Sunday, 14 June 2015

ClinicSpeak: MS comorbidities and survival

Are you being managed holistically? #ClinicSpeak #MSBlog #MSResearch

"The results from the UK GP database show that mortality in MSers is not only driven by MS-related disability but by comorbidities, for example infections (pneumonia, flu and urinary tract infections), depression, alcohol abuse, smoking, heart disease, cancer and depression. One could argue that many of these comorbidities are linked to having MS and if you didn't have MS they wouldn't be an issue, particularly pneumonia, urinary tract infection and depression.  The MSers who I look after who abuse alcohol tell me that their alcohol abuse is due to them having MS; they find alcohol treats their anxiety. In other words drinking is the way they treat their own depression and anxiety."

"From a clinical perspective it is irrelevant to the management of individual MSer to argue about what came first; MS or the comorbidity. As healthcare professionals looking after people with MS we need an holistic approach to the disease. In other words we need to treat the depression, prevent urinary tract infections and aspiration pneumonia, try and get MSers to stop smoking, treat their other addictions and modify their cardiovascular risk factors to prevent cardiac disease. If possible we should screen for malignancies, particularly if they are on an immunosuppressive therapy, and refer promptly the relevant specialty for treatment when we detect a malignancy. We have to take responsibility for maximising health, in particular brain health of people with MS. The latter is a two-way street and MSers have to engage in the process as well. Self-management is the name of the game in 2015 and the next phase of preventive health care will be developing programmes to nudge patients towards self-management of chronic disease. Prevention is better than cure. It is easier to prevent disability than to treat the consequences of having disability."
"The following is my tube map analogy of the holistic approach to the management of MS; each stop on the map is an issue that needs to be addressed by MSers and their HCPs."



Epub: Jick et al. Epidemiology of multiple sclerosis: results from a large observational study in the UK.J Neurol. 2015 Jun 13.

Background: MS progression to mortality may not be solely determined by the underlying autoimmune process.

Objective: We conducted a study in a large cohort of MS patients with the aim of describing characteristics of MSers and identification of predictors for all-cause mortality in this patient group.

Methods: We performed a retrospective analysis of primary care data from the UK Clinical Practice Research Datalink. Incident MS cases diagnosed between 1993 and 2006 were identified and validated using electronic and original medical records. MSers were followed to identify deaths; hazard ratios (HRs) and 95 % confidence intervals (CIs) were estimated using Cox proportional regression with age as time-scale. 

Results: In total, 1713 incident MS cases were identified. Following MS diagnosis, frequent comorbidities were infections (80 %), and depression (46 %). Adjusted HRs (95 % CIs) for all-cause mortality were: 2.0 (1.2-3.4) for current smoking; 7.6 (3.2-17.7) for alcohol abuse; 2.7 (1.6-4.5) for pneumonia and influenza; 4.1 (2.7-6.3) for urinary tract infections; 2.2 (1.2-4.2) for heart disease and 4.9 (2.9-8.0) for cancer. 

Conclusions: Our results suggest that MS survival is influenced not only by the underlying autoimmune process, but also by patient comorbidities and lifestyle factors.

12 comments:

  1. I believe the mantra that MS shortens survival because of infections is a bit wrong in that the infections are caused by the immunosupressives not MS per se.

    If you have autoimmune diseases and don't take any drugs (psoriasis for example) you never hear of lower life expectancy due to infections - my granpa lived until 82 without any problems.

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    1. Whilst I can see your point about immunosuppressives, if you are immobile e.g. stuck in bed or you can't empty your bladder properly is very different from a skin problem.

      However one problem with your argument is that most SPMSers are not getting immunosuppressives

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    2. And before immunesuppressors were around people died from MS, such as a childhood friend of mine. From malignant MS. The immunesuppressors are just a new potential risk.

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    3. http://www.ncbi.nlm.nih.gov/pubmed/25491660

      Life expectancy in psoriasisers: " Males expected by 2.7 ± 11.1 more, while females expected by 5.2 ± 9.3 less life years compared to the average statistical gender- and age-matched life expectancy (P < 0.05)."

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    4. Perhaps it's enough to take immunosuppressants during the RRMS stage (10-15 years) to weaken one's immune responses for good MD?

      Also, I am obviously not talking about fulminant MS which is rare and can well cause death but the 'usual' RRMS-SPMS one which kinda simmers along forever.

      The bladder problem we've got as well with another uncle who got Parkinson's - he stuck it out until 80.

      I am just cautious about suppressives and wouldn't like to mess up with my immune system in old age since I've seen first hand that you need a strong system to fight off the viruses and infections that most older folks die of since their defenses are weaken anyway - no need to drive it down artificially.

      I can only rely on my DNA and my family history - all have autoimmunity in all combinations, be it skin, stomach, joints, thyroid or my MS - so far they are doing well passing the 70s and 80s mark (except me since I'm 36).

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    5. ii agree with anon 10:09am.

      The immunosuppressive drugs that potentially boost vulnerability to infections, are very dangerous. Neurologists hit MSers with drugs like mitoxantrone that weaken the heart. Newer DMT drugs cause PML and brain infections.

      What we need is better treatments.

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    6. Mousedoctor, Psoriasis is a horrible disease with serious comorbidities please don't dismiss it as just a skin problem.

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    7. I agree an unpleasant condition too

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    8. Yes we need better treatments like antigen specific therapy. Does HSCT induction therapy could as a bad immunotherapy. You are at serious risk of infection but then there is no drug in the system.

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    9. Although you have no drugs in your system after HSCT, your immune system is changed such that your CD4 cells are lowered (possibly permanently) compared to baseline. We will have to see what consequences this will have down the road.

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  2. I think stress needs to be added to the list of risks. I am not saying stress is the main cause of MS. My MS reared it's ugly head for the first time (first symptom) when I was under severe psychological stress for a long time. I am not the only MSer to experience this.
    Perhaps I had very benign MS to begin with and it was ready to show it's self when I was rundown, exhausted, anxious and stressed for a long time.

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  3. Interesting that anxiety is under at risk on the holistic approach to MS. Chronic anxiety produces adrenaline and cortisol which deplete production of natural killer cells.

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