#ClinicSpeak: a double-whammy

#

If you thought having MS was bad enough the Swedish study below confirms that people with MS are more likely to have a raft of other diseases, which include cardiovascular disease (CVD), stroke, heart failure, venous thromboembolism, other autoimmune conditions, bowel dysfunction, depression and fractures. These results replicate what we see from other studies and are not dissimilar what we see in other autoimmune diseases such as rheumatoid arthritis (RA). 

It is clear that some comorbidities, in particular, venous thromboembolism, bowel problems, depression and fractures, are probably due to MS. However, the other comorbidities are associated with MS. Why pwMS are at increased risk of CVD, stroke and heart failure is interesting and needs more study. Is it because pwMS live an unhealthy lifestyle; poor diet, less exercise and a higher rate of smoking? Or is the systemic inflammation that occurs in MS driving the vascular disease? Should we be doing trials to test preventive strategies to address this problem? I suspect the answer to all of these questions is YES.

#ClinicSpeak

What are the clinical implications of these findings? We know from other studies that pwMS with vascular and other comorbidities become disabled more quickly. A person with MS with vascular comorbidity will on average need a walking stick 6 years earlier than a pwMS who does not have vascular comorbidity. This 6-year gap is larger than the treatment effect of our platform therapies.  Six years is a long time in the life of someone with MS.

Therefore, if you want to manage MS holistically pwMS need to be screened for comorbidities and have them managed. This is part of my marginal gains strategy. Who should do the comorbidity screening? In the UK it usually falls to the family doctor or GP to do this screening, but I have found many pwMS simply don’t see their GP regularly enough for health checks. This is why it may be important for you as individuals with MS, and a stake in your own health, to take control and have yourself screened. 

More importantly, prevention is better than cure. So if you have MS you should do everything you can to prevent yourself from developing comorbidity. This means adopting a heart- and brain-healthy lifestyle; stop smoking, improving your diet, maintaining a healthy weight, exercising regularly, reducing your alcohol consumption to safe limits, having your blood pressure, cholesterol and sugar levels checked. In addition, you need the inflammation due to your MS controlled; this may require DMTs and a highly-effective DMT.

I am aware this advice is easier said than done, but at the end of the day, there is only so much that your HCP can do and a lot of the advice above is about self-management and empowering yourself to take responsibility for your own health. 

Castelo-Branco et al. Non-infectious comorbidity in patients with multiple sclerosis: A national cohort study in Sweden. Mult Scler J Exp Transl Clin. 2020 Aug 14;6(3):2055217320947761.

Background: Comorbidity is of significant concern in multiple sclerosis (MS). Few population-based studies have reported conditions occurring in MS after diagnosis, especially in contemporary cohorts.

Objective: To explore incident comorbidity, mortality and hospitalizations in MS, stratified by age and sex.

Methods: In a Swedish population-based cohort study 6602 incident MS patients (aged ≥18 years) and 61,828 matched MS-free individuals were identified between 1 January 2008 and 31 December 2016, using national registers. Incidence rates (IRs) and incidence rate ratios (IRRs) with 95% CI were calculated for each outcome.

Results: IRs of cardiovascular disease (CVD) were higher among MS patients than MS-free individuals, (major adverse CVD: IRR 1.42; 95% CI 1.12-1.82; hemorrhagic/ischemic stroke: 1.46; 1.05-2.02; transient ischemic attack: 1.65; 1.09-2.50; heart failure: 1.55; 1.15-2.10); venous thromboembolism: 1.42; 1.14-1.77). MS patients also had higher risks of several non-CVDs such as autoimmune conditions (IRR 3.83; 3.01-4.87), bowel dysfunction (2.16; 1.86-2.50), depression (2.38; 2.11-2.68), and fractures (1.32; 1.19-1.47), as well as being hospitalized and to suffer from CVD-related deaths ((1.91; 1.00-3.65), particularly in females (3.57; 1.58-8.06)).

Conclusion: MS-patients experience a notable comorbidity burden which emphasizes the need for integrated disease management in order to improve patient care and long-term outcomes of MS.

CoI: multiple

About the author

Prof G

Professor of Neurology, Barts & The London. MS & Preventive Neurology thinker, blogger, runner, vegetable gardener, husband, father, cook and wine & food lover.

28 comments

  • “This means adopting a heart- and brain-healthy lifestyle; stop smoking, improving your diet, maintaining a healthy weight, exercising regularly, reducing your alcohol consumption to safe limits, having your blood pressure, cholesterol and sugar levels checked. In addition, you need the inflammation due to your MS controlled; this may require DMTs and a highly-effective DMT.”

    Prof G,

    I totally agree about being responsible for looking after your own health. I’m doing all of the above (I never smoked and never drank alcohol). I had an IRT 10+ years ago and take Vit D supplements / sunbathe. My blood pressure is in the ideal range (I bought a blood pressure monitor a few years ago). I exercise for c. 45 mins a day (20 min walking and 25 min cycling). I followed your example and follow the Keto diet – my BMI is in the healthy range + my waist measurement is ideal. My thyroid issue is monitored and controlled.

    Unfortunately, my GP practice doesn’t offer regular health screening / blood tests etc. I have a private health check every 18 months. It’s a couple of hundred pounds which luckily I can afford. So having access to monitoring of cholesterol and sugar levels is not as easy as you might suppose.

    So I am following all the guidance and feel very healthy for it. But it raises a question about what more can I do? I suspect not a lot more. Will MS research / neurology offer me anything in the next 5-10 years? I hope so, as I’m making a lot of effort to push back the need for a walking stick for a few years!

  • I completely agree that MSers need to take control as much as they can, for their general good health. It would be great if we could have gym, exercise support like diabetics get weight watchers etc. I purchased a trike, with arm levers to keep me fit as walking is slow and short. The trike cost £7000.

    A well being sports voucher rather than a wheelchair would be a good starting point. Maybe we need to look at places like Holland who have a far more positive approach to rehab. Ooh, yesterday the trike decided to play up and I couldn’t steer it. So now an expensive bill and time without trike. You see all the extra challenges we have, despite trying, with less energy at the starting post. And then there is Covid. Personally I love to swim. Despite half hour swim takes about 3-4 hour recovery. Can’t do that at present. Having being shielding I feel the pool is a risk too far. So I can fully understand why my fellow MSers throw the towel in. It’s exhausting at times just to be our best version.

  • “It is clear that some comorbidities, in particular, […] depression […] are probably due to MS. […]
    […]
    I am aware this advice is easier said than done, but at the end of the day, there is only so much that your HCP can do and a lot of the advice above is about self-management and empowering yourself to take responsibility for your own health.”

    Sorry but no. It’s a team effort.

    Depression and mental health issues are not only caused by MS but self-perpetuate. We know that exercise can help alleviate some symptoms of depression but one of the hallmarks of depression is lack of motivation. We also know that depression usually precludes self-motivation.

    You’re effectively letting the HCP off the hook here. Why even bother telling a patient with depression that they need to exercise and change their diet and motivate themselves? Why not just tell them, “never mind this depression, pull yourself together and un-depress yourself”? You know it doesn’t work, the patient knows it doesn’t work but hey, to it’s a box-ticking exercise and the HCP has done their job.

    Alternatively, if you really are helping patients address their mental health and physical and mental issues:
    1.) Please share the list of resources you direct patients to so they can start to address their mental health issues.
    2.) Please share the list of resources patients can access to help them gain access to cheaper or subsidised exercise facilities and equipment.
    3.) Please share the list of resources patients can use to help them sort out their diets.

    It’s not enough to say, “I’m a busy HCP, I don’t have time or space to deal with this maintenance stuff” – because as you state yourself, prevention is better than a cure.

    I agree, it is the patient’s responsibility to look after themselves. However the point about depression is it makes exercising that responsibility practically impossible.

    • I agree with you Simon, those 3 points are something a lot of people are never given by their healthcare professionals. Not just MS, loads of illnesses.
      Even without mental health problems, people struggle to know where to start and find information online or the amount of books etc overwhelming. It’s always a good start being given some structured information and actionable resources. GP’s or the specialists should have a list of resources they hand out to anyone diagnosed with a life long illness IMO. My GP practise are very good regarding mental health and do provide useful info for anyone with MH problems; resources, self help book lists, places to seek help, as well as self referral for CBT/talking therapy. I feel like they are very forward in their approach though and a lot of surgeries across the UK don’t have that support in place at all. Until that practise, in my experience – it’s just pushing drugs and see you later – with a yearly check up that goes something like “do you want to kill yourself? No? All good, here’s your prescription ok’d for the year!!”. I imagine it’s a similar process for illness like type 2 diabetes a lot of the time too..
      With diet I don’t really know where to start so just try my best, but don’t follow any particular thing. Theres probably much more to improve and I’m a pretty motivated young person…
      Exercise, it’s a bit easier to just move more and hope for the best..
      I can completely see why a lot of people just give up and can’t be bothered.

      • Prof G I understand that some pwms have access to a neuropsychologist and some don’t. In your opinion is it a valuable service that all pwms should be able to access, and how does neuropsychiatry help pwms?

      • PwMS can get depression not just due to MS biologically. Factors such as loss of mobility, job, social life, friendships and partners, marriage breakdown, feeling isolated due to bladder bowel and issues. Lack of sleep and exercise, poor diet, side effects of medication…..

        Then having an MS diagnosis itself can trigger depressive feelings. In other words, I feel it is important to consider a wide range of factors that contribute to depression in pwMS.

        • “MS diagnoses can trigger depressive feelings”

          This reminds me of when the betaferon producers tried to abdicate responsibility for the damage their DMT does to patients’ teeth. “Oh they have MS, they’re too weak to brush their teeth properly”…

          No – DMTs (all of them, it seems) are associated with tooth decay.

          And MS – as it causes brain damage – is a CAUSE of both fatigue and mental health problems including depression.

          Psychologically it damages patients if they think (even subconsciously) that their perceived mental “weakness” is as a result of the diagnosis. As though if they hadn’t been told of the diagnosis, they wouldn’t have had the mental health issues…

          And it psychologically strengthens patients – empowers us – to know that the mental health problems and fatigue we face on a daily basis are not a sign of weakness on our part but simply one of the effects of the disease. “It’s not ‘me’, it’s the MS”.

          It allows us to understand that it was unavoidable – sure it’s treatable and we must treat it – but it was as unavoidable as those first lesions prior to diagnosis and the grinding, smouldering MS (until Prof G manages to find a fix for that too :-D)

  • MS, menopause, PCOS, leg swelling with collapsed veins, raised V111, arthritis, IBS, disinterested GP, overwhelm. Weight loss is vital but the failures are depressing. Taking control is sometimes easier said than done. 🙁

    • It does feel as though things are stacked against us. We do need a more rounded support network other than drugs. Some areas have great MS resource centres. Mine doesn’t. I use MR Motivator for seated exercises. On You Tube. Take a look. It makes you smile if nothing else! I’m afraid to say a part from medication us MSers are mostly left floundering and looking from online support groups to say a float and get information on diet etc when I was diagnosed it was suggested I stop exercising through the winter by a rather portly neurologist. He said to conserve my energy! I’m glad to say I ignored him. I carried on running and cycling whist I could. I knew more than him 19 years ago. Many would have heeded his advice. The all knowing Neurologist.

    • I walk to work and home five times a week, this has definitely made a difference to my mental well-being. I feel happier after this exercise. I don’t need the motivation to do this exercise.

      Although the walking has helped made my bladder and bowel regular, which on one hand is positive, it can be inconvenient. When there is no public toilet open on route and I can’t stop the urgency to go.

      • Boots the chemist run ‘NHS health checks for people aged 40 to 74 years old’. It includes a cholesterol check. Available at over 50 Boots pharmacy branches in England. I’m guessing there is no charge and it’s NHS funded ??

  • Would be really interstng to tease out in what ways a rheumatological condition like RA is analogous to MS per se in terms of being a chronic systemic inflammatory state. I’ve only ever really thought about it in terms of the CNS and the attendant co-morbities you might see from physical and psychological disabilities.

    • Up to anti-TNF RA was thought of as MS of the joint..or to be more realistic, MS is RA of the brain:-), where people are less risk adverse

  • Over the almost five years since my diagnosis I’ve found so much valuable information on this site, and your other site ‘Brain Health: Time Matters in MS ’ Also via MS News Today, Aaron Boster on YouTube, sites such as Medical Xpress and google searches on subjects such as neuro protection and promoting cognitive health.
    As a result of which I’ve made life-style changes that I’m hoping will prove to be of benefit further to my having received Alemtuzumab.

    These regular posts you provide concerning comorbidities are of benefit to flag up the advantages of self-care and may be enhanced by providing a list of relevant information that’s accessible on this site – everything from the studies into Lipoic Acid to exercise being another type of DMT.

    Or perhaps do a survey and find out what we as PwMS who read the Blog are doing/taking
    OR invite some of us with MS to submit a post on this.

    • I would be interesting to have a HCP who is also a pwMS submit a post. It wouldn’t matter if they are annonymous, I would understand.

  • ProfG,

    You can take a horse to water but you cannot make it drink. I think the motivation levels amongst many people with MS is pretty good already. As the level of disability increases so it becomes harder to take aerobic exercise or have the energy for mental exercise

    The first casualty for me was running then walking and now just getting changed to go for a swim makes even that impossible. Instead I spend about fifteen minutes a day at home pretending to punch. That significantly increases my heart rate. Sudoku helps my concentration and cognition.

    If an HCP could provide signposts for mental and physical exercises that match the person’s ability then so much the better. Just telling them is often counter productive

    Someone somewhere must have published sensible suggestions. Are you able to help?

  • I am 50 ish y/o white male with MS, diagnosed in 2012, I had a stellar lipid profile my entire life until the coin flipped recently to High Cholesterol in less than 1.5 yrs years. I was sort of shocked the bad lipids were high, I didn’t realize you could wreck the bad lipids so quickly.

    Several variables changed for the worse in my equation, I stopped working over 40 hours down to less active 15 hours, less cycling/walking due to worsening MS symptoms, diet worsened, and the increase in reading time, prohibiting exercising, I partially blame this blog and the loss of appetite after Lemtrada=less activity due to increase in fatigue/ less motivation or desire.

    I know what I need to do, but easier said than done, Should I start taking a Statin (Lipitor)?
    Lipitor may be a MS positive per the data, does the data still show Statins are a positive for pwMS?
    Question to the MS clinicians, do you prescribe a Statin for MS these days, if not warranted for high cholesterol? Very Curious?

    My last few years proved the Bad Lipids can spike quickly if not on top of your health, nevertheless I have time to improve my health or continue to decline adding more co morbidities.

    Thank you for helping us understand the complicated MS problems, we need more help than anyone knows !

  • I’m a very self reliant person with PPMS for 20 years +. I still take/need no medications and have no comorbidities. I take full responsibility for my own health, eat very healthily, and don’t expect any HCP to have many answers for me. But I must admit, I wish there were neuroprotectives available. That would help.

    • Great to hear you are coping Mr or Ms A. and making the best of your situation! You give me hope. Nevertheless, I watched my mother suffer with devastating MS damage, including exhausting long journey to diagnosis her over 20 yrs ago, passing at 59. Nothing I could do to stop MS then and now. But what I do know is I am gonna be pro-active, carefully choosing my treatments. I almost lost the use of my Legs 7 year ago, but never stopped walking to this day. I am called a miracle, which I shrugged off, but now looking back, only time will tell us. Who cares, it worked. MS hurts with every step and then hurts more. I am glad the medications taken every 6 hours do what they say and more or the future is gonna be a wild ride.

    • Mitoxatrone is cardio toxic are you saying Glatiramer acetate is cardiotoxic!….The mossad are comming your way as we speak:-)

      • Among the adverse cardiac reactions resulting in medication discontinuation, second-degree AV block (four patients), myocardial infarction 45 days after treatment discontinuation (one patient), and bradycardia (one patient) were observed.16

        Nine patients receiving ponesimod discontinued treatment due to cardiac adverse effects, with most experiencing onset with their first dose. In addition, respiratory adverse effects including dyspnea, and decreases in Forced Expiratory Volume over one second (FEV1) were observed in a dose-dependent manner in patients receiving ponesimod.21

      • cyclophosphamide

        FTY

        Conclusion

        Beneficial effects of fingolimod could be higher than its cardiovascular complications through administration of this agent under close observation regarding its side-effects on cardiovascular system. Indeed, we advise clinicians to report all of the cardiovascular manifestations they encounter using FTY.

        Cardiovascular effects of fingolimod: A review article

        https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4240927/

        Among the adverse cardiac reactions resulting in medication discontinuation, second-degree AV block (four patients), myocardial infarction 45 days after treatment discontinuation (one patient), and bradycardia (one patient) were observed.16

        Nine patients receiving ponesimod discontinued treatment due to cardiac adverse effects, with most experiencing onset with their first dose. In addition, respiratory adverse effects including dyspnea, and decreases in Forced Expiratory Volume over one second (FEV1) were observed in a dose-dependent manner in patients receiving ponesimod.21

        https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6281141/

        corticosteroids

        When taking oral corticosteroids longer term, you may experience:

        Clouding of the lens in one or both eyes (cataracts)
        High blood sugar, which can trigger or worsen diabetes
        Increased risk of infections, especially with common bacterial, viral and fungal microorganisms
        Thinning bones (osteoporosis) and fractures
        Suppressed adrenal gland hormone production, which may result in a variety of signs and symptoms, including severe fatigue, loss of appetite, nausea and muscle weakness
        Thin skin, bruising and slower wound healing

        Not cardiac direct related but if you ghave metabolic syndrome it can be a double-whammy

        https://www.mayoclinic.org/steroids/art-20045692

By Prof G

Translate

Categories

Recent Posts

Recent Comments

Archives