Complementary and Alternative Medicine in MS that includes both of these approaches is “complementary and alternative medicine,” or “CAM. …
National Multiple Sclerosis Society 733 Third Avenue New York, NY 10017-3288
Clinical Bulletin
Information for Health Professionals
Complementary and Alternative Medicine in MS
by Allen C Bowling, MD, PhD, Rocky Mountain MS Center COMPLEMENTARY AND ALTERNATIVE MEDICINE
n the United States, there is growing interest in what has become known as alternative medicine, especially among people with chronic diseases such as multiple sclerosis MS The use of unconventional therapies may be complementary used in combination with conventional medicine or alternative used instead of conventional medicine A broad term that includes both of these approaches is complementary and alternative medicine, or CAM Recent studies indicate that 5060 of people with MS use some form of CAM Popular CAM therapies include diets, dietary supplements, acupuncture, meditation, massage, and yoga Approximately 90 of people with MS who use CAM also use conventional medicine In other words, CAM is usually used in a
complementary manner by people with MS Unfortunately, MS patients often withhold information about their CAM use from their physicians Physicians often lack understanding about the use of CAM, and accurate information about CAM that is relevant to the treatment of MS is difficult to find To address these gaps, the CAM Program was developed at the Rocky Mountain MS Center This bulletin is based on information compiled from this source
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COMPLEMENTARY AND ALTERNATIVE THERAPIES
Herbal Medicine
Herbal therapy is one of the most accessible forms of CAM Since herbs are not under strict FDA regulation, they should be used with caution There are several important principles about herbal therapy:
x Herbs are often used as drugs x Herbs contain many different compounds, some of which may be toxic or interact with
other drugs
Tel: 1-866-MS-TREAT 678-7328 E-mail: MD_info@nmssorg HealthProf_info@nmssorg wwwnationalmssocietyorg/PRCasp
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x Herbs may contain compounds that have not been identified or characterized, and may
be different from those on the label
x The quality and composition of herbal preparations are variable x Herbs should only be used for a short time, for benign, self-limited conditions x Herbs should be avoided in women who are pregnant or breastfeeding, people with multi-
ple medical problems or taking multiple medications, and children Herbal preparations that may be effective include cranberry tablets for the prevention of urinary tract infections and psyllium for constipation FDA approved Valerian may be effective for insomnia St Johns wort has long been widely used in Europe for the treatment of depression While it may have an antidepressant effect, the strength of this effect and the full range of toxicity have not been established In an effort to clarify these issues, a multi-center
placebo-controlled clinical trial was conducted at Vanderbilt University Results of this study indicated that St Johns wort is not effective for moderate or severe depression A three-year, multi-site, clinical trial coordinated by Duke University and funded by the National Institutes of Health confirmed that St Johns wort is no more effective than placebo for moderately severe depression In separate studies, St Johns wort has been found to interact with an antiviral medication for HIV infection called indinavir, and with cyclosporine, a drug used to prevent rejection of organ transplants St Johns wort may also interfere with the effectiveness of oral contraceptives and medications for heart disease, seizures, and certain cancers Certain herbs might worsen MS or interact with medications MS patients should use care with herbs that may have immune-stimulating properties, including alfalfa, astragalus, echinacea, garlic, and Asian ginseng Patients who have fatigue or take sedating
medications, such as lioresal Baclofen, tizanidine Zanaflex, and diazepam Valium, should be careful about using potentially sedating herbs, which include chamomile, Asian and Siberian ginseng, goldenseal, kava kava, stinging nettle, passionflower, sage, St Johns wort, and valerian Steroid side effects may be worsened by some herbs, including aloe, bayberry, Asian ginseng, and licorice Herbs sometimes recommended for MS that may cause serious side effects include chaparral, comfrey, lobelia, and yohimbe
Vitamins
There are theoretical reasons why antioxidant vitamins, which include vitamins A, C, and E, may be beneficial for MS Antioxidant vitamins decrease the levels of free radicals, which, according to some evidence, may be a factor in the myelin and nerve damage that occurs in MS On the other hand, antioxidants stimulate the immune system and this could be harmful for MS MS can increase the risk for developing osteoporosis, and vitamin D and calcium may be beneficial in this regard
There is no clear indication for the use of vitamin B12 therapy in MS, except for the rare patient who also has documented vitamin B12 deficiency
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A Clinical Bulletin from the Professional Resource Center of the National Multiple Sclerosis Society
High doses of some vitamins and minerals may produce toxic effects Doses of vitamins and minerals to avoid include:
x Vitamin A or beta-carotene: greater than 10,000 IU daily may produce liver injury and
other toxic effects
x Vitamin B6 pyridoxine: greater than 50 milligrams daily may produce nerve injury x Vitamin C: greater than 1,000 milligrams daily may produce diarrhea and kidney stones x Vitamin D: greater than 1,000 IU daily may produce liver injury x Selenium: greater than 200 micrograms daily may produce multiple toxic effects
In addition, vitamin A and beta-carotene should probably be avoided in smokers, and warfarin Coumadin should not be taken with coenzyme Q10, vitamin E,
vitamin K, and possibly vitamin C
Other Supplements
Zinc is sometimes used to prevent or limit the severity of the common cold Often for unclear reasons, some CAM books recommend zinc supplements specifically for MS In people with MS, it may be best to avoid or limit zinc supplements since zinc may stimulate specific cells in the immune system Similarly, melatonin and DHEA, two hormones that are available as supplements, may activate the immune system
Traditional Chinese Medicine
Traditional Chinese medicine includes acupuncture and herbal therapy Acupuncture is increasingly recognized for its effectiveness in some types of pain and nausea, but studies in MS have been limited and contradictory Chinese herbal medicine should be used cautiously and with a clear understanding of the effects of the herbs Asian ginseng and astragalus, which are common components of Chinese herbal preparations, may stimulate the immune system Another form of Chinese medicine, Chinese proprietary medicine,
should probably be avoided since there are no well-established benefits in MS and some ingredients may be toxic
Other Possibly Beneficial Therapies
Limited studies indicate that several CAM therapies may be beneficial for people with MS Cooling therapy, which involves the use of cooling suits, may improve some MS symptoms Mindbody approaches, such as meditation, guided imagery, and yoga, may relieve anxiety and pain Yoga may also be helpful for spasticity Tai chi, which is a Chinese exercise regimen that involves slow body movements and specific breathing techniques, may improve walking ability and decrease spasticity Massage may be beneficial for anxiety, depression, pain, and spasticity Horseback riding, known as hippotherapy, may provide multiple therapeutic effects Rigorous clinical studies are needed to further evaluate the effectiveness of these therapies
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Miscellaneous Therapies Lacking Proven Benefit
Bee venom therapy is currently being studied in humans, but preliminary results from animal studies at Allegheny University indicate that it has no effect and may be harmful Therapies in which there is no strong evidence for a beneficial effect in MS include calcium EAP, chelation therapy, craniosacral therapy, enemas, hyperbaric oxygen, and dental mercury amalgam removal
PRINCIPLES OF CAM USE
Several guidelines should be followed when patients are considering CAM use:
x Consider conventional medicine first x Evaluate and directly address the reasons for wanting to use CAM x If CAM is chosen, direct the patient to keep the physician informed; monitor the response
to the therapy; and discontinue therapy when appropriate
x Stress caution to the patient
THE PLACEBO EFFECT
In trials of immunomodulating agents, the placebo effect has been quite high, with a transient 3040 reduction in relapses In some
trials, placebos have actually produced greater improvement than active medications Some studies have even suggested that placebos produce beneficial effects on specific cells in the immune system The placebo effect demonstrates the powerful influence that the mind may have over the body or brain This mind-body effect may be under-utilized in conventional medicine and may be an important component of some forms of CAM
A WELLNESS APPROACH
CAM and the influence of the mind over the body are two areas that may be incorporated into a more inclusive wellness approach that optimizes functioning in the different components of the MS patients life: health, physical fitness, psychological well-being, social connectedness, nutrition, sexuality, spirituality, and bowel and bladder function These components are interwoven; in a state of wellness, there is a sense of wholeness and balance among them A chronic disease such as MS may disrupt this wholeness and balance Integration of neurologic care
with a wellness focus requires a multidisciplinary approach, including medical, psychological, nursing, dietetic, and rehabilitation services
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HYPE OR HOPE?
Does CAM use in MS provide hope or is it simply meaningless hype? The answer is both Some therapies have produced promising results, others are excessively promoted but ineffective or unsafe, and a large number have yet to be studied carefully in people with MS This large variability in the possible effectiveness of different therapies is the cause for much of the confusion and controversy in CAM Improving the way in which CAM is used involves increasing communication between people with MS and health care professionals, providing accurate CAM information to people with MS, and conducting reliable studies to determine which therapies are effective
ADDITIONAL INFORMATION
The CAM
Initiative at the Rocky Mountain MS Center offers the following resources:
x Bowling AC: Alternative Medicine and Multiple Sclerosis Demos Medical Publishing, 2000 x wwwms-camorg: An interactive, regularly updated Website devoted exclusively to CAM
and MS Other helpful books on CAM include:
x Cassileth B: The Alternative Medicine Handbook Norton, 1998 x Foster SE, Tyler VE: Tylers Honest Herbal Haworth Herbal Press, 1999 x Jellin JM, Batz F, Hitchens K: Natural Medicines Comprehensive Database Therapeutic Research
Faculty, 1999
x Sarubin A: The Health Professionals Guide to Popular Dietary Supplements The American Dietetic
Association, 2000
x Spencer JW, Jacobs JJ: Complementary/Alternative Medicine; An Evidence-Based Approach Mosby,
1999 Supported by an unrestricted educational grant from Biogen Inc
2004 National Multiple Sclerosis Society
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