Home' Australian Pharmacist : Australian Pharmacist July 2013 Contents 64
Australian Pharmacist July 2013 I ©Pharmaceutical Society of Australia Ltd.
EVIDENCE IN PATIENT CARE
to achieve and maintain optimal levels of
serum 25(OH)D >50 nmol/L.21
Additional studies are necessary to
establish the clinical benefits of vitamin D
supplementation for patients with MS and
to determine a safe and effective dose.4,13
In general, the recommended minimum
vitamin D level is 50 nmol/L, however recent
research suggests there may be additional
benefit in maintaining vitamin D levels of
75 nmol/L or higher.13,21 Doses up to 3,000
IU daily may be necessary to achieve serum
vitamin D concentrations of 75 to 100
nmol/L. It is uncertain whether higher than
‘optimal’ serum 25(OH)D levels are necessary
to obtain the suggested beneficial effects
Patients with MS may be at increased risk
of vitamin D deficiency as their disease
progresses, highlighting the need for regular
monitoring and vitamin D supplementation
where necessary. A 2007 Tasmanian study
investigating the vitamin D status of patients
with MS and a group of matched controls
found patients with a higher disability were
three times more likely to have low vitamin
D levels (<40 nmol/L) compared to the
healthy control group.22 Level of disability
was strongly associated with lower levels
of 25(OH)D and with reduced sun exposure
indicating that MS patients with a higher
disability are also more likely to spend less
time outside and are therefore at greater risk
of vitamin D deficiency.22
1. Multiple sclerosis. 2013. At: www.patient.co.uk/doctor/multiple-
2. Luzzio C. Multiple sclerosis. Medscape Reference. At: http://
3. MS Australia. Understanding MS – an introduction for people living
with MS. At: www.mssociety.org.au/documents/publications/
4. Summerday NM, Brown SJ, Allington DR, et al. Vitamin D and
Multiple sclerosis: review of a possible association. J Pharm Pract
5. Tsang BKT. Multiple sclerosis: diagnosis, management and prognosis.
Aust Fam Physician 2011;40(12):948–55.
6. Singh NN. Vitamin B12 associated neurological diseases. Medscape
Reference. At: http://emedicine.medscape.com/article/1152670
7. Leishear K, Ferrucci L, Lauretani F, et al. Vitamin B12 and homocysteine
levels and 6-year change in peripheral nerve function and neurological
signs. J Gerontol A Biol Sci Med Sci 2012;67A(5):537–43.
8. Miller A, Korem M, Almog R, et al. Vitamin B12, demyelination,
remyelination and repair in multiple sclerosis. J Neurol Sci 2005;233(1-
9. Munger KL, Zhang SM, O’Reilly E, et al. Vitamin D intake and incidence
of multiple sclerosis. Neurol 2004;62(1):60–65.
10. Munger KL, Levin LI, Hollis BW, et al. Serum 25-hydroxyvitamin D levels
and risk of multiple sclerosis. JAMA 2006;296(23):2832–8 .
11. Raghuwanshi A, et al. Vitamin D and multiple sclerosis. J Cell Biochem
12. Islam T, Gauderman J, Cozen W, et al. Childhood sun exposure
influences risk of multiple sclerosis in monozygotic twins. Neurol
13. Jagannath VA, Fedorowicz Z, Asokan GV, et al. Vitamin D for the
management of multiple sclerosis. Cochrane Database of Systematic
Reviews 2010, Issue 12. Art. No.: CD008422. DOI: 10.1002/14651858.
14. Ramagopalan SV, Maugeri NJ, Handunnetthi L, et al. Expression of
the multiple sclerosis-associated MHC class II allele HLA-DRB1*1501 is
regulated by vitamin D. PLoS Genet 2009;5(2):e1000369.
15. Soilu-Hänninen M, Airas L, Mononen I, et al. 25 -Hydroxyvitamin D levels
in serum at onset of multiple sclerosis. Mult Scler J 2005;11(3):266–71 .
16. Soilu-Hänninen M, Åivo J Lindström B, et al. A randomised, double
blind, placebo controlled trial with vitamin D3 as an add on treatment
to interferon β-1b in patients with multiple sclerosis. J Neurol
Neurosurg Psychiatry 2012;83:565–71 .
17. Mowry EM, Waubant E, McCulloch CE, et al. Vitamin D status predicts
new brain magnetic resonance imaging activity in multiple sclerosis.
Ann Neurol 2012;72(2):234–40.
18. Reynolds EH. Multiple sclerosis and vitamin B12 metabolism. J Neurol
Neurosurg Psychiatry 1992; 55;339–40.
19. Vitamin D prevention trial for MS will commence in 2012. MS Research
Australia. 2013. At: www.msra.org.au/vitamin-d-prevention-trial-ms-
20. Ascherio A, Munger KL, Simon KC. Vitamin D and multiple sclerosis.
Lancet Neurol 2010;9(6):599–612.
21. Menzies Research Institute. Information on vitamin D levels for people
with multiple sclerosis. At: www.menzies.utas.edu.au/pdf/Vitamin_D _
22. van der Mei IAF, Ponsonby AL, Dwyer T, et al. Vitamin D levels in people
with multiple sclerosis and community controls in Tasmania, Australia.
J Neurol 2007;254(5):581–90.
Key learning points
• There are a number of environmental
risk factors for the development and
progression of MS.
• Low serum vitamin D levels are
associated with an increased risk of MS.
• Vitamin D levels have been found to
be significantly lower in MS patients
compared to healthy control subjects.
Vitamin D supplementation may
help to prevent disease relapse and
progression in patients with MS with
• Vitamin B12 has important
immunoregulatory effects including
modulation of cytokine activity.
Vitamin B12 deficiency may contribute
to the development of MS due to the
formation of defective central myelin,
triggering an autoimmune process.
• Additional studies are necessary to
elicit whether vitamin B12 deficiency in
MS reflects an increased demand for B12
for myelin repair or whether there is a
more direct causal relationship.
• Pharmacists can play an important
role by advising people with MS to
ensure they are regularly monitored for
vitamin D and B12 deficiency.
• Detection of vitamin D insufficiency
among people with MS and measures
to restore vitamin D status to adequate
levels should be considered as part of
the clinical management of MS.
1. Which ONE of the following is
correct? Multiple sclerosis:
a) is more common in males than
b) affects about one in 1,000 people in
c) tends to occur in later life.
d) is an inherited genetic condition.
2. Which ONE of the following is NOT a
risk factor for multiple sclerosis?
a) Family history.
b) Caucasian background.
c) Exposure to UV radiation.
d) Cigarette smoking.
3. Vitamin B12 may contribute to the
risk of MS and alter disease activity
a) causing down regulation of neurotoxic
b) interfering with myelin formation.
c) decreasing serum levels of
d) altering MHC gene expression.
4. Which of the following is a possible
sign of vitamin B12 deficiency?
c) Decreased visual acuity.
d) All of the above.
5. What is the MOST appropriate
advice regarding vitamin D for a
person recently diagnosed with
a) They should begin taking a vitamin
D supplement at a dose of 3000 IU to
prevent progression of their disease.
b) They should ensure their vitamin D
levels are monitored regularly and take
a supplement if they are found to be
deficient based on medical advice.
c) They should take high doses of vitamin
D during relapses to induce disease
d) They should advise all their family
members take a vitamin D supplement
to reduce their risk of developing MS.
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