MS CENTER

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MS CENTER
Research-Education-
Patient CareRocky Mountain Multiple Sclerosis
Center
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Levels of Involvement in CAM

• Dont ask, dont tell
• Refer to information sources
• Provide information
• Make recommendations
• Practice therapies

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Rocky Mountain MS Center
100 50 0
66
56
40
39
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Vitamins Prayer Diet
Massage Interferon, Methotrexate

Glatiramer
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Dietary Supplements

• Several types
• Vitamins
• Minerals
• Herbs
• Otherenzymes, hormones, amino acids

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Dietary Supplements

• Dietary Supplements Health and Education Act
  (1994)
• DSHEA
• No standards for quality, safety, efficacy
• Initiative to Provide Better Health Information
  for Consumers (www.cfsan.fda)
• To implement in 2004
• Good manufacturing practices (GMPs)
• Accuracy of content labeling
• Qualified health claims

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Your husbands cholesterol level is just fine.
Its his chlorophyll level thats got all the
doctors worried.
Your husbands cholesterol level is just fine.
Its his chlorophyll level thats got all the
doctors worried.
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Herbal Medicine

• Accessible and popular
• 5 billion/yr
• 60 million adults
• 54/person/yr
• Many conventional medications are derived from
  herbs
• 35 prescription drugs
• 60 OTC drugs

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Herbal Therapy
? ? ?
Herb
? ? ?
X

Drug
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Herbal Therapy
few side effects
? ?
Herb
? ? ?
X

Drug
Multiple side effects
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Herbal Therapy
?
?
Herb
? ? ?
X

Drug
None available
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The Good

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Modified Swank Diet

• Dietary changes
• Limit saturated fat intake
• Fish 2-3 times/week
• Possible supplements
• omega 3 fish oil, cod liver oil, EPA/DHA
• omega 6 sunflower, evening primrose
• omega 3 6 flaxseed oil
• NOT borage, black currant seed, spirulina

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Modified Swank Diet

• May be of interest to some patients
• NOT instead of FDA-approved medications
• IMPORTANT
• Vitamin E 100-400 IU daily

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Possibly Effective Herbs

• St. Johns Wort
• Depression-possibly
• Self dx or rx is not safe
• P450 inducer
• Photosensitivity, sedation
• Cranberry
• UTI prevention-possibly
• Inhibits bacterial adhesion
• Better evidence for cranberry than vitamin C
• NOT for UTI treatment

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Possibly Effective Herbs

• Valerian
• Insomnia-possibly
• Anxiety-uncertain efficacy
• Spasticity-unstudied
• Possibly sedating

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Ginkgo Biloba

• Two major constituents
• flavonoids antioxidant
• terpenes PAF antagonists
• EAE effective
• MS attacks NOT effective
• MS cognitive dysfunction
• possible (AAN,2002)
• Preventing attacks unstudied
• Possible bleeding and seizures

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Normal Osteoporotic
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Vitamin D and Calcium

• Osteoporosis and osteopenia
• Underdiagnosed and undertreated in MS
• MS risk factors nonambulatory, female, low body
  weight, low sun exposure, ?steroids
• Disease course
• EAE vitamin D is effective
• MS vitamin D analog ineffective in small study
• Some patients may consider reasonable
• Daily vitamin D doses should be

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Good or Bad?
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B Vitamins

• B vitamins generally
• Used commonly
• No large MS clinical trial studies
• Vitamin B12
• Subgroup may be B12 deficient
• If not B12 deficient, no known benefit
• Vitamin B6 (pyridoxine)
• Daily doses
• Vitamin B3 (niacin)
• Daily doses

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Antioxidants and MS

• Possibly beneficial
• Axonal injury
• Myelin damage
• Oxidative markers increased
• Possibly harmful
• Stimulate T cells and macrophages

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Antioxidants and MS

• Compounds currently being studied

• Alpha-lipoic acid
• Inhibits MMP-9
• Decreases T-cell trafficking
• Decreases severity of EAE

• Inosine
• Precursor of uric acid
• Decreases peroxynitrite effects
• Limited evidence in EAE and MS

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Antioxidants and MS

• Various approaches
• Simple approach fruits and vegetables
• If supplements taken, modest doses
• Vitamin A,
• Vitamin C, 60-90 mg daily
• Vitamin E, 100-400 IU daily
• Designer antioxidants no clear benefit,
  expensive
• If high PUFA diet, vitamin E supplements

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LDNLow Dose Naltrexone

• Opioid antagonist
• Claims
• boost the immune systemhelping those with
  HIV/AIDS, cancer, and autoimmune diseases.
• Positive MS anecdotes
• Evidence
• Immune system variable effects including
  increased Th1 response
• EAE high dose worsens disease
• MS clinical trials none
• Conclusion unstudied, theoretical risks

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Ambrotose

• Manufactured by Mannatech
• Contains polysaccharides
• Company literature
• extracts of certain fungi and plants may be of
  assistance in the treatment of cancer. On
  investigation, many of these extracts have been
  found to possess potent immune-stimulating
  activitythis activity is attributable to complex
  carbohydrates.
• Dr. Ian Tizard

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Ambrotose

• Claimed to be effective for AIDS, cancer, MS, and
  many other diseases
• Anecdotal MS reports
• MS studies
• EAE none
• MS clinical studies none
• Conclusion unstudied, theoretical risks

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Prokarin

• Transdermal patch histamine and caffeine
• Two published trials
• 1999 study N55, not controlled, 67 improvement
• 2002 study N27, controlled, possibly fatigue
• Web-based survey-www.ms-cam.org
• Total n1326, 125 users of Prokarin
• 49 benefit, 66 discontinued
• Breathing problems, 2 rash, 44
• Cost 150-250/month

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The Bad
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Immune-stimulating Supplements

• Usually limited to in vitro studies
• Sometimes recommended as MS treatment in lay
  books
• Herbs
• Echinacea
• Alfalfa, astragalus, cats claw, garlic, ginseng,
  others
• Other supplements
• Antioxidants vitamins A, C, E selenium
• Others DHEA, melatonin, zinc

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Kava Kava

• Used in South Pacific
• Kavapyrones-act on GABA-A receptors
• Anxiety-possibly effective
• Insomnia-uncertain
• Possibly sedating
• ? severe liver toxicity

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Sedating Herbs

• Asian ginseng
• Barberry
• Black cohosh
• Calendula
• Catnip
• Chamomile
• Couchgrass
• Goldenseal

• Henbane
• Kava kava
• Passionflower
• St. Johns wort
• Scullcap
• Siberian ginseng
• Stinging nettle
• Valerian

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Sedating Herbs

• Asian ginseng
• Barberry
• Black cohosh
• Calendula
• Catnip
• Chamomile
• Couchgrass
• Goldenseal

• Henbane
• Kava kava
• Passionflower
• St. Johns wort
• Scullcap
• Siberian ginseng
• Stinging nettle
• Valerian

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Herb-Drug Interactions

• Immune-modulating and immune-suppressing drugs
• Immune-stimulating supplements
• Methotrexate
• Immune-stimulating supplements
• Echinacea liver toxicity
• Salicylate-containing herbs
• Black cohosh, meadowsweet, poplar, sweet birch,
  willow, wintergreen

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Herb-Drug Interactions

• Steroids
• Asian ginseng, cascara sagrada, ephedra,
  fenugreek, licorice, lily-of-the-valley, squill
• SSRIs
• St. Johns wort
• Tricyclic antidepressants
• Belladonna, henbane, mistletoe, St. Johns wort,
  scopolia
• Amantadine
• Belladonna, henbane, pheasants eye, scopolia

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The Ugly

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Dangerous Supplements Recommended for MS

• Borage seed oil hepatotoxicity
• Chaparral severe hepatotoxicity
• Comfrey hepatotoxicity
• Ephedra severe hypertension, arrhythmias, death
• Germanium renal toxicity, death
• Lobelia tachycardia, hypotension, death
• Scullcap severe hepatotoxicity
• Yohimbe hypertension, hypotension, arrhythmias,
  death

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Dangerous Supplements Recommended for MS

• Borage seed oil hepatotoxicity
• Chaparral severe hepatotoxicity
• Comfrey hepatotoxicity
• Ephedra severe hypertension, arrhythmias, death
• Germanium renal toxicity, death
• Lobelia tachycardia, hypotension, death
• Scullcap severe hepatotoxicity
• Yohimbe hypertension, hypotension, arrhythmias,
  death

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• Dietary supplements that are popular or relevant
  to MS
• Arranged alphabetically
• Includes
• Dosage
• Contraindications
• Drug interactions
• Side effects

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Alternative Medicine Websitewww.ms-cam.org

• 15,000 users
• MS-relevant CAM information
• 40 therapies
• Professional version with references
• Forum
• Email system
• Newsletters
• Surveys

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References

• Dietary Supplements and Multiple Sclerosis
• A Health Professionals Guide.
• Bowling AC, Stewart TM. Demos Medical Publishing,
  2004.
• Alternative Medicine and Multiple Sclerosis.
  Bowling AC, Demos Medical Publishing, 2001.

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References

• Alternative medicine and multiple sclerosis an
  objective review from an American perspective.
  Bowling AC, Ibrahim R, Stewart TM. International
  Journal of MS Care 2000 2 14-21.
  (www.mscare.com)
• Current complementary and alternative therapies
  for multiple sclerosis.
• Bowling AC, Stewart TM. Current Treatment Options
  in Neurology 2003 5 55-68.

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References

• Dietary Supplements Generally
• Natural Medicines Comprehensive Database, Jellin
  JM, Batz F, Hitchens K, Therapeutic Research
  Faculty, 2002. (www.NaturalDatabase.com)
• The Health Professionals Guide to Popular
  Dietary Supplements, Fragakis A, American
  Dietetic Association, 2002.
• Alternative Medicine Generally
• Complementary and Alternative Medicine A Desktop
  Reference, Ernst E, Mosby, 2001.

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Conclusions

• CAM is rewarding
• Broadens your view of disease
• Forces you to think from patient perspective
• Patients appreciate your efforts
• Can provide CAM information in a timely way
• Improves patient care

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Acknowledgments

• Thomas Stewart, JD, PA-C
• Ronald Murray, MD
• Patricia Kennedy, RN, CNP
• Lee Shaughnessy
• Gina Ibrahim, PhD
• Julie Lawton
• CAM website users

• Rocky Mtn. MS Center
• Teva Neuroscience
• Biogen
• Serono
• Berlex
• HealthOne Foundation
• Denver Botanic Gardens
• Hudson Gardens

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