Why Supplements Aren't More Widely Recommended By Physicians Who Treat Multiple Sclerosis

Most MS specialists are open to the idea of various supplements, particularly vitamin D.  The reason supplements are not at the top of the agenda items during a routine clinic visit is the relative lack of data behind them.  That is not to say that supplements can't help the MS disease course, it just means that the data is limited to come to that conclusion when compared to the FDA approved disease modifying therapies.

The field of medicine is in an era of evidenced-based medicine.  Physicians spend much of their time outside the clinic keeping up to date on clinical research that impacts their patients.  With this data, we have to balance the significance behind the research data in terms of a therapeutic's efficacy (ability to positively impact the disease) compared to the risks (in regards to safety, tolerability, and drug-drug interactions).  If the evidence if there, and the balance is favorable, we share this in clinic which helps patients make informed decisions about their care.

Although this is a responsible way to deliver medical care, we have to acknowledge that there is much we don't know, particularly around supplements where the data is not as strong (or completely non-existent) to guide recommendations.  The FDA does not regulate supplements (aka, nutraceuticals or 'complementary alternative medicine'-CAM) the same way pharmaceuticals are.  It is not uncommon for supplement manufacturers to make claims about their products that are not supported by rigorous scientific evidence, but around a couple anecdotes.  Simply put, anecdotes do not equal proof.  Moreover, supplements do have potential to interact with prescribed medications, so it is important to let you doctor know everything you are taking. 

It is my belief that supplements are acceptable if there is no significant concern for harm (particularly in regards to drug-drug interactions with other medications you are on), and there is a plausible scientific mechanism that may confer benefit for MS.  Supplements such as vitamin D and fish oil appear to have the capacity to influence the immune system (or modulate it).  For instance, there are vitamin D receptors on cells of the immune system (ie, t-cells, b-cells, etc.).  That fact right there makes vitamin D biologically plausible to help MS.  Add this to the fact that there are observational studies that have shown an association between low blood levels of vitamin D and more active brain scans and clinical relapses when compared to patients with higher levels of circulating vitamin D.  

Taken together, this is strong circumstantial evidence that vitamin D is helpful for the MS disease course.  BUT... this is where the story diverges from the FDA approved therapies.  Rigorous scientific evidence demands a head to head trial of the experimental therapeutic to placebo in order to establish a "cause and effect" relationship which effectively "proves" that a therapeutic is beneficial. Association studies cannot do this, only prospective placebo controlled trials (or active comparator trials) can do this.  All of the 12 FDA approved therapies to date, have exceeded this requirement. The supplements have not.

The reason for this comes down to money.  Placebo controlled trials are extremely expensive.  Since the FDA does not regulate supplements the same was as pharmaceuticals, anyone can market a supplement without having to prove their product's effectiveness.  Because of this, manufacturers are not going to put millions of dollars into clinical trial testing since they will never recoup that money by selling the product (which is especially true if the testing proved no benefit over placebo).  

As physicians who work under the premise of evidence-based medicine, we would like to see placebo-controlled data on the supplements because we want to be able to provide our patients with the best information on the subject.  In the case of vitamin D, the circumstantial evidence is so compelling that there are such trials underway.  These are physician/investigator initiate trials.  The final verdict is still out.

With that said, I frequently recommend vitamin D in clinic because it has known benefit for bone health, may very well help MS, and has very little down-side in regard to side effects/risk.  I have primarily discussed vitamin D in this blog post, but I would encourage you to read what Dr. Allen C. Bowling has written and discussed on the subject.  He is a MS neurologist in Colorado who has published actively on CAM therapies and discussed what evidence there is behind them.  In fact, I believe he has published a book on the subject for MS patients.  This is such a huge topic that it can't all be discussed here, but I would encourage you to check out what Dr. Bowling has written about the subject.  In fact, here is an extensive interview he gave:  http://www.msfocus.org/article-details.aspx?articleID=310

I will end by saying that because I feel strongly that evidence-based medicine should drive MS care, I cannot recommend CAM as the sole therapy for a patient with relapsing MS.  If CAM is to be used, it really should be in conjunction with a proven MS therapeutic.  I would encourage readers to also look at Dr. Kinkel's blog that discusses this topic:  http://www.healthcarejourney.com/q--a-for-virtual-ms-center/platform-therapy-for-ms-5-essential-steps

A. Scott Nielsen MD MMSc
Virginia Mason Multiple Sclerosis Center