Vitamin D a useful add-on treatment in MS


Highlights of the 29th Congress of the European Committee for Treatment and Research in MS (ECTRIMS), Copenhagen, DK, October 2-5, 2013 – Vitamin D supplementation for MS prophylaxis and treatment was the topic of debate at the European Charcot Foundation symposium at ECTRIMS. Speakers Dr. George Ebers, UK, and Dr. Alberto Ascherio, US, noted that numerous studies have linked low serum 25(OH)D levels with MS risk.

For example, Munger et al. reported a decreasing risk of developing MS in Caucasians for each 50 nmol/L increase in serum 25(OH)D; no association was seen for vitamin D and MS risk in blacks and Hispanics (Munger et al. JAMA 2006;296:2832-2838).

The evidence for intervention is less clear. While a number of individual studies have suggested that vitamin D supplementation may be beneficial in MS patients, a recent meta-analysis found no significant association between high-dose vitamin D treatment and the risk of MS relapse (odds ratio 0.98) (James et al. Mult Scler 2013; epublished May 22, 2013). A systematic analysis of intervention studies similarly found that the evidence for vitamin D as a treatment for MS is inconclusive (Pozuelo-Moyano et al. Neuroepidemiology 2013;40:147-153). While the evidence for benefit is not well established, the general advice from the panel was to recommend vitamin D (2,000 IU/day) since supplementation is generally safe and cost-effective.

Two new studies to determine if vitamin D can slow the development of MS in patients with clinically isolated syndrome (CIS) were announced at the Charcot Foundation session by Dr. Gilles Edan, Rennes, France. The two-year D-Lay trial will involve 30 centres in France. Planned enrollment is 316 patients. Subjects will receive 100,000 IU of vitamin D q2weeks. All centres will have started recruitment by December 2013. The PrevANZ phase IIb trial plans to enrol 240 CIS patients at 21 centres in Australia. Subjects will be randomized to placebo or one of three vitamin D arms (1,000 IU, 5,000 IU or 10,000 IU per day) for 12 months. The study began in June and nine patients have been recruited thus far.

Two new studies presented at ECTRIMS examined whether vitamin D supplementation may be a useful adjunct to disease-modifying therapies (DMTs). Ascherio et al. have analysed serum 25(OH)D levels for patients enrolled in the BENEFIT trial (Kappos et al. Neurology 2006;67:1242-1249) of interferon-beta-1b in clinically isolated syndrome (CIS) (Ascherio et al. ECTRIMS 2013; abstract 96). Serum 25(OH)D data were available at 6 and 12 months for 334 of 468 patients. Subjects with higher 25(OH)D levels had less disease activity, a slower rate of progression and a longer time to conversion to MS. For patients with a 50 ng/L higher serum 25(OH)D level, the hazard ratio for conversion to MS was 0.44 between months 6-60. A 50 ng/L higher levels was also associated with a lower relapse rate (57% reduction), a lower rate of new active lesions (57% reduction), and a lower increase in T2 lesion volume (25% reduction). The authors concluded that vitamin D may be a useful add-on to an interferon regimen in patients with CIS/early MS.

A prior study of concomitant vitamin D supplementation and interferon-beta therapy in MS reported a reduction in the number of T2 and Gd+ T1 lesions with the combination (Soilu-Hanninen et al. J Neurol Neurosurg Psychiatry 2012;83:565-571). However, there was not a  significant reduction in the annual relapse
rate or in accumulated disability.

A second study examined the effect of vitamin D in 68 MS patients treated with fingolimod (Rotstein et al. ECTRIMS 2013; abstract P419). The mean serum 25(OH)D level at baseline was 28.9 ng/mL. The mean duration of follow-up was 1.2 years. During fingolimod treatment, there was a trend to a lower relapse risk in patients with higher serum vitamin D levels (p=0.096). The authors concluded that a target serum 25(OH)D level of 30-35 ng/mL may be protective in MS patients treated with fingolimod.

Guest Reviewer: Dr. Paul S. Giacomini, Associate Director, MS Clinic, Montreal Neurological Hospital and Institute, Assistant Professor, Department of Neurology and Neurosurgery, McGill University, Montréal, Québec.


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