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People who have multiple sclerosis (MS) often receive an astonishing number and variety of medications. Some of them carry the complication of making bones weaker. Here are two things people who get these drugs need to know.

Multiple sclerosis (MS) is very difficult to live with, and it's a never-ending challenge for the doctors to manage. MS tends to remit and relapse, come and go. A medication that seems to be a break-through may not be working as well at it seems because the underlying disease is temporarily going into remission. A medication that seems not to be working may actually be doing its job, but the effects are not as noticeable because the disease is relapsing.

This effect is also true for natural and nutritional interventions for the disease.  And since MS is treated with immunomodulators, corticosteroids, immunosuppressants, sphingosine 1-phosphate receptor modulators, dopamine agonists, muscle relaxants, alpha2-adrenergic agonists, benzodiazepines, stimulants, hydantoin anticonvulsants, other anticonvulsants, selective serotonin/norepinephine receptor inhibitors, nonsteroidal anti-inflammatory drugs, urinary antispasmodics, both laxatives and medications to control diarrhea, central anticholinesterases, and potassium channel blockers, for a less than comprehensive list, keeping up with side effects is practically a full-time job.

Several of the kinds of medications people with MS take can cause osteoporosis. Corticosteroids taken in a dose of more than 15 mg a day can do damage to bone in just six months. Selective serotonin/norepinephrine receptor inhibitors (these are drugs like venlafaxine, which is marketed in the United States as Effexor) can cause mineral loss from bone if they are used over a period of a couple of years. Potassium channel blockers like Ampyra (dalfampridine) modify bone metabolism so there is an increased risk of fractures. 

Just about everyone who has MS will take one or more drugs that have the side effect of causing brittle bones. Rather than try to keep up with the side effects of MS meds on bone health in terms of individual medications, it's safe to assume fractures can be in your future and you should go ahead and take some simple steps for prevention. Here are just two things to keep in mind.

1. Avoid falls if you have MS and osteoporosis

That seems pretty basic, doesn't it? People who have MS hardly need some online health commentator to tell them they need to avoid falls. However, there are certain kinds of falls that are more likely to result in broken bones than others.

The side effects of MS drugs can cause weakness in the bones of the spine, hip, and wrist. Many spine fractures are due to compression. They occur slowly. They are not due to a fall or an impact. They are not as easy to prevent. However, in people who have MS, bone mineral density in the spine (something the endocrinologist measures) is a good predictor of the risk of fractures in other bones.

Hip fractures, on the other hand, more often than not are due to a fall, and the kind of fall that is the most problematic is a fall to one side (not falling forward or backward). These are falls that occur when getting into a car or when gripping for a side rail and missing it. People break their hips when they are stepping sideways to get out of a tub. Preventing these kinds of falls prevents one of the major risks of osteoporosis.

Wrist fractures in people who have MS are most often happen after putting out the hands to break a fall forward. Using a walker prevents many of these falls. It also helps to wear shoes with non-slip soles.

A reality of osteoporosis is sometimes falls cause fractures, but other times fractures cause falls. If they bone has already failed, a fall may be inevitable. It's possible to have a fracture and not know it. But simple safety measures help prevent two of the three most common kinds of osteoporotic fractures.

2. Take calcium and vitamin D, along with magnesium and vitamin K2

Building bones takes calcium, and most diets do not provide enough. Taking 1000 to 1500 mg of calcium per day, in doses of not more than 500 mg each (that means you take at least two or three tablets a day, several hours a part), helps reduce the risk of fractures. Calcium supplements, even the "cheap" kinds, help prevent fractures. But calcium doesn't work without vitamin D, magnesium, and vitamin K2.

Most people who have MS are deficient in vitamin D. This vitamin helps the digestive tract absorb calcium. It also keeps the parathyroid glands from producing a hormone that "steals": calcium from bone. If you don't get sun, you definitely need vitamin D supplements. As little as 1000 IU per day makes a difference. (Don't take more than 10,000 IU per day. Excessive vitamin D can have a reverse effect on bone health.) 

Magnesium helps bone-building cells use calcium. You need about half as much magnesium as calcium every day. Unless you are a big fan of leafy green vegetables, taking up to 600 mg of magnesium per day is helpful. Don't take more; excessive magnesium can have a laxative effect.

And the obscure vitamin K2 helps calcium go where it is needed, into bone, rather than into cholesterol deposits in the linings of your arteries. A beneficial dose is 45 mg per day. Product labels may identify K2 as M-4 or M-7 or menaquinone.

There are entire books to be written on the topic of comorbid osteoporosis and multiple sclerosis. But MS is hard enough to manage without torrents of additional information. These two topics are the basics of keeping bones healthy even when treating MS aggressively. These two precautions help many people avoid making their condition even worse.

  • Coskun Benlidayi I, Basaran S, Evlice A, Erdem M, Demirkiran M. Prevalence and risk factors of low bone mineral density in patients with multiple sclerosis. Acta Clin Belg. 2015 Jun.0(3):188-92. doi: 10.1179/2295333715Y.0000000002.
  • Lublin FD, Reingold SC. Defining the clinical course of multiple sclerosis: results of an international survey. National Multiple Sclerosis Society (USA) Advisory Committee on Clinical Trials of New Agents in Multiple Sclerosis. Neurology. 1996 Apr. 46(4):907-11.
  • Rae-Grant A, Day GS, Marrie RA, Rabinstein A, Cree BAC, Gronseth GS, et al. Practice guideline recommendations summary: Disease-modifying therapies for adults with multiple sclerosis: Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology. Neurology. 2018 Apr 24. 90 (17):777-788.
  • Rae-Grant A, Day GS, Marrie RA, Rabinstein A, Cree BAC, Gronseth GS, et al. Comprehensive systematic review summary: Disease-modifying therapies for adults with multiple sclerosis: Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology. Neurology. 2018 Apr 24. 90 (17):789-800.
  • Photo courtesy of SteadyHealth

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