A Yale professor of neurology shares his experience in working with diet and specific nutrients with patients with multiple sclerosis
Nutrition In Focus recently had the pleasure of chatting with Dr. Joseph Guarnaccia, a board-certified neurologist at The Multiple Sclerosis Treatment Center in Derby, Connecticut, and Assistant Clinical Professor in the neurology department of Yale University. In this article Dr. Guarnaccia shares his insights on the importance of addressing diet and nutritional supplementation with biotin (vitamin B7), vitamin D, and vitamin B12 when supporting patients with multiple sclerosis (MS).
NutritionInFocus: As the former co-director of the Yale Multiple Sclerosis Program, you were at the forefront of one of the most prestigious institutions in the northeast. The research you have participated in has often involved large clinical trials comparing different medications. And yet your approach to treating multiple sclerosis is surprisingly open and broad-based, including a willingness to consider off-label medications and nutritional supplements.
Guarnaccia: I take an empirical approach to the treatment of multiple sclerosis, at the same time using therapies and approaches that have a solid scientific basis and conform to established principles in medicine. Sometimes that involves using drugs that are off label for multiple sclerosis, such as rituximab, which is used in treating certain cancers and other autoimmune diseases. And sometimes that includes recommending nutritional supplements that have some scientific basis for their use. Of course, while we may not have Class I clinical trials supporting efficacy of various supplements, I endorse their use in patients who feel that this helps their symptoms and increases their quality of life. I consider this a reasonable approach.
NutritionInFocus: Which supplements do you most commonly suggest for your patients?
Guarnaccia: The newest supplement of interest is high-dose biotin, a B vitamin. Promising new research suggests that biotin may be helpful in slowing or halting progression of both primary and secondary progressive multiple sclerosis in a subset of patients.,, I have seen a range of responses in my own patients, both those with primary and secondary MS, and those with relapsing-remitting MS. I have seen improvements in energy, cognition, and overall feelings of well being. Some patients report an improvement in ambulation and motor strength, or better bladder control. Like many prescription and nonprescription treatments, there is a range of responses. I take high dose biotin myself although I don’t have MS and feel a subtle benefit. The scientific basis for biotin relates to its role in energy metabolism and myelin formation.
The scientific basis for biotin relates to its role in energy metabolism and myelin formation.
NutritionInFocus: The research thus far has focused on patients with primary or secondary progressive MS. Have you found it helpful for relapsing/remitting MS as well?
Guarnaccia: Yes, but I don’t think there is an absolute division between these disease classifications. I have patients who are on the very mild end of the scale with relapsing/remitting MS and have almost no functional limitations but still suffer symptoms such as fatigue, pain, bladder control issues, and cognitive dysfunction that significantly impact their lives, who potentially may respond to high dose biotin. Studies have shown that loss of neurons can occur very early in multiple sclerosis and we do not have any FDA-approved treatments that focus specifically on neuroprotection, which biotin may offer.
NutritionInFocus: What other supplements do you recommend?
Guarnaccia: Like many specialists who work with MS, I stress vitamin D in my practice. Most, if not all, of my colleagues are recommending vitamin D supplementation for this patient population. Research has shown that MS risk is linked to low vitamin D levels, and there is some evidence that patients with higher levels do better in terms of relapse rates., Additionally, low vitamin D levels are linked to a number of other illnesses, including cardiac disease, depression, and colon cancer.
Research has shown that MS risk is linked to low vitamin D levels, and there is some evidence that patients with higher levels do better in terms of relapse rates.
I also routinely check vitamin B12 levels and find that vitamin B12 supplementation frequently improves fatigue. We often have to resort to off-label prescription medications to treat MS fatigue because there are no on label treatments; the problem is that these medications are often costly and the process of getting insurance coverage is frequently difficult.
NutritionInFocus: Do you feel there is an emerging synergy for MS patients of nutrition, supplementation, and medication?
Guarnaccia: With supplements like biotin coming to the fore with support from multiple scientific studies, and with an increasing emphasis and research on the significance of dietary changes, I do think there’s a dimension to using nutritional supplementation and diet with MS patients that can impact their quality of life. Recently the Wahls diet has gained renown, and I think for motivated patients, diet can make a difference. I have patients who avoid gluten, or eat micronutrient dense diets, and they do feel better. They lose weight, they feel more energetic, and their thinking is clearer. There is much more serious academic research today devoted to diet and the gut microbiome and how it may alter immune response. There are studies on the way that salt activates the gut immune system, and clinical trials on low-salt diets are underway by world-renowned MS scientists, such as David Hafler, Chair of the Department of Neurology at Yale.
Working in this specialty has been very gratifying. When I started, in 1993, the first FDA-approved drug for MS had just been released. Since that time, we’ve gained many more drugs that control the inflammatory pathogenesis of MS, as well as insights about diet, lifestyle, and supplements. It is an exciting time to be in the field. It is very gratifying as a physician to experience the feeling that we are having a significant impact on a young or middle-aged individual’s future and to work with patients to find the best fit in terms of medications and lifestyle factors to optimize their quality of life.
More about Dr. Guarnaccia:
Dr. Joseph Guarnaccia is a board-certified neurologist at The Multiple Sclerosis Treatment Center, in Derby, Connecticut and Assistant Clinical Professor in the neurology department of Yale University. From 1993 to 2000 Dr. Guarnaccia was director of the Multiple Sclerosis Clinic, Department of Neurology at Yale University. In 2015 he was inducted into the National Multiple Sclerosis Society’s Volunteer Hall of Fame, for his more than twenty years of volunteer service focused on impacting public policy in healthcare. His research has been published in journals such as the Lancet, Archives of Neurology and Biological Psychiatry.
Key Papers by Dr. Guarnaccia & Study Group Collaborators
Ansell EB, Rando K, Tuit K, Guarnaccia J, Sinha R. Cumulative adversity and smaller gray matter volume in medial prefrontal, anterior cingulate, and insula regions. Biol Psychiatry. 2012 Jul 1;72(1):57-64.
Kinkel RP, Dontchev M, et al.; Controlled High-Risk Avonex Multiple Sclerosis Prevention Study in Ongoing Neurological Surveillance Investigators. Association between immediate initiation of intramuscular interferon beta-1a at the time of a clinically isolated syndrome and long-term outcomes: a 10-year follow-up of the Controlled High-Risk Avonex Multiple Sclerosis Prevention Study in Ongoing Neurological Surveillance.Arch Neurol. 2012 Feb;69(2):183-90.
O’Connor P, Filippi M, et al.; BEYOND Study Group. 250 microg or 500 microg interferon beta-1b versus 20 mg glatiramer acetate in relapsing-remitting multiple sclerosis: a prospective, randomized, multicenter study. Lancet Neurol. 2009 Oct;8(10):889-97.
Radue EW, Stuart WH, et al.; SENTINEL Investigators. Natalizumab plus interferon beta-1a reduces lesion formation in relapsing multiple sclerosis. J Neurol Sci. 2010 May 15;292(1-2):28-35.
Click here to see References
Tourbah A, et al. MD1003 (high-dose biotin) for the treatment of progressive multiple sclerosis: A randomized, double-blind, placebo-controlled study. MultScler. 2016 Nov;22(13):1719-1731.
Sedel F, et al. Targeting demyelination and virtual hypoxia with high-dose biotin as a treatment for progressive multiple sclerosis. Neuropharmacology. 2016 Nov;110(Pt B):644-653. Review.
Peyro Saint Paul L, et al. Pharmacokinetics and pharmacodynamics of MD1003 (high-dose biotin) in the treatment of progressive multiple sclerosis. Expert Opin Drug MetabToxicol. 2016;12(3):327-44. Review.
Dankers W, et al. Vitamin D in autoimmunity: molecular mechanisms and therapeutic potential. Front Immunol. 2017 Jan 20;7:697. Review.
Hempel S, et al. A systematic review of the effects of modifiable risk factor interventions on the progression of multiple sclerosis. MultScler. 2017 Feb 1:1352458517690271.
McCaddon A. Vitamin B12 in neurology and ageing; clinical and genetic aspects. Biochimie. 2013 May;95(5):1066-76. Review.