Bone metabolism and vitamin D status in patients with multiple sclerosis

Short-Term Risk Factors for Bone Loss in Multiple Sclerosis: A Prospective Study and Literature Review

BACKGROUND

Reduced bone mass and increased osteoporosis risk are common in people with multiple sclerosis (pwMS). The aim of the study was to identify risk factors for short-term bone loss in MS.

METHODS

This prospective study included 139 pwMS (ages 18-65). Baseline data included demographics, body-mass index, physical activity, smoking, menopause status, 25-hydroxy vitamin D levels, and history of glucocorticoid use. Bone mineral density (BMD) was measured at baseline and after 2 years using dual-energy X-ray absorptiometry (DXA) for the lumbar spine and hip. Disability worsening was assessed by the Expanded Disability Status Scale (EDSS). Additionally, a literature review was conducted on longitudinal data regarding BMD in MS.

RESULTS

Over the 2-year follow-up period, significant BMD loss was observed in the hip (baseline g/cm2: median 0.898; IQR 0.808-1.014; 2-year follow-up: 0.882; 0.784-1.01; p < 0.001), but not in the lumbar spine. Overall, 101 (73.1%) experienced hip BMD loss, with a median decrease of 3.5%. Patients with disability worsening had an approximately 7-times higher risk of bone loss compared to those without disability worsening (p = 0.013). PwMS with fractures during the follow-up period had significantly lower hip BMD (0.760, 0.546-0.890 vs. 0.909, 0.828-1.015; p = 0.024), a higher EDSS score (4.4, 2.8-5.8 vs. 2.0, 1.0-4.0 vs. p = 0.026), and were older (59, 46-62 vs. 47, 37-54; p = 0.030) compared to those without fractures.

CONCLUSION

Disability worsening was identified as a risk factor for BMD loss. These findings underscore the need for active monitoring of pwMS with disability worsening to prevent bone loss and, thus, to reduce fracture risk.

Bone loss and fracture in people with multiple sclerosis: A systematic review and meta-analysis

BACKGROUND

People with multiple sclerosis (PwMS) exhibit reduced bone mineral density (BMD) across several anatomical regions. Studies have indicated that PwMS are at a heightened risk of fractures due to decreased BMD and increased prevalence of osteopenia and osteoporosis. This study aimed to investigate the prevalence and risk of osteopenia, osteoporosis, and fracture among PwMS.

METHODS

Relevant studies were identified through comprehensive searches of databases (PubMed/MEDLINE, Scopus, Embase, and Web of Science) from January 1, 2000, to January 21, 2024. R software version 4.4.0 and random-effects models were employed to estimate the pooled prevalence, odds ratio (OR), and risk ratio (RR) of osteopenia, osteoporosis, and fracture among PwMS, along with their respective 95 % confidence intervals (CIs).

RESULTS

From a total of 2039 articles, 51 studies with 1,503,785 PwMS met our inclusion criteria. The pooled prevalence of osteopenia, osteoporosis, and overall fracture among PwMS was 41.41 % (95 % CI: 36.14% to 46.69 %, I2=97 %), 14.21 % (95 % CI: 10.75 % to 17.68 %, I2=99 %), and 12.84 % (95 % CI: 8.49 % to 17.19 %, I2 = 100 %), respectively. The likelihood of osteopenia (OR=2.02, 95 % CI: 1.46 to 2.8, p-value<0.01, I2=17 %) and osteoporosis (OR=1.71, 95 % CI: 1.27 to 2.31, p-value<0.01, I2=74 %), as well as the probability of overall fracture (RR=1.86, 95 % CI: 1.61 to 2.14, p-value<0.01, I2=74 %) were significantly higher in PwMS than healthy controls (HCs).

CONCLUSION

PwMS were at a substantially increased risk of developing osteopenia (2-fold), osteoporosis (1.7-fold), and overall fractures (1.9-fold). Well-designed studies are needed to explore these associations further.

High-intensity interval training improves bone remodeling, lipid profile, and physical function in multiple sclerosis patients

Multiple sclerosis (MS) is a demyelinating and neurodegenerative disease due to an autoimmune chronic inflammatory response, yet the etiology is currently not completely understood. It is already known that physical activity plays an essential role in improving quality of life, especially in neuropathological conditions. The study was aimed to investigate the possible benefits of high-intensity interval training (HIIT) in bone and lipid metabolism markers, and neuromotor abilities in MS patients. 130 participants were recruited; 16 subjects with MS met the inclusion criteria and were included in the data analysis. The patients were randomly assigned to two groups: a Control group (CG) (34.88 ± 4.45 yrs) that didn't perform any physical activity and the Exercise group (EG) (36.20 ± 7.80 yrs) that performed HIIT protocol. The training program was conducted remotely by a kinesiologist. It was performed three times a week for 8 weeks. At the beginning (T0) and the end of the study (T1) physical function tests, bone remodelling markers, and lipid markers analyses were performed. After 8 weeks of training the wall squat (s) (T0 = 27.18  ±  4.21; T1 = 41.68 ± 5.38, p ≤ 0.01) and Time Up and Go test (s) (T0 = 7.65 ± 0.43; T1 = 6.34 ± 0.38 p ≤ 0.01) performances improved; lipid markers analysis showed a decrease in Total (mg/dl) (T0 = 187.22 ± 15.73; T1 = 173.44 ± 13.03, p ≤ 0.05) and LDL (mg/dl) (T0 = 108 ± 21.08; T1 = 95.02 ± 17.99, p < 0.05) cholesterol levels. Additionally, the levels of osteocalcin (µg/L), a marker of bone formation increased (T0 = 20.88 ± 4.22; T1 = 23.66 ± 6.24, p < 0.05), 25-OH Vitamin D (µg/L) improved after 8 weeks (T0 = 21.11 ± 7.11; T1 = 27.66 ± 7.59, p < 0.05). HIIT had an effect on lower limb strength and gait control, improved bone formation, and lipid management, in MS patients.

The prevalence of osteoporosis/osteopenia in patients with multiple sclerosis (MS): a systematic review and meta-analysis

BACKGROUND

The prevalence of osteoporosis is reported differently. We designed this systematic review and meta-analysis to estimate pooled prevalence of osteoporosis and osteopenia in patients with MS.

METHODS

Independently, two researchers searched PubMed, Scopus, EMBASE, Web of Science, and google scholar along with gray literature (conference abstracts and references of the references) up to March 2021. We collected data regarding first author, country of origin, number of enrolled patients, number cases with osteoporosis/ osteopenia, mean age, F/M ratio, mean EDSS, and mean duration of the disease.

RESULTS

Literature search revealed 847 articles and 658 remained after deleting duplicates. Finally, 29 original articles and 6 conference papers remained for meta-analysis. A total of 13,906 patients were evaluated. The pooled prevalence of osteoporosis was 17% (95% CI: 14-20%) (I² = 90.4%, p < 0.001). The pooled prevalence of osteopenia was 43% (95% CI: 35-51%) (I² = 97.9%, p < 0.001).

CONCLUSION

Osteoporosis/osteopenia should be considered in patients with MS.

Vitamin D status, proinflammatory cytokines and bone mineral density in Mexican people with multiple sclerosis

BACKGROUND

Vitamin D (VD) has been classically associated with calcium homeostasis and bone mineral density since it has a key role on mineralization and resorption. Immunomodulatory effects have been attributable to VD; low concentrations of VD have been associated with elevation of inflammatory markers. Inflammatory autoimmune diseases, such as multiple sclerosis (MS), a chronic neurodegenerative suffering, whose etiology is still unknown, is directly related to an increase in pro-inflammatory cytokines such as interleukin 17 and interleukin 1β who play an important role in this physiopathology. Nowadays, even though additional studies have linked MS's clinical signs with low VD concentration, there is scarce information of this association in people from regions with sufficient sun exposure. The aim of this study was to evaluate serum VD and cytokine concentrations, and bone density, in Mexican people with MS.

METHODS

Vitamin D (25OHD), interleukin 1β, interleukin 6 and interleukin 17 concentrations of twenty-five volunteers with MS were determined by enzyme-linked immunosorbent assay. Bone mineral density and body composition assessment was performed by dual energy X-Ray absorptiometry.

RESULTS

A mean concentration of 17.3 ± 4.6 ng/ml of 25OHD was obtained, in a range of 5.15 to 25.71 ng/ml; when international advisory bodies thresholds were applied 76% of the participants exhibited some degree of VD inadequacy. Pro-inflammatory markers were detectable among the participants: interleukin 1β in 100%, interleukin 6 in 64%, whereas interleukin 17 was found in 24% of the volunteers. Bone mineral density below the expected for the age was found in 8% of the participants, with lumbar spine as the most affected anatomic region. Non-significant correlations were found between VD and bone mineral density (Z-score) or pro-inflammatory markers.

CONCLUSION

Although non-significant correlations were found between VD and bone mineral density or cytokines, it is important to highlight that an important percentage of our participants exhibited some degree of VD inadequacy, an unknown fact for them, since these are not included in routine clinical evaluations. The low concentrations of VD among this sample regardless of annual UVB sun exposure may suggest the involvement of endogenous and not environmental factors. Further works are needed in order to deepen the physiological causes and effects of VD deficiency in people with MS.

MicroRNAs, Multiple Sclerosis, and Depression

Multiple sclerosis (MS) is a chronic disease of the central nervous system that affects the brain and spinal cord. There are several disease courses in MS including relapsing–remitting MS (RRMS), primary progressive MS (PPMS), and secondary progressive MS (SPMS). Up to 50% of MS patients experience depressive disorders. Major depression (MD) is a serious comorbidity of MS. Many dysfunctions including neuroinflammation, peripheral inflammation, gut dysbiosis, chronic oxidative and nitrosative stress, and neuroendocrine and mitochondrial abnormalities may contribute to the comorbidity between MS and MD. In addition to these actions, medical treatment and microRNA (miRNA) regulation may also be involved in the mechanisms of the comorbidity between MS and MD. In the study, I review many common miRNA biomarkers for both diseases. These common miRNA biomarkers may help further explore the association between MS and MD.

Herpesvirus Antibodies, Vitamin D and Short-Chain Fatty Acids: Their Correlation with Cell Subsets in Multiple Sclerosis Patients and Healthy Controls

Although the etiology of multiple sclerosis (MS) is still unknown, it is commonly accepted that environmental factors could contribute to the disease. The objective of this study was to analyze the humoral response to Epstein-Barr virus, human herpesvirus 6A/B and cytomegalovirus, and the levels of 25-hydroxyvitamin D (25(OH)D) and the three main short-chain fatty acids (SCFA), propionate (PA), butyrate (BA) and acetate (AA), in MS patients and healthy controls (HC) to understand how they could contribute to the pathogenesis of the disease. With this purpose, we analyzed the correlations among them and with different clinical variables and a wide panel of cell subsets. We found statistically significant differences for most of the environmental factors analyzed when we compared MS patients and HC, supporting their possible involvement in the disease. The strongest correlations with the clinical variables and the cell subsets analyzed were found for 25(OH)D and SCFAs levels. A correlation was also found between 25(OH)D and PA/AA ratio, and the interaction between these factors negatively correlated with interleukin 17 (IL-17)-producing CD4+ and CD8+ T cells in untreated MS patients. Therapies that simultaneously increase vitamin D levels and modify the proportion of SCFA could be evaluated in the future.

Vitamin D, vitamin D binding protein, vitamin D receptor levels and cardiac dysautonomia in patients with multiple sclerosis: a cross-sectional study

OBJECTIVES

Vitamin D is a pleiotropic steroid hormone that modulates the autonomic balance. Its deficiency has been described as an environmental risk factor for multiple sclerosis (MS). The aim of this study was to investigate the serum levels of vitamin D, vitamin D binding protein (VDBP) and vitamin D receptors (VDR) and to evaluate cardiac dysautonomia in MS patients due to bidirectional interaction between vitamin D and the autonomic nervous system.

METHODS

The current cross-sectional study was conducted on 26 patients with relapsing-remitting MS and on 24 healthy controls. Twenty-four-hour ambulatory blood pressure variability (BPV) was calculated and the participants were evaluated for orthostatic hypotension and supine hypertension. Serum levels of vitamin D, VDBP and VDR were measured.

RESULTS

The mean serum vitamin D level was significantly lower in MS patients than in controls (p = 0.044); however there was no significant difference in terms of VDR and VDBP levels between the groups. Supine hypertension and orthostatic hypotension were significant and the 24-hour systolic BPV was significantly decreased in patients with MS (p < 0.05) compared to controls. No correlation was found between vitamin D, VDBP and VDR with supine hypertension, orthostatic hypotension and systolic BPV values (p > 0.05). Also, there was a negative correlation between VDBP and the EDSS (p = 0.039, r = -0.406).

CONCLUSION

There was no correlation between orthostatic hypotension, supine hypertension and systolic BPV values and serum vitamin D, VDBP and VDR in MS patients. Future prospective studies with large number of patients may help us to better understand the relationship between vitamin D and the autonomic nervous system.

Vitamin D deficiency and its association with fatigue and quality of life in multiple sclerosis patients

Background

Vitamin D deficiency is associated with the incidence and prevalence of a variety of neurologic disorders, including multiple sclerosis. However, available studies to date have not provided convincing evidence that vitamin D treatment improves fatigue and life quality in patients with multiple sclerosis.

Aim

To assess the relationship of vitamin D deficiency with health-related quality-of-life issues and fatigue in multiple sclerosis patients.

Methods

Vitamin D3 levels were measured in 149 multiple sclerosis patients. In patients with lower than 30 ng/mL levels, vitamin D was administered. Fatigue and health-related quality of life scores were measured at baseline and months 1, 3, 6, and 12 after the beginning of vitamin D3 administration.

Results

Among 149 patients, 90% were vitamin D deficient. After vitamin D supplementation, health-related quality of life and fatigue scores improved significantly. There was a direct association between health-related quality of life with absence of fatigue and vitamin D status at the end of study.

Conclusion

The 90% frequency of multiple sclerosis patients with vitamin D deficiency, together with the significant association of vitamin D status with the absence of fatigue and improved physical and functional well-being, points to vitamin D supplementation as a potential therapy to enhance the patient's quality of life.

Relevance of the article for predictive preventive and personalized medicine

This article emphasizes that vitamin D supplementation can improve clinical outcome in multiple sclerosis patients providing immune modulation and neuroprotection. Identification and correction of vitamin D deficiency has the potential to treat the related quality of life in patients with multiple sclerosis.

The Interaction between Viral and Environmental Risk Factors in the Pathogenesis of Multiple Sclerosis

Multiple sclerosis (MS) is a chronic debilitating inflammatory disease of unknown ethology targeting the central nervous system (CNS). MS has a polysymptomatic onset and is usually first diagnosed between the ages of 20–40 years. The pathology of the disease is characterized by immune mediated demyelination in the CNS. Although there is no clinical finding unique to MS, characteristic symptoms include sensory symptoms visual and motor impairment. No definitive trigger for the development of MS has been identified but large-scale population studies have described several epidemiological risk factors for the disease. This list is a confusing one including latitude, vitamin D (vitD) levels, genetics, infection with Epstein Barr Virus (EBV) and endogenous retrovirus (ERV) reactivation. This review will look at the evidence for each of these and the potential links between these disparate risk factors and the known molecular disease pathogenesis to describe potential hypotheses for the triggering of MS pathology.

Assessment of Biochemical and Densitometric Markers of Calcium-Phosphate Metabolism in the Groups of Patients with Multiple Sclerosis Selected due to the Serum Level of Vitamin D3

Background

In addition to the widely known effect of vitamin D₃ (vitD₃) on the skeleton, its role in the regulation of the immune response was also confirmed.

Aim

The assessment of biochemical and densitometric markers of calcium-phosphate metabolism in the groups of patients with relapsing-remitting multiple sclerosis (RRMS) selected due to the serum level of vitamin D₃.

Methods

The concentrations of biochemical markers and indices of lumbar spine bone densitometry (DXA) were determined in 82 patients divided into vitamin D₃ deficiency (VitDd), insufficiency (VitDi), and normal vitamin D₃ level (VitDn) subgroups.

Results

The highest level of the parathyroid hormone (PTH) and the highest prevalence of hypophosphatemia and osteopenia were demonstrated in VitDd group compared to VitDi and VitDn. However, in VitDd, VitDi, and VitDn subgroups no significant differences were observed in the levels of alkaline phosphatase (ALP) and ionized calcium (Ca²⁺) and in DXA indices. A negative correlation was observed between the level of vitamin D₃ and the Expanded Disability Status Scale (EDSS) in the whole MS group. The subgroups were significantly different with respect to the EDSS scores and the frequency of complaints related to walking according to the EQ-5D.

Conclusions

It is necessary to assess calcium-phosphate metabolism and supplementation of vitamin D₃ in RRMS patients. The higher the clinical stage of the disease assessed with the EDSS, the lower the level of vitamin D₃ in blood serum. Subjectively reported complaints related to difficulties with walking were reflected in the EDSS in VitDd patients.

Survivorship and Outcomes in Patients With Multiple Sclerosis Undergoing Total Joint Arthroplasty

BACKGROUND

Patients with multiple sclerosis (MS) frequently require total joint arthroplasty (TJA). The outcomes of TJA in patients with MS, who are frequently on immunomodulatory medications and physically deconditioned, remain largely unknown. The aim of this study is to elucidate the survivorship and reasons for failure in this patient population.

METHODS

A single-institution retrospective review of 108 TJAs (46 knees and 62 hips) was performed from 2000 to 2016. An electronic chart query based on MS medications and International Classification of Diseases, Ninth Revision codes was used to identify this population followed by a manual review to confirm the diagnosis. Outcomes were then assessed using revision for any reason as the primary end point. Functional outcomes were assessed using Short Form 12 scores. Survivorship curves were generated using the Kaplan-Meier method.

RESULTS

At an average follow-up of 6.2 years, 19.4% (21/108) of patients required a revision surgery. Instability (5.6%, P = .0278) and periprosthetic joint infection (4.6%, P = .0757) were among the most common reasons for revision. The overall survivorship of TJA at years 2, 5, and 7, respectively, was 96.5% (95% confidence interval [CI], 92.6-100), 86.3% (95% CI, 77.7-94.5), and 75.3% (95% CI, 63.5-87.0). Functional score improvement was less in MS cohort than patients without MS.

CONCLUSION

Patients with MS are at increased risk of complications, particularly instability and periprosthetic joint infection. Despite this increased risk of complications, patients with MS can demonstrate improved functional outcomes, but not as much as patients without MS. Patients with MS should be counseled appropriately before undergoing TJA.