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MS research update - Can vitamin D treat MS fatigue? - 28 October 2014

Summary

Fatigue is one of the most common symptoms of MS and it can have a major impact on people's lives. There are no medications that are specifically approved to treat MS fatigue. Alfacalcidol is a man-made version of vitamin D that is usually used to treat vitamin D deficiency. This study examined if it had an effect on MS fatigue.

158 people with severe levels of fatigue were included in the study and randomly assigned to receive a capsule containing 1mcg of alfacalcidol or a capsule containing a placebo oil once a day for six months.

In the group that had taken alfacalcidol for six months there was a significant decrease in the severity of fatigue. During the study the treatment group also had significantly less relapses than the control group, although after the trial ended and the group stopped treatment the number of relapses increased again.

The authors conclude that alfacalcidol might be a safe and effective treatment for MS fatigue, but larger studies, with participants from more than one country and conducted over a time period longer than six months would be needed to confirm the effect on fatigue and investigate the effect on relapses and disease progression in more detail.

Background

Fatigue is one of the most common symptoms of MS and it can have a major impact on people's lives. Treatment is based on helping someone find ways of managing their life to prevent or lessen the impact of fatigue. There are no medications that are specifically approved to treat MS fatigue.

Alfacalcidol is a type of vitamin D. It is a man-made version that is used to treat vitamin D deficiency. Previous studies have shown it can have positive effects such as reducing the number of falls in the elderly and improving muscle strength. It is also known to have effects on the immune system. This study examined if it had an effect on MS fatigue.

How this study was carried out

600 people with MS were randomly selected from the Sheba MS registry in Israel and assessed for fatigue using the Fatigue Severity Scale (FSS). 158 people with severe levels of fatigue and who met the other eligibility criteria, of being aged between 18 and 55 years and had an EDSS score of up to 5.5 were included in the study.

Participants were randomly assigned to receive either a capsule containing 1mcg of alfacalcidol (treatment group) or a capsule containing a placebo oil (control group) once a day for six months. There were 78 participants in the treatment group and 80 in the control group, in both groups EDSS scores, age, number of women and men, and the number of people taking disease modifying therapies was very similar.

Participants were assessed every month during the six month long trial period and were assessed again two months after the end of the trial. Each assessment included measurement of EDSS, recording the number of relapses, the Fatigue Impact Scale (FIS), the Modified Fatigue Impact Scale (MFIS) and the RAYS questionnaire which evaluates quality of life. Higher scores in the FIS and MFIS indicate greater fatigue.

What was found

In the group that had taken alfacalcidol for six months there was a significant decrease in the severity of fatigue. In this group the average score on the FIS was 40% lower than at the start of the study, this decrease in fatigue was also accompanied by improvements in quality of life scores as fatigue was having less impact on their lives.

During the study the treatment group also had significantly less relapses than the control group, although after the trial ended and the group stopped treatment the number of relapses increased again.

What does it mean?

The study showed that a daily dose of alfacalcidol appeared to reduce fatigue in people with MS. It also appeared to have an effect of reducing the number of relapses. The authors conclude that it might be a safe and effective treatment for MS fatigue, but larger studies, with participants from more than one country and conducted over a time period longer than six months would be needed to confirm the effect on fatigue and investigate the effect on relapses and disease progression in more detail.

Comment

This study has encouraging results, but the trial was in a small number of people and further larger trials are needed to confirm the results. Although alfacalcidol is already licensed in the UK as a treatment for vitamin D deficiency in people with certain metabolic conditions, such as kidney disorders, further trials would assess the safety as well as the effectiveness of treatment in people with MS. Vitamin D supplements available in the shops are usually either vitamin D2 (ergocalciferol) or vitamin D3 (cholecalciferol). Vitamin D3 is usually created by skin cells in response to ultraviolet B radiation in sunlight. Vitamin D2 occurs naturally in some mushrooms and yeast.

Achiron A, Givon U, Magalashvili D, et al.
Effect of Alfacalcidol on multiple sclerosis-related fatigue: A randomized, double-blind placebo-controlled study.
Mult Scler. 2014 Oct 24. [Epub ahead of print]
abstract

More about fatigue

Fatigue is believed to be the most common symptom in MS and it can often have a major impact on people's lives. The causes of fatigue in MS are not well understood and it is thought to be a combination of factors. It can be caused by the MS itself, through 'short-circuiting' nerves and it can be caused partly by other factors, including heat, inadequate diet, poor fitness and stress. As there are several causes of fatigue, there are also a number of ways that it can be managed and its impact reduced. Most management techniques revolve around ensuring the best levels of energy are available and then using the energy in the most efficient way.

How to maximise energy:

  • Sleep. Poor sleep can make fatigue worse. Establishing a bedtime routine, avoiding caffeine and winding down before bedtime can improve sleep quality.
  • Heat. Many people find that heat makes their MS worse and can make them feel more fatigued, especially during the summer months. There are several tips for keeping cool on our website, including having regular cold drinks and tepid showers.
  • Nutrition. A poor diet and nutrition can make fatigue worse. Sugary snacks might give an initial boost, blood sugar levels quickly drop again leaving energy levels low. A balanced diet can help reduce fatigue and improve energy levels, but preparing food can be tiring work. There are a number of suggestions in Living with fatigue for reducing the impact of fatigue when preparing and eating meals.
  • Relaxation techniques. Relaxation can help with fatigue as it promotes good sleep patterns, increases benefit from rest periods during the day and can be used to manage stressful situations.
  • Exercise. In the past, people with multiple sclerosis were advised to avoid exertion but now it is known that muscles that are not used regularly become weakened and require more energy to do tasks, making fatigue worse. Exercise can be something energetic or something more leisurely.

How to use energy efficiently:

  • Planning. This involves taking some time to stop and think about what needs to be done and what can be achieved. Avoid doing too many energy-demanding activities in a short period of time.
  • Prioritising and delegating. If energy is limited, this involves working out what are the most important tasks that need to be done and what can wait for another day when energy levels might be higher. Alternatively, the task can be shared or someone else can be asked to help out.
  • Organisation. It is helpful to have everything to hand when doing a task, this prevents unnecessary rushing around gathering items.
  • Pacing. This involves taking planned breaks or rests within or between activities, doing things more slowly when energy levels are lower, or breaking tasks up into smaller activities.

More suggestions can be found in Living with fatigue which can be, downloaded as a pdf file or ordered as a printed version.

More about Vitamin D

Vitamin D has several important roles in the body including keeping bones and teeth strong and healthy and regulating immune responses. It can be obtained in several ways. It is manufactured by the skin when it is exposed to sunlight, it can be obtained in the diet by eating food such as oily fish (including salmon and sardines) or fortified foods such as fat spreads and breakfast cereals or by taking supplements.

Its possible role in multiple sclerosis is the focus of much debate and research. It is known that multiple sclerosis is more common in countries further from the equator. As vitamin D is made in the skin, this has led to the hypothesis that low sunlight exposure and consequent low vitamin D production triggers the development of MS. There is some evidence that lower levels of vitamin D are associated with higher relapse rates and greater disability. Studies are underway to investigate both the role of vitamin D as a protective agent against the development of MS and as a treatment for people with the condition.

You can also read more about Vitamin D in the A to Z of MS.

Research by topic areas...

CCSVI

Hagens MH, Hoogervorst EL, Frequin ST, et al.
Cerebrospinal venous outflow in multiple sclerosis patients versus fatigue and/or depression.
Interv Neurol. 2014 Aug;2(4):193-200.
abstract
Read the full text of this paper

Disease modifying treatments

Strassburger-Krogias K, Ellrichmann G, Krogias C, et al.
Fumarate treatment in progressive forms of multiple sclerosis: first results of a single-center observational study.
Ther Adv Neurol Disord. 2014 Sep;7(5):232-8.
abstract
Read the full text of this paper

Bomprezzi R, Pawate S.
Extended interval dosing of natalizumab: a two-center, 7-year experience.
Ther Adv Neurol Disord. 2014 Sep;7(5):227-31.
abstract
Read the full text of this paper

Epidemiology

Berg-Hansen P, Moen SM, Sandvik L, et al.
Prevalence of multiple sclerosis among immigrants in Norway.
Mult Scler. 2014 Oct 24. [Epub ahead of print]
abstract

Other treatments

Goodman AD, Brown TR, Schapiro RT, et al.
A pooled analysis of two phase 3 clinical trials of dalfampridine in patients with multiple sclerosis.
Int J MS Care. 2014 Fall;16(3):153-60.
abstract
Read the full text of this paper

Skovgaard L, Pedersen IK, Verhoef M.
Exclusive use of alternative medicine as a positive choice: a qualitative study of treatment assumptions among people with multiple sclerosis in denmark.
Int J MS Care. 2014 Fall;16(3):124-31.
abstract
Read the full text of this paper

Paediatric MS

Squillace M, Ray S, Milazzo M.
Changes in gross grasp strength and fine motor skills in adolescents with pediatric multiple sclerosis.
Occup Ther Health Care. 2014 Oct 22. [Epub ahead of print]
abstract

Physical activity

Downing A, Van Ryn D, Fecko A, et al.
Effect of a 2-week trial of functional electrical stimulation on gait function and quality of life in people with multiple sclerosis.
Int J MS Care. 2014 Fall;16(3):146-52.
abstract
Read the full text of this paper

Prognosis

Simon J, Kinkel R, Kollman C, et al.
Ten-year follow-up of the 'minimal MRI lesion' subgroup from the original CHAMPS Multiple Sclerosis Prevention Trial.
Mult Scler. 2014 Oct 24. [Epub ahead of print]
abstract

Provision of care

National Clinical Guideline Centre (UK).
Multiple sclerosis: management of multiple sclerosis in primary and secondary care.
London: National Institute for Health and Care Excellence (UK); 2014 Oct.
abstract
Read the full text of this paper

Psychological aspects

Sinay V, Perez Akly M, Zanga G, et al.
School performance as a marker of cognitive decline prior to diagnosis of multiple sclerosis.
Mult Scler. 2014 Oct 24. [Epub ahead of print]
abstract

Self-management

Kalina JT.
Clutter management for individuals with multiple sclerosis.
Int J MS Care. 2014 Fall;16(3):117-22.
abstract
Read the full text of this pape

Symptoms and symptom management

Miller AK, Basso MR, Candilis PJ, et al.
Pain is associated with prospective memory dysfunction in multiple sclerosis.
J Clin Exp Neuropsychol. 2014 Oct 23:1-10. [Epub ahead of print]
abstract

Reynard AK, Sullivan AB, Rae-Grant A.
A systematic review of stress-management interventions for multiple sclerosis patients.
Int J MS Care. 2014 Fall;16(3):140-4.
abstract
Read the full text of this paper

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