Vitamin D3 for Multiple Sclerosis
by Jeffrey Dach MD
Many of the old time clinicians have known for decades that Multiple Sclerosis is caused by Vitamin D deficiency and MS patients benefit from taking Vitamin D. Perhaps some MS patients have been cured simply by taking sufficient quantities of Vitamin D.
Above left image: Multiple Sclerosis. Animated Brain CAT scans one month apart, showing migratory enhancing white matter lesions in the periventricular area, changing with time, courtesy of wikimedia commons.(2)
Abram Hoffer MD and Vitamin D3
Years ago, I attended a medical meeting in which another attendee, a Canadian nurse, had confided in me during lunch that her son had been cured of Multiple Sclerosis by Abram Hoffer MD with Vitamin D3 as described in his book, Orthomolecular Medicine For Everyone: Megavitamin Therapeutics for Families and Physicians. So, it is no surprise we are seeing mainstream neurology journal articles like this one from Dr. Charles Pierrot-Deseilligny of Paris France, demonstrating the benefits of Vitamin D3 for MS patients.(1)(3)
Vitamin D3 and MS Relapse Rate.
How Much of a Reduction in Relapse Rate ?
The authors found a linear relationship between Vitamin D3 level and MS relapse rate. For every 10 nmol increase in 25-OH-D level, this was associated with a reduction in the relapse incidence rate of 13.7%. (Note: 25 ng/ml = 10 nmol/l Vitamin D)
How Much Vitamin D3 ?
They doubled the Serum Vitamin D3 levels from about 50 nmol/l before vitamin D3 supplementation to about 110 nmol/l.
Here is the data from the article: (Table 2 Data ) Table 2.Note Red numbers show marked reduction in relapse rate after Vitamin D.
…………………………..Relapse Incidence Rate(IR) Incidence Rate Ratio (IRR)
…………………….IR1 (before D3) IR2 (after D3) IRR
Whole population 0.70 0.18 0.25
Group 1 0.50 0.16 0.32
Group 2 0.89 0.20 0.22
IR= incidence rate for relapse
IR1, before vitamin D3 supplementation;
IR2, under vitamin D3 supplementation;
IRR, incidence rate ratio, results are expressed with two-sided 95% confidence interval;
Group 1, IMT started prior to vitamin D supplementation;
Group 2, IMT started concomitantly with vitamin D supplementation;
IMT= immunomodulatory treatment.
Analysis of Data Table
Group 2 patients, before vitamin D and before IMT ,had the highest relapse incidence rate of 0.89. These are the patients prior to any therapy at all.
Group 1 patients, on mainstream treatment with IMT (prednisone and other drugs) had a relapse incidence rate reduced to 0.50. This is not a bad result for mainstream treatment with prednisone and other immune suppressing drugs.
However, when vitamin D supplements are given, there is a further significant reduction in relapse incidence rate into the area of 0.16-0.20 for all patients.
Note: all patients on Vitamin D were also on IMT (immune modulating drugs, such as prednisone). This study shows that Vitamin D reduced the relapse rate far beyond the rates achieved with IMT (mainstream treatment with prednisone (called IMT).
One might wonder about the outcome and data for Vitamin D alone, or Vitamin D and B12 injections without the (IMT) prednisone?
Above image: MRI of MS lesions in Brain courtesy of wikimedia commons.
MRI Study Shows Fewer New Brain Lesion with Vitamin D
In 2023, Dr. Weronika Galus studied 135 multiple sclerosis (MS) patients with serial gadolinium enhanced MRI brain scans over 2 years following the MS lesions in the brain. In the first group, 95 patients were supplementing with vitamin D. The other 40 patients (Group 2) were not supplementing with vitamin D. For Group one (Vitamin D Group) there were fewer new demyelinating brain lesions (T2-weighted lesions) in the brain after 24 months. A vitamin D level greater than 30 ng/ml was associated with fewer new demyelinating brain lesions. Dr. Weronika Galus writes:
Several studies confirmed that higher vitamin D serum level is associated with better clinical and radiological outcomes in patients with multiple sclerosis…many experts suggest regular measurements of vitamin D serum levels and supplementation in patients with multiple sclerosis. In this study, 133 patients with multiple sclerosis (relapsing–remitting subtype) were prospectively observed in a 0-, 12- and 24-month time span in a clinical setting. The study group consisted of 71.4% of patients (95 out of 133) supplementing vitamin D. The associations between vitamin D serum levels, clinical outcomes (disability status expressed by EDSS, number of relapses and time to relapse) and
radiological outcomes (new T2-weighted lesions and number of gadolinium-enhanced lesions) were evaluated… Fewer new T2-weighted lesions were observed in patients with vitamin D supplementations (p = 0.034) in 24 months of observation. Moreover, an optimal or higher level of vitamin D (>30 ng/mL) maintained throughout the entire observation period was associated with a lower number of new T2-weighted lesions in 24 months of observation (p = 0.045). These results support vitamin D implementation commencement and amelioration in patients with multiple sclerosis.(11)
Vitamin B12 for MS
I should add here that MS patients may have a deficiency in B12, and may respond to B12 supplements or B12 injections with a good clinical outcome.(4-6) Since many MS patients are treated with prednisone, which may cause gastric ulceration, there is a common practice to add various types of antacid drugs which are known to cause B12 malabsorption and B12 deficiency. This iatragenic form of B12 deficiency may worsen the MS symptoms and MS relapse rate. (6) In my opinion, the hydroxycobalamin or the methylcobalamin forms of B12 are superior and these should be used. I advise against using the cyanocabalamin form of B12 since the biologically active form does not contain cyanide. Sublingual methylcobalamin tablets are readily available in 5000 mcg dosage at the vitamin store.
More Studies on Vitamin D level and MS
Additional studies from the University of California at San Fransisco, and from Turku, Finland also highlight the importance of Vitamin D levels for Multiple Sclerosis (7-8)
From U. of California study: A total of 2,362 (3T) brain MRI scans were acquired from 469 subjects. In multivariate analyses, each 10ng/ml higher 25-hydroxyvitamin D level was associated with a 15% lower risk of a new T2 lesion. (7)
From the Finland study:
Vitamin D3 add on treatment to IFNB reduces MRI disease activity in MS (8)
Gluten Free Diet Found Beneficial in MS
In a 2014 Randomized Trial of Gluten Free Diet for MS patients, Dr Rodrigo reports considerable benefit. Gluten free diet was found neurpprotective, improved physical capacity, and improved activity of lesions on MRI scan.(10):
“In the present study, we also found that a GFD (Gluten Free Diet) has a neuroprotective role in a majority of MS patients, especially in improving the physical capacity, as determined by EDSS, and the activity of lesions seen on MRI”.(10)
Our Program for Multiple Sclerosis patients:
1) Vitamin D3 supplementation given to reach the upper end of the normal range for serum vitamin D3.(80-100) Do not use vitamin D2, the wrong vitamin. Use D3.
2) Low Dose Naltrexone (4.5 mg capsule Qhs) LDN has been found useful in Multiple Sclerosis.
3) Vitamin B12 (methyl cobalamin) injections preferably 1000 mcg Im or SQ weekly. Hydroxycobalamin is also OK. Do not use the cyanocobalamin form, as this is less effective.
4) Gluten Free Diet : Gluten consumption has now been firmly linked to a long list of autoimmune diseases, including MS.(10) A gluten free diet is essential for the recovery of any MS patient. See my four part article on gluten sensitivity and autoimmune disease.
5) Niacin: Niacin and a Complete Nutritional Program for MS is outlined in article from the Orthomolecular Medicine News Service, April 24, 2018, entitled Nutritional Treatments for Multiple Sclerosis by W. Todd Penberthy and Robert G. Smith. In 2009, Dr Perberthy wrote on the importance of Niacin in MS (9):
“Existing data indicate that glia may serve critical functions as an essential supplier of NAD (Nicotinamide-Adenosine-Dinuclide) to neurons during times of stress. Administration of pharmacological doses of non-tryptophan NAD precursors (Niacin) ameliorates pathogenesis in animal models of MS (Multiple Sclerosis).”(9)
Jeffrey Dach MD
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Links and References
1) Pierrot-Deseilligny, Charles, et al. “Relationship between 25-OH-D serum level and relapse rate in multiple sclerosis patients before and after vitamin D supplementation.” Therapeutic advances in neurological disorders 5.4 (2012): 187-198. Relationship between 25-OH-D serum level and relapse rate in multiple sclerosis patients before and after vitamin D supplementation
Background:Vitamin D could play a protective role in multiple sclerosis.
Methods:In an observational, uncontrolled study, vitamin D3 supplementation (3010 IU/day on average) was given to 156 consecutive patients with relapsing–remitting multiple sclerosis, under first-line immunomodulatory therapy and with initial 25-OH-D serum level lower than 100 nmol/l (40 ng/ml). Relapses were determined for 29.1 ± 8.4 months during vitamin D and 29.8 ± 10.1 months before supplementation. The 25-OH-D level was measured before supplementation and several times during supplementation. The incidence rate of relapses before and during supplementation was estimated using negative binomial regression models with follow-up durations as offset terms. The incidence rate and incidence rate ratio of relapses at various 25-OH-D levels were also calculated using negative binomial regression models.
Results:In 76 patients, immunomodulatory therapy preceded vitamin D supplementation (by 4.2 ± 2.7 years) and in 80 patients both treatments were started simultaneously.
Under supplementation, the 25-OH-D level increased from 49 ± 22 nmol/l to 110 ± 26 nmol/l on average. Pooling data collected before and during supplementation, we found a significant strong inverse relationship between the relapse incidence rate and the 25-OH-D level (p < 0.0001), suggesting that vitamin D did indeed influence the relapse rate.
Results of univariate, bivariate and multivariate analyses were analogous: in the multivariate model adjusted for age, disease duration and previous use of immunomodulatory therapy, every 10 nmol increase in 25-OH-D level was associated with a reduction in the relapse incidence rate of 13.7%.
Dividing iteratively the population made up of pooled periods into two subgroups according to the 25-OH-D levels, the relapse incidence rate ratio decreased as the 25-OH-D level increased up to 110 nmol/l, but a plateau effect was observed beyond this limit.
Conclusion:Further studies are warranted for accurate quantification of the vitamin D effect.
Solomon, Andrew J., and Ruth H. Whitham. “Multiple sclerosis and vitamin D: a review and recommendations.” Current neurology and neuroscience reports 10 (2010): 389-396.
A relationship between vitamin D and several diseases, including multiple sclerosis (MS), has recently received interest in the scientific community. Vitamin D appears to have important actions beyond endocrine function, particularly for the immune system. Risk of development of MS, as well as disease severity, has been associated with vitamin D in a variety of studies. There remains a need for prospective studies to further establish this relationship. Given the current evidence of the potential benefits of vitamin D, it appears to be reasonable and safe to consider vitamin D supplementation at dosing adequate to achieve normal levels in patients with MS and clinically isolated syndrome.
B12 and MS
Miller, Ariel, et al. “Vitamin B12, demyelination, remyelination and repair in multiple sclerosis.” Journal of the neurological sciences 233.1-2 (2005): 93-97.
Multiple Sclerosis (MS) and vitamin B12 deficiency share common inflammatory and neurodegenerative pathophysiological characteristics. Due to similarities in the clinical presentations and MRI findings, the differential diagnosis between vitamin B12 deficiency and MS may be difficult. Additionally, low or decreased levels of vitamin B12 have been demonstrated in MS patients. Moreover, recent studies suggest that vitamin B12, in addition to its known role as a co-factor in myelin formation, has important immunomodulatory and neurotrophic effects. These observations raise the questions of possible causal relationship between the two disorders, and suggest further studies of the need to close monitoring of vitamin B12 levels as well as the potential requirement for supplementation of vitamin B12 alone or in combination with the immunotherapies for MS patients.
Sandyk, Reuven, and Gavin I. Awerbuch. “Vitamin B12 and its relationship to age of onset of multiple sclerosis.” International journal of neuroscience 71.1-4 (1993): 93-99.
Attention has been focused recently on the association between vitamin B12 metabolism and the pathogenesis of multiple sclerosis (MS). Several recent reports have documented vitamin B12 deficiency in patients with MS. The etiology of this deficiency in MS is unknown. The majority of these patients do not have pernicious anemia and serum levels of the vitamin are unrelated to the course or chronicity of the disease. Moreover, vitamin B12 does not reverse the associated macrocytic anemia nor are the neurological deficits of MS improved following supplementation with vitamin B12.
It has been suggested that vitamin B12 deficiency may render the patient more vulnerable to the putative viral and/or immunologic mechanisms widely suspected in MS. In the present communication, we report that serum vitamin B12 levels in MS patients are related to the age of onset of the disease.
Specifically, we found in 45 MS patients that vitamin B12 levels were significantly lower in those who experienced the onset of first neurological symptoms prior to age 18 years (N = 10) compared to patients in whom the disease first manifested after age 18 (N = 35).
In contrast, serum folate levels were unrelated to age of onset of the disease. As vitamin B12 levels were statistically unrelated to chronicity of illness, these findings suggest a specific association between the timing of onset of first neurological symptoms of MS and vitamin B12 metabolism. In addition, since vitamin B12 is required for the formation of myelin and for immune mechanisms, we propose that its deficiency in MS is of critical pathogenetic significance.
Corticosteroids are standard treatment for patients with multiple sclerosis experiencing acute relapse. Because dyspeptic pain is a common side effect of this intervention, patients can be given a histamine receptor-2 antagonist, proton pump inhibitor or antacid to prevent or ameliorate this disturbance. Additionally, patients with multiple sclerosis may be taking these medications independent of corticosteroid treatment. Interventions for gastric disturbances can influence the activation state of the immune system, a principal mediator of pathology in multiple sclerosis. Although histamine release promotes inflammation, activation of the histamine receptor-2 can suppress a proinflammatory immune response, and blocking histamine receptor-2 with an antagonist could shift the balance more towards immune stimulation.
Studies utilizing an animal model of multiple sclerosis indicate that histamine receptor-2 antagonists potentially augment disease activity in patients with multiple sclerosis. In contrast, proton pump inhibitors appear to favor immune suppression, but have not been studied in models of multiple sclerosis. Antacids, histamine receptor-2 antagonists and proton pump inhibitors also could alter the intestinal microflora, which may indirectly lead to immune stimulation. Additionally, elevated gastric pH can promote the vitamin B12 deficiency that patients with multiple sclerosis are at risk of developing. Here, we review possible roles of gastric acid inhibitors on immunopathogenic mechanisms associated with multiple sclerosis.
Vitamin D and MS
Mowry, Ellen M., et al. “Vitamin D status predicts new brain magnetic resonance imaging activity in multiple sclerosis.” Annals of neurology 72.2 (2012): 234-240.
We sought to determine whether vitamin D status is associated with developing new T2 lesions or contrast-enhancing lesions on brain magnetic resonance imaging (MRI) in relapsing multiple sclerosis (MS).
METHODS:EPIC is a 5-year longitudinal MS cohort study at the University of California at San Francisco. Participants had clinical evaluations, brain MRI, and blood draws annually. From the overall cohort, we evaluated patients with clinically isolated syndrome or relapsing-remitting MS at baseline. In univariate and multivariate (adjusted for age, sex, ethnicity, smoking, and MS treatments) repeated measures analyses, annual 25-hydroxyvitamin D levels were evaluated for their association with subsequent new T2-weighted and gadolinium-enhancing T1-weighted lesions on brain MRI, clinical relapses, and disability (Expanded Disability Status Scale [EDSS]).
RESULTS:A total of 2,362 3T brain MRI scans were acquired from 469 subjects. In multivariate analyses, each 10ng/ml higher 25-hydroxyvitamin D level was associated with a 15% lower risk of a new T2 lesion (incidence rate ratio [IRR], 0.85; 95% confidence interval [CI], 0.76-0.95; p = 0.004) and a 32% lower risk of a gadolinium-enhancing lesion (IRR, 0.68; 95% CI, 0.53-0.87; p = 0.002). Each 10ng/ml higher vitamin D level was associated with lower subsequent disability (-0.047; 95% CI, -0.091 to -0.003; p = 0.037). Higher vitamin D levels were associated with lower, but not statistically significant, relapse risk. Except for the EDSS model, all associations were stronger when the within-person change in vitamin D level was the predictor.
INTERPRETATION:Vitamin D levels are inversely associated with MS activity on brain MRI. These results provide further support for a randomized trial of vitamin D supplementation.
Soilu-Hänninen, Merja, 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.” Journal of Neurology, Neurosurgery & Psychiatry 83.5 (2012): 565-571.
Department of Neurology, University of Turku, Turku, Finland.
To study the safety and efficacy of vitamin D3 as an add on therapy to interferon ß-1b (IFN in patients with multiple sclerosis (MS).
METHODS:1 year, double blind, placebo controlled, randomised study in 66 MS patients. The primary outcomes were T2 burden of disease (BOD) on MRI scans, proportion of patients with serum levels of 25-hydroxyvitamin D (25(OH)D) =85 nmol/l or intact parathyroid hormone (PTH) =20 ng/l, and number of adverse events. Secondary outcomes were number of MRI enhancing T1 lesions and new T2 lesions, annual relapse rate, changes in the Expanded Disability Status Scale score, timed 25 foot walk test and timed 10 foot tandem walk tests.
RESULTS:Median change in BOD was 287 mm(3) in the placebo group and 83 mm(3) in the vitamin D group (p=0.105).
Serum levels of 25(OH)D increased from a mean of 54 (range 19-82) nmol/l to 110 (range 67-163) nmol/l in the vitamin D group. 84% of patients reached a serum 25(OH)D level >85 nmol/l in the vitamin D group and 3% in the placebo group (p<0.0001).
Patients in the vitamin D group showed fewer new T2 lesions (p=0.286) and a significantly lower number of T1 enhancing lesions (p=0.004), as well as a tendency to reduced disability accumulation (p=0.071) and to improved timed tandem walk (p=0.076). There were no significant differences in adverse events or in the annual relapse rate.
CONCLUSION:Vitamin D3 add on treatment to IFNB reduces MRI disease activity in MS.
9) Penberthy, W. Todd, and Ikuo Tsunoda. “The importance of NAD in multiple sclerosis.” Current pharmaceutical design 15.1 (2009): 64-99.
Existing data indicate that glia may serve critical functions as an essential supplier of NAD to neurons during times of stress. Administration of pharmacological doses of non-tryptophan NAD precursors ameliorates pathogenesis in animal models of MS.
Gluten Free Diet
10) Rodrigo, L., et al. “Randomised clinical trial comparing the efficacy of a gluten-free diet versus a regular diet in a series of relapsing remitting multiple sclerosis patients.” Int J Neurol Neurother 1 (2014): 2. Randomised clinical trial comparing Gluten Free Diet vs Regular in Multiple Sclerosis Rodrigo Int J Neurol Neurother 2014
In the present study, we also found that a GFD(Gluten Free Diet) has a neuroprotective role in a majority of MS patients, especially in improving the physical capacity, as determined by EDSS, and the activity of lesions seen on MRI.
11) Galus, Weronika, et al. “Radiological Benefits of Vitamin D Status and Supplementation in Patients with MS—A Two-Year Prospective Observational Cohort Study.” Nutrients 15.6 (2023): 1465.
Abstract: Current data emphasize the immunomodulating role of vitamin D in enhancing the antiinflammatory response. Vitamin D deficiency is an established risk factor for developing multiple sclerosis—the autoimmune demyelinating and degenerative disease of the central nervous system.
Several studies confirmed that higher vitamin D serum level is associated with better clinical and radiological outcomes in patients with multiple sclerosis…many experts suggest regular measurements of vitamin D serum levels and supplementation in patients with multiple sclerosis. In this study, 133 patients with multiple sclerosis (relapsing–remitting subtype) were prospectively observed in a 0-, 12- and 24-month time span in a clinical setting. The study group consisted of 71.4% of
patients (95 out of 133) supplementing vitamin D. The associations between vitamin D serum levels, clinical outcomes (disability status expressed by EDSS, number of relapses and time to relapse) and
radiological outcomes (new T2-weighted lesions and number of gadolinium-enhanced lesions) were evaluated… Fewer new T2-weighted lesions were observed in patients with vitamin D supplementations
(p = 0.034) in 24 months of observation. Moreover, an optimal or higher level of vitamin D (>30 ng/mL) maintained throughout the entire observation period was associated with a lower number of new T2-weighted lesions in 24 months of observation (p = 0.045).
These results support vitamin D implementation commencement and amelioration in patients with multiple sclerosis.
12) Wang, C., et al. “Lower 25-Hydroxyvitamin D is associated with higher relapse risk in patients with relapsing-remitting multiple sclerosis.” The journal of nutrition, health & aging 22.1 (2018): 38-43.
13) Gandhi, Fenil, et al. “Impact of Vitamin D Supplementation on Multiple Sclerosis.” Cureus 13.10 (2021).
14) Wesnes, Kristin, et al. “Low vitamin D, but not tobacco use or high BMI, is associated with long-term disability progression in multiple sclerosis.” Multiple Sclerosis and Related Disorders 50 (2021): 102801.
15) Berezowska, Monika, Shelly Coe, and Helen Dawes. “Effectiveness of vitamin D supplementation in the management of multiple sclerosis: a systematic review.” International journal of molecular sciences 20.6 (2019): 1301.
16) Feige, Julia, et al. “Vitamin D supplementation in multiple sclerosis: a critical analysis of potentials and threats.” Nutrients 12.3 (2020): 783.
17) Camu, William, et al. “Cholecalciferol in relapsing-remitting MS: A randomized clinical trial (CHOLINE).” Neurology-Neuroimmunology Neuroinflammation 6.5 (2019).
18) Jagannath, Vanitha A., et al. “Vitamin D for the management of multiple sclerosis.” Cochrane database of systematic reviews 9 (2018).
19) Pierrot-Deseilligny, Charles, and Jean-Claude Souberbielle. “Vitamin D and multiple sclerosis: an update.” Multiple sclerosis and related disorders 14 (2017): 35-45.
The most recent findings linking exposure to sun and vitamin D insufficiency to multiple sclerosis (MS) are reviewed. Due to insufficient sunshine and changing lifestyles, hypovitaminosis D is widespread in temperate countries. Numerous epidemiological studies have strongly suggested that sunshine and vitamin D insufficiency contributes to MS risk in these countries. Moreover, several large genetic studies in MS patients have recently stated unequivocally that diverse abnormalities involving vitamin D metabolism are related to the risk of the disease. The important implications of such results are discussed here. Then, the interactions of hypovitaminosis D with the other genetic and environmental protective and risk factors, such as the allele HLA DRB1*1501, Epstein-Barr virus infection, obesity, smoking and sexual hormones, are summarized. Vitamin D insufficiency and sufficiency could be a risk and a protective factor, respectively, among many other factors possibly continuously modulating the global MS risk from the mother’s pregnancy to the triggering of MS in adulthood. However, many interactions between these different factors occur more particularly between conception and the end of adolescence, which corresponds to the period of maturation of the immune system and thymus and may be related to the dysimmune nature of the disease. The main mechanisms of action of vitamin D in MS appear to be immunomodulatory, involving the various categories of T and B lymphocytes in the general immune system, but neuroprotector and neurotrophic mechanisms could also be exerted at the central nervous system level. Furthermore, several controlled immunological studies performed in MS patients have recently confirmed that vitamin D supplementation has multiple beneficial immunomodulatory effects. However, there is still an enduring absence of major conclusive randomized clinical trials testing vitamin D supplementation in MS patients because of the quasi-insurmountable practical difficulties that exist nowadays in conducting and completing over several years such studies involving the use of a vitamin. Nevertheless, it should be noted that similar robust statistical models used in five different association studies have already predicted a favorable vitamin D effect reducing relapses by 50-70%. If there is now little doubt that vitamin D exerts a beneficial action on the inflammatory component of MS, the results are as yet much less clear for the progressive degenerative component. Lastly, until more information becomes available, vitamin D supplementation of MS patients, using a moderate physiological dose essentially correcting their vitamin insufficiency, is recommended.
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