Smoking and MS

Smoking and MS

Smoking is a major lifestyle issue for those who seek optimal health, but there is now evidence of its specific detrimental effects in MS. Smoking, with all its harmful effects on the body, has a role in MS development. An important point to emerge from a large study on nurses’ health was the very clear association between cigarette smoking and multiple sclerosis.1  The Nurses’ Health Study found that, compared with women who had never smoked, the risk of getting MS was 1.6 times greater for current smokers, and 1.2 times greater for past smokers. There was also a clear relationship between the duration of smoking and risk of MS. The risk was highest (1.7 times) for those who had smoked for over 25 years. This was supported by a Norwergian smoking MS study which showed a very similar risk, with smokers 1.8 times more likely to develop MS than non-smokers.2
Now there are enough reasons for anybody to give up smoking even without this data. With all the serious health problems smoking causes, from heart disease and lung cancer through to a range of other cancers, the single biggest positive health decision any smoker can make is to quit the habit. But for people with MS, or if MS runs in the family, there are even more compelling reasons to give up. This study didn’t look at whether smoking worsens existing MS, just at whether it is associated with its development, but a more recent smoking MS study has examined the issue of how smoking influences MS progression. Researchers at Harvard School of Public Health conducted a well designed case-control study on smokers with MS.3 People with MS who had ever smoked were 3-4 times more likely to develop secondary progressive MS than those who had never smoked. A Swedish smoking MS study in 2008 confirmed in a group of 122 people with MS for a mean duration of six years, that smokers were significantly more likely to have progressive disease, and to progress at an earlier age.4

A French case-control smoking MS study showed that children were more than twice as likely to get MS if their parents smoked, and the longer they were exposed, the more likely MS was to develop.5 So passive smoking is harmful in MS as well. Another smoking MS study from Austrian researchers published in 2008 showed that for people who had had an initial attack suggestive of MS, smokers were nearly twice as likely to go on and develop definite MS, and to develop it earlier than non-smokers.6 This has important implications for relatives of people with MS. Both passive smoking in the household and active smoking by as yet unaffected relatives make the development of MS more likely. A 2009 report from Johns Hopkins University presented to the AAN meeting in Seattle noted that those who started smoking earlier, in their study, before the age of 17, were considerably more likely to develop MS.

Unfortunately, studies have shown more people with MS smoking than in the general population.7 Smoking is an important potential modifier of the progression of MS. For people with MS who still smoke, this strong evidence means that making a positive choice about giving up smoking for better health in general is likely to favourably affect the course of MS as well. It is a reasonably simple lifestyle change which can make a great difference to disease progression.

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  1. Hernan MA, Oleky MJ, Ascherio A. Cigarette smoking and incidence of multiple sclerosis. Am J Epidemiol 2001; 154:69-74.
  2. Riise T, Nortvedt MW, Ascherio A. Smoking is a risk factor for multiple sclerosis. Neurology 2003; 61:1122-1124
  3. Hernan MA, Jick SS, Logroscino G, et al. Cigarette smoking and the progression of multiple sclerosis. Brain 2005
  4. Sundstrom P, Nystrom L. Smoking worsens the prognosis in multiple sclerosis. Mult Scler 2008
  5. Mikaeloff Y, Caridade G, Tardieu M, et al. Parental smoking at home and the risk of childhood-onset multiple sclerosis in children. Brain 2007; 130:2589-2595
  6. Di Pauli F, Reindl M, Ehling R, et al. Smoking is a risk factor for early conversion to clinically definite multiple sclerosis. Mult Scler 2008
  7. Nortvedt MW, Riise T, Maeland JG. Multiple sclerosis and lifestyle factors: the Hordaland Health Study. Neurol Sci 2005; 26:334-339

Multiple sclerosis: current and emerging disease-modifying therapies and treatment strategies.

Multiple sclerosis: current and emerging disease-modifying therapies and treatment strategies.

Author information

  • 1Department of Neurology, Mayo Clinic, Scottsdale, AZ. Electronic address:
  • 2Department of Neurology, Mayo Clinic, Scottsdale, AZ. Electronic address:


Multiple sclerosis (MS) is a chronic inflammatory demyelinating central nervous system disease that typically strikes young adults, especially women. The pathobiology of MS includes inflammatory and neurodegenerative mechanisms that affect both white and gray matter. These mechanisms underlie the relapsing, and often eventually progressive, course of MS, which is heterogeneous; confident prediction of long-term individual prognosis is not yet possible. However, because revised MS diagnostic criteria that incorporate neuroimaging data facilitate early diagnosis, most patients are faced with making important long-term treatment decisions, most notably the use and selection of disease-modifying therapy (DMT). Currently, there are 10 approved MS DMTs with varying degrees of efficacy for reducing relapse risk and preserving neurological function, but their long-term benefits remain unclear. Moreover, available DMTs differ with respect to the route and frequency of administration, tolerability and likelihood of treatment adherence, common adverse effects, risk of major toxicity, and pregnancy-related risks. Thorough understanding of the benefit-risk profiles of these therapies is necessary to establish logical and safe treatment plans for individuals with MS. We review the available evidence supporting risk-benefit profiles for available and emerging DMTs. We also assess the place of individual DMTs within the context of several different MS management strategies, including those currently in use (sequential monotherapy, escalation therapy, and induction and maintenance therapy) and others that may soon become feasible (combination approaches and “personalized medicine”). We conducted this review using a comprehensive search of MEDLINE, PubMed, EMBASE, Cochrane Database of Systematic Reviews, and Cochrane Central Register of Controlled Trials, from January 1, 1990, to August 31, 2013. The following search terms were used: multiple sclerosis, randomized controlled trials, interferon-beta, glatiramer acetate, mitoxantrone, natalizumab, fingolimod, teriflunomide, dimethyl fumarate, BG-12, alemtuzumab, rituximab, ocrelizumab, daclizumab, neutralizing antibodies, progressive multifocal leukoencephalopathy.

Copyright © 2014 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.

Neuromyelitis optica: association with paroxysmal painful tonic spasms.

Neuromyelitis optica: association with paroxysmal painful tonic spasms.

[Article in English, Spanish]



Paroxysmal painful tonic spasms (PPTS) were initially described in multiple sclerosis (MS) but they are more frequent in neuromyelitis optica (NMO). The objective is to report their presence in a series of cases of NMO and NMO spectrum disorders (NMOSD), as well as to determine their frequency and clinical features.


We conducted a retrospective assessment of medical histories of NMO/NMOSD patients treated in 2 hospitals in Buenos Aires (Hospital Durand and Hospital Álvarez) between 2009 and 2013.


Out of 15 patients with NMOSD (7 with definite NMO and 8 with limited NMO), 4 presented PPTS (26.66%). PPTS frequency in the definite NMO group was 57.14% (4/7). Of the 9 patients with longitudinally extensive transverse myelitis (LETM), 44.44% (9/15) presented PPTS. Mean age was 35 years (range, 22-38 years) and all patients were women. Mean time between NMO diagnosis and PPTS onset was 7 months (range, 1-29 months) and mean time from last relapse of LETM was 30 days (range 23-40 days). LETM (75% cervicothoracic and 25% thoracic) was observed by magnetic resonance imaging (MRI) in all patients. Control over spasms and pain was achieved in all patients with carbamazepine (associated with gabapentin in one case). No favourable responses to pregabalin, gabapentin, or phenytoin were reported.


PPTS are frequent in NMO. Mean time of PPTS onset is approximately one month after an LETM relapse, with extensive cervicothoracic lesions appearing on the MRI scan. They show an excellent response to carbamazepine but little or no response to pregabalin and gabapentin. Prospective studies with larger numbers of patients are necessary in order to confirm these results.

Copyright © 2014 Sociedad Española de Neurología. Published by Elsevier Espana. All rights reserved.


Esclerosis múltiple; Espasmos tónicos paroxísticos dolorosos; Espectro de la neuromielitis óptica; Longitudinally extensive transverse myelitis; Mielitis transversa longitudinal extensa; Multiple sclerosis; Neuromielitis óptica; Neuromyelitis optica; Neuromyelitis optica spectrum disorders; Paroxysmal painful tonic spasms

Heterogeneity of Multiple Sclerosis White Matter Lesions Detected With T2*-Weighted Imaging at 7.0 Tesla.

Heterogeneity of Multiple Sclerosis White Matter Lesions Detected With T2*-Weighted Imaging at 7.0 Tesla.



Postmortem studies in multiple sclerosis (MS) indicate that in some white matter lesions (WM-Ls), iron is detectable with T2 *-weighted (T2 *-w), and its reciprocal R2 * relaxation rate, magnetic resonance imaging (MRI) at 7.0 Tesla (7T). This iron appears as a hyperintense rim in R2 * images surrounding a hypointense core. We describe how this observation relates to clinical/radiological characteristics of patients, in vivo.


We imaged 16 MS patients using 3T and 7T scanners. WM-Ls were identified on T1 -w/T2 -w 3T-MRIs. Thereafter, WM-Ls with a rim of elevated R2 * at 7T were counted and compared to their appearance on conventional MRIs.


We counted 36 WM-Ls presenting a rim of elevated R2 * in 10 patients. Twenty-three (64%) lesions coincided with focal WM-Ls on T2 -w MRIs; 13 (36%) coincided with only portions of larger lesions on T2 -w images; and 20 (56%) corresponded to a hypointense chronic black hole. WM-Ls presenting a rim of elevated R2 * were seen in both relapsing-remitting patients with low disability and in those with long-standing secondary progressive MS.


WM-Ls with a contour of high R2 * are present at different MS stages, potentially representing differences in the contribution of iron in MS disease evolution.

The case for vitamin D supplementation in multiple sclerosis



  • Vitamin D meets Hill criteria of correlation, plausibility for altering MS activity.
  • The temporality, dose-response, and reversibility criteria are yet to be fully met.
  • Supplementation seems well-tolerated; long-term safety and optimum dose are unclear.
  • Supplementation may reduce inflammation, relapse risk, and/or disability in MS.
  • More prospective cohorts and double-blind RCTs with placebo/comparator arms needed.



Given that vitamin D has a role in immunomodulation, and its levels appear to correlate with the development of Multiple Sclerosis (MS), it is conceivable that vitamin D may also influence disease activity in MS patients. In this regard, we conducted a systematic review investigating the evidence for: (1) the role of vitamin D in disease activity in MS, and (2) the therapeutic supplementation of vitamin D in MS.


A comprehensive search of Medline, Embase, Pubmed, clinical trials registries, and conference proceedings, followed by screening and application of inclusion and exclusion criteria, yielded 57 studies for detailed appraisal. Following careful data extraction, studies addressing the role of vitamin D in disease activity were appraised on the basis of common epidemiological principles, while those involving vitamin D supplementation were assessed for potential bias using Cochrane guidelines. The overall evidence was interpreted in the context of the Bradford-Hill criteria of causation, and the number needed to treat (NNT) to prevent one patient from relapsing over a year was calculated for each supplementation study examining relapse rate.


Both cross-sectional and longitudinal studies have fairly consistently demonstrated a strong positive correlation between vitamin D deficiency and subsequent relapse and/or disability in patients with MS. As well, there appears to be a negative correlation between vitamin D levels and inflammatory markers in MS patients, suggesting that vitamin D modifies serum cytokines to a more anti-inflammatory profile. Therefore, vitamin D fulfills the Bradford-Hill criteria for strong and consistent association, biological plausibility, and coherence. However, the criteria of temporality, dose-response, and experimental evidence are yet to be adequately met, although there is preliminary evidence from longitudinal studies and randomized clinical trials (RCTs) of supplementation that vitamin D can attenuate the autoimmune response in patients, and potentially reduce relapse rates and burden of disease. Currently published data on relapse prevention with vitamin D indicates the possibility of small NNTs in the range of 1.36–25.00, but they arise from very heterogeneously designed studies.


Ultimately, the current evidence does not permit inference of a causal relationship between vitamin D deficiency and disease activity in MS. Vitamin D supplementation appears to be a promising treatment worthy of further exploration, but owing to the paucity of RCTs with placebo or comparator arms, the evidence is not definitive and appropriate dosing remains uncertain.

Managing Symptoms of Multiple Sclerosis – Re-post Nation MS society website

Managing symptoms

A wide variety of medications are used to help manage the symptoms of MS. Below are common symptoms of MS and the medications used to treat those symptoms.

Bladder Problems



Bowel Dysfunction


Dizziness and Vertigo

Emotional Changes

  • Nuedexta (dextromethorphan + quinidine)




Sexual Problems



Walking (Gait) Difficulties

Terry Wahls, MD, talks about her popular regimen for progressive MS.

MS Clinical Focus: The Wahls Protocol

Terry Wahls, MD, talks about her popular regimen for progressive MS.


Discussant: Terry Wahls, MD

With no clearly proven treatments available for progressive forms of multiple sclerosis (MS), the door has been opened for what are usually called alternative or complementary therapies. One that has gained many adherents in the MS community is the Wahls Protocol, a regimen of diet, exercise (including electrical neuromuscular stimulation), and meditation techniques.

MedPage Today asked for comments from its eponymous developer, Terry Wahls, MD, clinical professor of medicine at the University of Iowa Carver College of Medicine in Iowa City. Wahls is an MS patient and devised the protocol initially for herself. On her website, she claims to have climbed out of a wheelchair and improved enough to complete an 18-mile bike ride within 1 year.

In the accompanying video, Wahls describes the regimen and the ongoing clinical studies with which she is involved.

MedPage Today also contacted neurologists at academic medical centers to ask for brief comments on the Wahls Protocol. Not surprisingly, their assessments were more cautious:

“I am a firm believer in the power of good nutrition, exercise, intense rehabilitation, and a great attitude, but they have to go hand in hand with the medical treatment — as clearly stated by Dr. Wahls, she underwent chemotherapy, which likely played a role in slowing the progression of her disease.” — Flavia Nelson, MD, University of Texas Health Science Center in Houston

“Wellness promotion approaches including a healthful diet, exercise, and stress reduction are widely recommended by MS experts to their patients. That said, neither Dr. Wahls’ program, nor any other wellness regimen, regardless of how thoughtfully conceived and well intentioned, has been proven rigorously to alter the MS disease process in randomized, controlled trials such as those required by the FDA for the approval of new therapies. Naturally, we all want people with MS to feel better and do better, but we ought to be cautious about possibly promoting false hope.” — Andrew Goodman, MD, University of Rochester in New York.

“Multiple sclerosis is a disease which usually causes disability and should therefore usually be treated with medications that have solid scientific evidence that they help decrease clinical attacks, new MRI lesions, and/or delay progression of disability. While there is accumulating evidence that vitamin D supplementation may be of benefit, no other supplement or dietary regimen has this level of evidence. It would usually be a mistake to use an alternative therapy (whether pharmaceutical, dietary supplement, or diet) instead of traditional care. Many lifestyle modifications such as generally healthy diet, exercise, and stress management may be beneficial for all of us, including people with MS.” — Rock Heyman, MD, University of Pittsburgh Medical Center