Vitamin D: its role in MS. Vitamin D & MS: developments Michael Hutchinson
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1 Vitamin D: its role in MS Vitamin D & MS: developments Michael Hutchinson
2 Outline of talk Evidence that vitamin D deficiency contributes to the susceptibilty to MS increases disease activity in MS Evidence that vitamin D supplementation will be of benefit in people with MS. NEW DATA, ON-GOING TRIALS What should you do at present?
3 environment and MS the changing face of multiple sclerosis
4 Changing epidemiology of MS: increasing prevalence of MS (Denmark) 60+ yrs yrs yrs Denmark; increased prevalence due to: increased survival, improved diagnosis, and also increased incidence. Bentzen et al., Mult Scler J 2010
5 Prevalence of MS in women in Denmark has increased four fold, in men two-fold. Bentzen et al., Mult Scler 2010 men women Increased incidence in women is not explained by Improved diagnosis or longevity. Environment must play a role.
6 In Canada the sex ratio has almost doubled in last 50 yrs Orton SM et al. 2006
7 Environment and increased MS incidence in women Delayed pregnancy? Increased use of oral contraceptives? Increase in cigarette smoking? Lower levels of vitamin D in women? No Differential effects of Vitamin D on immune system in women? - possibly Other unidentified environmental agent?
8 Evidence that vitamin D is the environmental factor in MS Vitamin D deficiency and susceptibility to MS Migration studies UK to South Africa, West Indies to UK, India to UK MS prevalence and latitude Australia, NZ, France, North America Vitamin D deficiency predisposes to MS Nurses observational study (Munger et al 2004, 2006)
9 Geoffrey Dean s seminal observations 1950s-90s Immigration before age 15 causes one to acquire the risk for MS of the new country
10 10 o S There is a seven-fold difference in the prevalence of MS over the eastern coast of Australia McLeod et al., Med J Aust o S 75.6
11 Incidence of first ever demyelinating event (CIS) increases with latitude in Australia Rate of increase in incidence of CIS is 9.6% per higher degree of latitude (Brisbane to Hobart) Taylor et al., Mult Scler 2010
12 Non- Maori / Pacifika RRMS women RRMS men Maori PPMS New Zealand Pronounced prevalence gradient for RRMS, women >men Latitudinal factors that influence prevalence act differentially by gender ethnicity and MS phenotype Taylor et al., Multiple Sclerosis 2010
13 Latitude and prevalence of MS: linked to sunshine in France The latitudinal anomaly of MS prevalence in Norway Ebers, Lancet neurol, 2008
14 JNNP 2011 prevalence Donegal: 290/10 5 mean vit D: 37 nmol/l Vitamin D deficiency (< 25 nmol/l) 28% MS patients v 19% controls (p< 0.004) vitamin D deficiency alone does not explain prevalence difference prevalence Wexford: 145/10 5 mean vit D: 40 nmol/l
15 Vitamin D sufficiency protects against MS Prospective study, , of 7 million military personnel, serum stored at entry. 148 whites developed MS, 296 controls. Risk of subsequently developing MS decreased with higher vitamin D levels at the time of entry to the military. Munger et al.,jama 2006
16 Vitamin D deficiency relates to disease activity in MS Seasonal variation in relapse activity and MRI activity Seasonal variation in the onset of MS and month of birth of people with MS Vitamin D deficiency is more marked in relapses of MS than in remission.
17 March June MS relapses are more common in March - June each year in the Northern hemisphere & September - December in the Southern hemisphere (the lowest point of vitamin D levels) Spelman et al., 2014
18 Seasonal variation in relapses- Tasmania Nadir of relapse rate was in February over a 3 year period and RR correlated with environmental UV exposure Tremlett et al., 2008
19 Gadolinium + lesions in MS MRI scans / month and serum vitamin D levels Serum 25(OH)D /month Mean number Gad +/month Embry et al., Ann Neurol 2000
20 Variation in susceptibility to MS by month of birth MS patients are more frequently born in the spring than the autumn. 22% more in spring; 16% less in autumn (W Scotland) Similar pattern in Sweden, Canada, Denmark, UK. (Willer et al., 2005) Spring births in MS patients HLA-DRB1*15 positive are more prevalent than those negative. Does vitamin D deficiency at birth or in utero, prime the immune system?
21 Vitamin D deficiency increases risk of MS relapse 110 paediatric onset MS/CIS patients Followed mean of 1.7 years, 52% relapsed Baseline vitamin D was 22±9ng/ml (adequate > 30) Only 15% had adequate vitamin D levels Every 10ng/ml increase in the baseline Vit D level was associated with a 34% reduction in the risk of subsequent relapse (RR 0.66, 95% CI; 0.46,0.95) Mowry et al., Ann Neurol 2010
22 Tasmania, Australia Prospective study of 145 pts with RRMS and six monthly vitamin D levels Risk of relapse in a six month period was inversely related to vitamin D level Each 10 nmol/l increase in serum vitamin D was associated with a 12 % reduction in risk of a subsequent relapse Simpson et al., Ann Neurol 2010;68:
23 patients with a first MS symptom in in a clinical trial of Betaferon and followed for 5 years higher vitamin D levels reduce new brain lesions in multiple sclerosis over 5 years Ascherio et al., 2014
24 higher vitamin D levels partially protect against brain atrophy in early multiple sclerosis over 5 years Ascherio et al., 2014
25 Genetics of MS & vitamin D metabolism People with MS inherit from their parents multiple genetic variations including genes affecting vitamin D metabolism which increase their risk of MS. Nature Genetics 2009
26 genetically lowered vitamin D levels increase the risk of MS two-fold PLOS Medicine August 2015
27 PwMS metabolise vitamin D faster Patients with MS and healthy control participants took vitamin D 5000 IU daily over 90 days. Over 90 days the rise in serum vitamin D was about 20 nmol/l less in the MS patients than in controls. MS patients are genetically more susceptible to vitamin D deficiency Bhargava et al.,2015
28 Immunological effects of Vit D 1,25(OH) 2 D interacts with the intracellular vitamin D receptor (VDR) VDR present in monocytes, dendritic cells, B cells and CD4+ T cells. a VDR element is found in HLA-DRB1*1501 vitamin D deficiency in such a setting could reduce the central deletion of auto-reactive T cells
29 Vitamin D - basics Vitamin D3 (cholecalciferol) is produced by sunlight acting on 7-dehydrocholesterol in the skin. Also available in foods and tablets. Foods: fatty fish (herring 1300 IU/100g; egg 20 IU ; fortified milk) Vitamin D3 is not biologically active it is hydroxylated in the liver to 25(OH)D (calcifediol) then hydroxylated in kidney to 1,25 (OH) 2 D (calcitriol) 1,25 (OH) 2 D (calcitriol) is the biologically active form
30 four genetic variations in the metabolism of vitamin D which cause lower vitamin D levels and increase the susceptibility to multiple sclerosis
31 Vitamin D deficiency is common country latitude Number Controls Winter serum vitamin D mean levels (nmol/l) controls deficiency % < 25nmol/L controls insufficiency % < 50nmol/L Ireland 53 o N Belgium 50 o N No data 34 Estonia 59 o N Finland 60 o N Italy 40 o N Japan 35 o N No data 87
32 How much vitamin D do we need? No universally agreed level of intake Everyone in high latitudes is Vitamin D deficient in winter/spring Calcichew D3 contains 400iu/ tablet Tolerable official upper limit is 2000 iu/day Sunlight safely provides 20,000 iu/day Older adults are advised to have serum levels of 75 nmol/l for bone health thus need 4000iu/day For the immunological effects of vitamin D September serum 2015 levels > 100nmol/L probably needed
33 recommended daily intake of vitamin D from various sources Food Safety Authority Ireland Vitamin D council Food & Nutrition Board (US) Endocrine Society 800 IU 5000 IU IU 2000 IU markedly divergent recommendations for daily allowance from various authorities
34 vitamin D and health in multiple sclerosis Lonergan et al., 2011 sufficient for immune effects AIM: take 5000 IU + /day bone health 4000 IU/ d insufficient mean level Irish MS pts deficient 30% Irish MS patients
35 10,000 IU Vitamin D/d 10,000iu of vitamin D daily will produce a serum 25(OH)D level of >200 nmol/l within 3 months
36 Clinically isolated Syndrome (CIS) patients presenting with the first symptom of demyelination, ie optic neuritis. NOT MS yet no dissemination in time (DIT). CIS patients with two + asymptomatic lesions on MRI are at high risk of further relapse 45% over next 24 months have a clinical relapse BUT 85% have MRI evidence of DIT in 24 months At 6 months: 51% at 12 months: 74% One can use the power of the MRI to detect DIT in a CIS cohort to increase frequency of endpoint and the effect of a drug on the endpoint.
37 What evidence do we need? 1) a double-blind randomised controlled trial of vitamin D versus placebo in the prevention or delay of the development of MS in patients at risk of MS. 2) a double-blind RCT of vitamin D plus a standard disease modifying therapy in reducing relapses and MRI activity in multiple sclerosis.
38
39 pilot study of vitamin D dosing in patients with first MS symptom and controls with vitamin D at 5000 IU & 10,000 IU over 6 months a) people at risk of MS, given large doses of vitamin D, achieve significantly lower serum levels of vitamin D than healthy control participants b) 50% PwMS are deficient in vitamin D at first presentation
40 what does all this mean for MS? 1) vitamin D levels are deficient in the general population for 9 months of the year. 2) people with a genetic susceptibility to MS have even lower levels of vitamin D. 3) this lower serum vitamin D level increases the likelihood of developing MS and having more active disease. 4) vitamin D sources (sun & food) are poor in Ireland (unless eating salmon & mackeral). 5) PwMS should take vitamin D supplements.
41 Proving that vitamin D is an effective therapy for MS: trials in process (1) Clinically Isolated Syndrome: delaying a development of a second episode or new MRI lesion PrevANZ: Australia, New Zealand & Ireland Doses: Placebo, 1000, 5000 or 10,000 IU daily in four arms. D-LAY: France (completion June 2019). 316 patients randomised to a) Vitamin D 100,000 IU every 14 days b) Placebo
42 Proving that vitamin D is an effective therapy for MS: trials in process (2) relapsing MS (vit D + interferons / glatiramer). EVIDMS (December 2018) SOLAR (completed - no results yet, poor recruitment) + others NO DEFINITIVE STUDY RESULTS
43 Vitamin D supplements: how much? (1) WE NEED DEFINITIVE EVIDENCE THAT VITAMIN D SUPPLEMENTATION WORKS: TO PREVENT MS TO AMELIORATE MS VITAMIN D IS NOT A SUBSTITUTE FOR DISEASE MODIFYING THERAPIES - IT IS COMPLEMENTARY
44 Vitamin D supplements: how much? (2) CHECK WITH YOUR GP THAT YOU DO NOT HAVE ANY CONTRAINDICATION TO VITAMIN D there are a number of rare disorders to be excluded DOCTORS CAN ONLY PRESCRIBE 800 IU daily THIS WILL RAISE YOUR VITAMIN D LEVELS BY ONLY nmol/l.
45 Vitamin D supplements: how much? (3) YOU WILL HAVE TO BUY VITAMIN D IN A HEALTH-FOOD STORE. BUY THE CHEAPEST FORM TAKE 2000 IU (at least) to 5000 IU daily IF YOU MISS A DAY TAKE THEM ALL TOGETHER OBESITY IS BAD FOR MS AND VITAMIN D LEVELS (LOSE WEIGHT- STOP THE CARBS).
46 SIX THINGS YOU CAN DO FOR YOUR (RELAPSING) MS AVOID BEING OVER-WEIGHT STOP SMOKING ATTEND A NEUROLOGIST YEARLY (at least) HAVE A YEARLY MRI SCAN TAKE YOUR PRESCRIBED MEDICATION EXERCISE- KEEP REASONABLY FIT TAKE A VITAMIN D SUPPLEMENT
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