.


Vitamin D is vital for bone health and can influence immune function and is made in humans following sun exposure. This study was in mice, furry animals who prefer to live in the dark. In this study they gave lots of vitamin D and it stops the development of EAE. 
 

That EAE returns after you stop delivering drug is no big shakes and should be expected to happen.

 

If you have a decent disease induction protocol (as the antigen depot is there) and the natural regulation that occurs with disease development has not been generated, then disease comes back after a few days or weeks following stopping drug treatment. Unfortunately, this can come as a shock to the people not experienced in the world of EAE. This has led to cancelled clinical trial because of the risk of MS rebound. 


This happens with Tysabri and other drugs in MS too

 

A logical extreme extension of this idea is that vitamin D works in a way similar to Tysabr to block white cells getting in the brain. So it there evidence that sunshine causes PML? (The brain disease that can occur due to stopping white blood cells getting into the CNS)……….Well No. 


So the treatment effect is not going to be in the same league as Tysabri. However, to take another extreme with high dose statins we showed that they could inhibit EAE development and could block migration of cells through brain blood vessels because it could inhibit rearrangement of their cellular skeleton. Within two days of stopping drug disease returned (See D below). So what happened in MS? Despite some influence on lesion load in a few studies in MS as shown in EAE studies….the clinical effect has yet to be shown to be earth shattering at the doses used as found in a few studies. So we can go from something ace to it being a damp squib.

 

 

 

In the study they find apparently that it works by blocking a chemokine receptor called CXCR3 (CD182) is reduced, which is a molecule a bit like a stamp that helps it find the brain postcode (ZIP code) by being attracted to molecules that can be produced in MS lesions. Now, what happens in mice were CXCR3 has been removed, well maybe not a lot in some people’s hands and EAE can develop just fine in the absence of CXCR3 following inhibition


This study suggests that vitamin D works by stopping white blood cells from entering the brain because it reduces a homing receptor. If this is the actual case if should be easy to test. Giving vitamin D to cells in the test tube in humans suggests that there may be an immune modulatory effect, so not quite the same as found in this mouse study. However, you could for example take bloods from any Northern European/American in winter (who will be vitamin D deficient, particularly if they are non-VD supplementing non-whites) show the cells migrate in test-tube assays, now give the person vitamin D to make them vitamin D replete and you should see a major change. 


Will it be incremental or Earth shattering?

 

If vitamin D had such a dramatic impact, there are enough MSers now supplementing with vitamin D for MSers to see a dramatic impact. I personally think that neutriceuticals will have incremental effects, because otherwise they would also come with big side-effects. You may need pharmaceuticals to have major impact.  ProfG may think otherwise.


The suggestions that Vitamin D is a risk factor are clear but it maybe has more practical impact in determining whether you will get MS. 

 

 

 

Therefore, we should all be ensuring are children are vitamin D replete. This is to my mind where studies should focus. I will be surprised if some clinical trials ongoing will provide useful answers but we will see.

 

 

So another bit of Vitamin D in the media last week was questioning whether vitamin D was influencing autoimmunity (in diabetes) in humans. But if you are not doing the right studies are you going to get a useful answer? 

 

You need to ensure you have good bone health to deal with falls and if it limits autoimmunity this is a plus point.

MS Trust annual conference 2012

MS Trust conference – part 1.

In November I attended the MS Trust’s annual conference for healthcare professionals working in the field of MS.

I really enjoyed this year’s conference, and will summarise what I learned below.

The first speaker was Gavin Giovanonni, top MS researcher at Royal London Hospital. This is a pic from his blog, which you can follow at http://multiple-sclerosis-research.blogspot.co.uk/ http://multiple-sclerosis-research.blogspot.co.uk/. It includes ‘the mouse doctor’ (?) who is co-blogger.

vcm_s_kf_repr_150x126

to this talk resonated with everything I have been thinking for the last few years. You could sum it up as MS – which is more important – inflammation or degeneration? This argument has been recently explored in the article

‘Will the real MS please stand up?’ by Peter K. Stys, Gerald W. Zamponi, Jan van Minnen & Jeroen J. G. Geurts  – here’s a link to the full text article http://mssociety.ca/chapters/calgary/pdf/2012_Stys_507.pdf.

This article  weighs heavily on the side of looking at the importance of degeneration, so doesn’t really discuss the benefits of early aggressive treatment of inflammation.

Giovannonni’s blog calls this article ‘myopic ramblings’ ; it’s a dog-eat-dog world out there in academia, but Peter Stys has received funding from the MS Society of Canada to research progressive MS, which has got to be good news.

To illustrate what this discussion is about,  I’ve done a rough diagram based on one by Professors Coles & Compston Lancet. 2002;359:1221-1231

inflammation or degeneration

Basically, the tall skyscrapers represent inflammation –  relapses or new symptoms. They are the part of MS that pretty much all the research and medications for MS have always been aimed at; that’s why research trials always only want to recruit people with relapsing –remitting MS.

But the disappointment over the last few years has been realising that although the  disease modifying MS drugs can show a reduction in relapses, they have not been able to prove a reduction in the progression of MS.

The progressive element of MS is represented by the green block, and represents damage to and loss of axons, the long part of the neurons, or nerve cells.

The argument that Giovannonni presented, which is being mirrored by various thinkers around the world at present, is that perhaps research/pharmaceuticals have been focussing on the wrong part of MS. Perhaps the periods of inflammation in MS are the body’s reaction to a degenerative process that is going on.

As in this article, Giovanonni described his team’s interest in HERVs ( human entero-retrograde viruses – virus which are within the genes) and other virus which we can contract later in life; in particular, the Epstein Barr virus which causes glandular fever, and is part of the Herpes virus family. They want to see whether by suppressing these viruses, the driving force of the degenerative process might be taken out, and they have just received funding to do the preliminary research with anti-virals, which is great news.

It made me think again about looking into powerful natural anit-virals, and I’m going to speak to all the people who tried using some last spring to hear about  experiences and see how they’ve been doing since.

Another big factor in his research is Vitamin D; for a long time he has been an advocate of high dose vitamin D3 supplementation. I’ve got previous posts about this so won’t go into the pro side of vitamin D, BUT…

vitamin D

The subject got pretty confusing later when Professor Carolyn Young, Consultant Neurologist and Honorary Professor of Neurology

Walton Centre for Neurology & Neurosurgery, Liverpool led an 

Update on Vitamin D.

The professor warned us that this would be a challenging session, and it was. This is really important, as high dose vitamin D has become a mainstay of treatment for anyone who’s had their ear to the ground in the last few years, and neurologists have started to also take it seriously and recommend it.

She introduced us to all the formative research on vitamin D and MS; the Nurse’s study, which is scientifically important and excellent due to the enormous size of the sample –  92,253 women followed from 1980 to 2000) and Nurses’ Health Study II (NHS II; 95,310 women followed from 1991 to 2001. This study showed that having higher vitamin D blood levels, and taking supplements containing vitamin D had a strong effect of protecting a person from developing MS.

The US army study; likewise, great numbers and scope of years, showing 7 million army recruits from 1992-2004 and compared the vitamin D levels with their risk of developing MS.18 They found 257 new cases of MS in the group. There was a significant decrease in risk with increasing vitamin D levels among white, but not black or Hispanic people, who had lower vitamin D levels than whites. Levels of around 100nmol/L or more seemed to be protective, with almost a two thirds reduction in risk for those with these higher levels.

A good factsheet summarising research on vitamin D and MS is on the MS Trust website at http://www.mstrust.org.uk/downloads/vitamind.pdf

She then gave feedback on 4 or 5 more recent studies, where vitamin D supplementation ( mostly D3 but one study used D2) was given at various doses, over various timescales, none of which showed any influence on annual relapse rate, or level of disability at all.

We then went on to discuss what to make of this?

One point was that an association is not necessarily a cause

For example, low levels of vitamin D in the blood are associated with relapses in MS – but maybe they do not go towards causing it – maybe the low level of vitamin D is caused by the relapse or inflammation?

One point was that it may not be possible to extract the active ingredient – whatever that is – from the foods in order to make an effective supplement, and that sometimes other helpful substances in foods are responsible for the absorption of a nutrient.

I asked whether there was a difference between getting your vitamin D from the action of sunlight on the skin and a supplement? I didn’t get the full answer I was looking for, but Prof Young did make the point that there are other actions that the sun has on the immune system and inflammation that are generally beneficial.

People wanted to know what we should advise ‘while the scientists work it out’. Prof Young’s advice was that she felt that 1000IU should be the top recommendation a healthcare professional makes to a person with MS, and that it chould be checked that the person doesn’t have any kidney problems, as if they do, high dose vit D could cause kidney stones.

I’m going to ask Giovannonni on his blog/twitter/whatever what his response to this is, and also check what George Jelinek has been making of it.

I think if I have any thoughts on this so far, they are that perhaps people with MS need to try to get a s much Vit D as possible from foods and from the action of sunlight on the skin. In this country that only works between April and October, and when the sun is high in the sky.

It makes me wonder about sunbeds, I haven’t gone right into this, but just asking around, apparently you can get vitamin d from using a sunbed, but it has to put out UVB rays.

( and obviously, use sensibly, don’t get burned or overdo it)

I think I’m probably going to carry on recommending 5000IU, due to all the other research I’ve seen, but will be keeping my ear to the ground.

I’ve got more from the conference and will post as soon as I get time to write it up!

We also had a great time at the gala dinner fancy dress night, so In the meantime, this is for the Bedfordshire people – if you ever wondered whether your MS nurses were arch rivals or accomplices in crime, here’s something to confuse you further….!

vcm_s_kf_repr_624x832

haha

it’s not my normal look…

but I did enjoy being Marylin for the night!