alcohol – Prof G's MS Blog Archive

#MSCOVID19: alcohol

Barts-MS rose-tinted-odometer: ★

She recently turned 32 and has had multiple sclerosis for just shy of 4 years. She previously described herself as a moderate drinker having 2 to 3 glasses of wine per day in the week and maybe a bottle of wine per day on weekends. She would have typically her first drink of the day in the early evening when she got home from work. However, with COVID-19 and being forced to work from home she started drinking earlier, typically midafternoon. She has started drinking wine out of a mug to disguise it from her work colleagues on her zoom calls.

Now in the second lockdown, she has her first glass of wine with lunch. Her wine consumption has increased to more than a bottle per day. She admits to being unable to stop drinking and feels hungover on most mornings. She admits that her drinking has become a crutch. She feels lonely as she lives on her own and has not been able to visit family and friends, which is one of the reasons she is now drinking so heavily.

Does this scenario sound familiar? Alcohol consumption data during COVID-19 is worrying; recent studies have shown a large increase in alcohol purchases and consumption.

Alcohol is an anxiolytic and is probably the most used drug on the planet. Its adverse event profile is well described and long-term chronic use is associated with neurological and systemic toxicity. Neuroscientists now say there is no safe level of alcohol consumption when it comes to your brain health.

There is limited data showing that alcohol and drug misuse is higher in people with MS (pwMS) than the general population. The latter is not surprising given anxiety is so common in pwMS. Similarly, social isolation and loneliness, which are strongly associated with alcohol misuse, are endemic in pwMS. A recent survey by the MS Society indicates that 3 out of 5 pwMS describe themselves as lonely.

If you are reading this and feel your alcohol consumption has got out of hand as a result of COVID-19 please contact your HCPs and let them know. There are things that can be done remotely to help you. Don’t be ashamed to admit you have a problem; HCPs are trained to be non-judgemental and understand the issues.

As part of the holistic or marginal gains approach to the management of MS reducing alcohol consumption is one of the lifestyle interventions we promote. I am aware that it is easier said than done, but unless you try you won’t optimise your potential longterm outcome.

If you have any personal experiences you want to share with us about alcohol and how it has affected your MS, we would appreciate hearing about them. Your stories may help your fellow readers.

Bombardier et al. Alcohol and drug abuse among persons with multiple sclerosis. Mult Scler. 2004 Feb;10(1):35-40.

Objective: To examine the one-month prevalence and impact of substance abuse in a large community sample of persons with multiple sclerosis (MS).

Method: Members of the Multiple Sclerosis Society of King County were surveyed by mail. This multifaceted health survey included questions pertaining to substance abuse. Seven hundred and thirty-nine out of 1374 potential participants (54%) returned the survey, while 708 reported a medically confirmed diagnosis of MS and provided sufficient data.

Results: Fourteen per cent of the sample screened positive for possible alcohol abuse or dependence, and 7.4% reported misusing illicit drugs or prescription medications within the previous month. Possible alcohol abuse and drug misuse were associated with younger age, less severe MS-related disability and being employed, as well as greater self-reported depressive symptomatology. Most persons with alcohol problems indicated an interest in learning more about ways to stop or cut down.

Conclusions: Substance abuse may be present in up to 19% of this sample and contribute to high rates of depression. There may be greater risk of harm due to substance abuse in people with MS because of the potential magnification of motor and cognitive impairments. Comprehensive MS care should include substance abuse screening and advice to cut down or abstain.

CoI: multiple

Twitter: @gavinGiovannoni Medium: @gavin_24211

Alcohol Awareness Week

This week is alcohol awareness week in the UK and the NHS is encouraging its patients/clients to look in the mirror and ask whether or not they are drinking too much. As part of the holistic management of MS and our marginal gains strategy for managing MS, we are encouraging all pwMS to do the same.

Excessive alcohol consumption is bad for MS in several ways. It disrupts your sleep pattern and may, therefore, make fatigue and other mental health issues worse. It can affect your balance and coordination and increase your risk of falls and fractures. Alcohol lowers your seizure threshold and increases your chances of having seizures. Longterm alcohol consumption is associated with accelerated brain volume loss and hence increases your chances of developing cognitive impairment and is likely to exacerbate MS-related cognitive impairment.

Alcohol is not good for bone health and is a known cause of osteopaenia. Alcohol is metabolised by the liver and can result in liver toxicity. Alcohol interacts with many drugs affecting their activity and metabolism and may interact with MS-related medication resulting in unpredictable side effects.

Alcohol is very calorific and may contribute to weight gain. In general, excessive alcohol consumption is bad for you.

Why don’t you log onto Drink Coach, or download the App, and take the alcohol test to see if you have a drinking problem?

CoI: multiple

What is end-organ damage?

Help! How do I manage progressive brain atrophy in a patient who is NEDA-3?

End-organ damage is a catch-all phrase for the degeneration of the brain; it occurs as part of the ageing process that some consider pathological and others as a normal fact of life. I have hinted that I consider it both because end-organ damage is potentially modifiable via lifestyle modifications and pharmacological interventions. If it was a normal process it should not be modifiable. How can you be more normal than normal? Making ageing a disease also has political ramifications, for example, it will almost certainly incentivise Pharma to develop treatments for ageing.

In MS end-organ damage is massively accelerated by the MS disease process itself, i.e. inflammation and demyelination, and from delayed downstream processes triggered by inflammation, for example, energy failure, microglial activation, ongoing inflammation driven by antibodies, possible slow viral infection and its consequences and comorbidities. It is clear that all people with MS will have end-organ damage, but what can we do about it? To be honest, apart from early treatment to prevent damage, we haven’t got an evidence base about how to manage this problem in MS.

As an example, I saw a patient earlier this week. He has relapsing-remitting MS diagnosed in the mid-2000s and started on interferon-beta (Avonex). He also has type 1 diabetes which he developed when he was 14 years of age, 8 years before he was diagnosed with MS. His diabetes was poorly controlled initially but is now well controlled on an insulin pump. He has renal (proteinuria), eye (retinopathy) and hypertension as complications of his diabetes. His hypertension is controlled on medication. He has been relapse-free and his MRI has not shown any obvious new lesions over the last 6 years; i.e. he is NEDA-3. He does not smoke, but he drinks between 3 and 4 units of alcohol per day. He was referred to me because he is sick and tired of injecting himself with interferon and he has heard of a new drug called ocrelizumab. He wants to be switched to it because is more efficacious and only give every 6 months. His treating neurologist said no, hence his referral to me for a second opinion.

When I went through his history it is clear he has had no relapses in the last 6 years and is fully functional and working full-time. I reviewed his MRIs and I agree he has no new lesions over the last 6 years, but he has developed quite profound and progressive brain atrophy over this timeframe; he is definitely not NEDA-4. What do I do?

Do I switch him from interferon-beta to ocrelizumab? Or do I leave him on Avonex, which is doing its job and rendering him NEDA-3?

If I do switch him to ocrelizumab, will it normalise his brain volume loss? Will he become NEDA-4?

What is causing his brain volume loss? MS, hypertension, diabetes, alcohol or something else?

Do I tell him about his gross brain atrophy, which he is blissfully unaware of?

Do I offer him a formal cognitive assessment to see if he has cognitive impairments? If he has a cognitive assessment and they come back abnormal, which they are likely to, how do I tell him? Will knowing he cognitively impaired affect his management?

Do I offer him a lumbar puncture to measure his spinal fluid neurofilament levels?

Do I recommend any add-on off-label treatments that may help?

Or do I just take the easy option and send him back to his neurologist with a recommendation to leave things as is?

Can I suggest we debate these issues over the next few days and I can then potentially do a live webinar on the issue of end-organ damage and how to handle the problem of progressive brain volume loss on DMTs when you are NEDA-3.