Nutrition and Supplements to Reduce Medication Side Effects in Myositis

Adapted from a talk at the Myositis Support Group of Hospital for Special Surgery


Isabelle Dube, RD, CDN
Clinical Nutritionist
Hospital for Special Surgery

Healthy eating is an important part of self-care for everyone, but particularly for those who have a chronic disease such as myositis. Good nutrition is especially important in view of some of the medications prescribed to treat myositis. Eating the right foods can help you feel better and reduce some unwanted side effects of these medications.

Medications and Possible Side Effects

Corticosteroids (such as prednisone), are often the initial medications prescribed to treat the inflammatory attack on muscle, skin and other body systems. These medicines control the inflammation and ease pain. Corticosteroids may have multiple side effects when taken for long term at higher doses. The following table lists side effects and nutrition management strategies to help alleviate some of the side effects.

 Side Effect  Nutrition Strategy
Osteoporosis (loss of bone density) Consume enough calcium and vitamin D through food and/or supplements. Dairy products are excellent sources of calcium. Consume low-fat milk, cheese and yogurt regularly. If you are lactose intolerant, choose Lactaid milk or calcium fortified soy milk.
Fluid retention and high blood pressure Avoid using salt and limit foods high in sodium such as instant foods, some frozen meals and canned foods. Read nutrition labels when you are shopping and choose foods that contain 140 mg of sodium or less per serving or 600 mg or less per entree.
Hyperglycemia (high blood sugar) OR steroid-induced diabetes Limit foods that contain excess sugar such as desserts and sweetened beverages. Choose whole grains instead of refined carbohydrates and carefully monitor portion sizes of foods that contain carbohydrates. Ask a dietitian to help with meal planning if you have already diabetes and are experiencing blood sugar changes.
Increased appetite and weight gain Choose foods that are low in fat and sugar such as low-fat or fat-free dairy products, fruit and vegetables, whole-grains and lean protein such as chicken and fish. Also, carefully monitor the portions of foods you eat. Supersizing portions leads to extra calories and weight gain. To help curb your appetite, eat small frequent meals and have some lean protein with each meal. The USDA MyPyramid guidelines are a good source to learn about planning a healthy diet.

Immunosuppressive agents such as methotrexate and azathioprine are introduced as second-choice medications and often are used to help patients taper off prednisone sooner to avoid unwanted side effects. Cyclophosphamide and cyclosporine are more potent immunosuppressive agents that are used in certain cases of myositis.

Immunosuppressive agents work by decreasing the activity of the immune system. While this helps prevent the body from attacking itself, it also increases your risk of infection. That's even more reason to have a healthy, well-balanced diet. In addition, methotrexate also impairs your body's ability to absorb folate. So it's important to eat foods high in folate, such as leafy green vegetables, fruits, and breads/cereals fortified with folic acid. In most cases, if you are on methotrexate you will be advised by your doctor to take a folic acid supplement, which would be sufficient without changing your diet. If you will be taking methotrexate, discuss with your doctor whether you should take folic acid supplements.

Some side effects of immunosuppressive drugs include nausea and a decrease in appetite. Eating small frequent meals that are easy to digest and eating slowly can help. Choose foods such as dry cereals, breads, crackers. Avoid fried, greasy, spicy and acidic foods since they may lead to further discomfort. Talk to your doctor if these symptoms do not go away.

Non-steroidal anti-inflammatory drugs (NSAIDs) include aspirin, ibuprofen, and naproxen (available over the counter) and many more potent ones available by prescription. All may increase your risk of stomach upset, ulcers, and gastric bleeding. Taking enteric aspirin, which is coated to avoid breakdown in the stomach, and taking your NSAID with meals may reduce symptoms.

Vitamins and Supplements

Creatine: Our bodies make creatine from the amino acids in protein. Good food sources are herring, cod, beef, pork, salmon, and milk. Vegetarians tend to have lower stores of creatine. The jury is still out on the benefits of creatine supplements to build muscle, and it is generally believed to be harmless. There are several studies going on to evaluate creatine in various types of myositis. However, one side effect of creatine supplements can be decreased kidney function. So be sure to discuss creatine with your doctor before taking it.

Coenzyme Q10 (CoQ10) is produced by the human body and is necessary for the basic functioning of cells and acts as an antioxidant. CoQ10 levels are decreased in some people with muscle disease and therefore supplements are sometimes used to increase the body’s level. CoQ10 may interact with other medications so talk to your doctor before taking it.

Fish Oil (omega-3 fatty acids) from fatty fish such as salmon, sardines and mackerel have been found to decrease inflammation and cytokine production, although there is significant debate about whether the doses patients generally take have a significant effect. They are usually well tolerated but may interact with other medications such as blood-thinners. High doses may cause stomach discomfort.

Anti-inflammatory spices: ginger and tumeric: these have antioxidant properties, and some limited data have suggested that they may have anti-inflammatory and pain-relieving properties. These spices can be safely added to foods when cooking.

Before taking any herbal or nutritional supplement, discuss your diagnosis with your physician in order to fully understand your medical problem. Don't self-diagnose. Spend some time researching supplements before experimenting with them and always let your doctors know about any supplement you are considering or already taking so that they can appropriately monitor for potential side effects.

Be very cautious about any herbal supplement or other alternative therapy because these products are not monitored by the Food and Drug Administration. Even if they are safe, the product may not contain the stated amount (or even any) of the supposed active ingredient, or the product may be contaminated with toxic substances. If you decide to take a supplement, choose a well-known reputable brand. Supplements with the USP (U.S. Pharmacopeia) label contain ingredients that have been tested for quality, potency and purity. If you are considering such supplements, even any vitamin/mineral, always discuss it with your physician because many such supplements may actually interfere with your prescription medications.

Avoid supplements that promise to boost your immune system, especially herbals such as echinacea. Any substance taken to boost the immune system may counteract drugs you are taking for myositis. Some doctors believe that these supplements can actually cause flares in some autoimmune diseases.

Balancing Food and Vitamin/Mineral Supplements

Your best source of vitamins and minerals is through food. However, supplements should be used whenever you need to fill a nutrition "gap" between what you need and what you eat. Make sure you know the recommended doses of supplements before you shop for them; avoid overdosing. Your calcium needs vary by age, although people with myositis who are on steroids need at least 1200 mg per day - or 1500 mg if you are a woman who has reached the menopause or a man 65 or over. At least 800 units a day of vitamin D is recommended to enable your body to absorb calcium.

Milk is a particularly good source of nutrients because it has a mix of calcium, potassium, and magnesium that helps build bones and may lower blood pressure. If you are lactose intolerant, Lactaid® or soy milk are good calcium sources, as are yogurt and cheese. However, yogurt is not fortified with vitamin D and studies have shown that the amount of vitamin D in “fortified” milk is variable, so almost everyone is advised to take supplemental Vitamin D. This is especially important if you are taking anti-inflammatory steroid therapy, such as prednisone or methylprednisolone (Medrol®).

If your calcium intake is primarily through supplements, be sure to take them in divided doses - with breakfast and dinner - because your body cannot absorb too much calcium at once. For example, if you are taking 1200 mg of calcium a day through supplements, it is best for optimal absorption to take 600 mg in the morning and the remaining 600 mg in the evening. You can consider a pill that combines calcium and vitamin D.

If you take a daily multivitamin, it is best to take it separately from your calcium supplement - by two to four hours - because the calcium supplement will interfere with your body's absorption of iron in the multivitamin. For this reason, do not take iron and calcium supplements at the same time.

Herbal and Other Dietary Supplements/Alternative Therapies

Resources

For further reading on the topic, consider the following:

  • The Arthritis Foundation's Guide to Alternative Therapies, by Judith Horstman
  • The Health Professional's Guide to Popular Dietary Supplements, by Allison Sarubin Fragakis, MS, RD with Cynthia A. Thomson, PhD, RD

Links

Key Nutrition Tips

  • Follow a low-fat, antioxidant rich diet
    • Foods high in saturated fats such as fried foods, full fat dairy products and high fat cuts of meat are pro-inflammatory (which means they cause inflammation). Stick to low-fat foods and cook foods with little extra fat. When you eat foods with fat, choose healthier fats like vegetable oils, nuts, avocadoes and seeds. 
    • Fruits and vegetables are high in antioxidants that fight inflammation. Aim to eat at least 5 servings of fruits and vegetables each day. It is not hard to meet the recommendation when you see how big a serving size really is:
      • 1 cup of cut-up fruit or berries (such as melon or strawberries)
      • 1 medium piece of fruit (such as an apple or orange)
      • 1/4 cup of dried fruit 
      • 3/4 cup (6 ounces) of 100% fruit or vegetable juice 
      • 1 cup of leafy vegetables (such as spinach and lettuce)
      • 1/2 cup of cooked or 1 cup raw vegetables

        Try to visualize the serving sizes. This may help: 
      • 1 medium apple or orange: the size of a tennis ball 
      • 1 cup vegetables or fruit: the size of a baseball 
      • 1 medium potato: the size of a computer mouse 
      • 1 cup of lettuce: 4 leaves
    • Eat at least 3 servings of fatty fish every week. Fatty fish like mackerel, lake trout, herring, sardines, albacore tuna and salmon are high in kinds of omega-3 fatty acids that help fight inflammation.
  • Make sure you eat plenty of lean protein
    • Chronic inflammation of the muscle can lead to losing lean muscle mass. Make sure you eat foods rich in protein such as fish, turkey, chicken, lean beef, pork, and eggs. Good protein sources for vegetarians include beans, soy, peanut butter, and dairy products.
  • Watch your weight
    • Changes in weight can occur. Weight gain can be an undesirable side effect of corticosteroids while some medications lead to a poor appetite and weight loss. Make sure you tell your doctor if you notice any significant changes.

See a nutritionist for a personally tailored diet plan if:

  • you are diagnosed with diabetes;
  • you have difficulty swallowing and are losing weight;
  • you have unintentional weight loss or gain of 10% of your usual body weight; or
  • you are diagnosed with osteoporosis.

Hospital for Special Surgery offers outpatient one-on-one nutritional counseling. If you are interested, please call (212) 774-7638.

Learn more about the Myositis Education and Support Group at HSS

    Summary prepared by Wendy Doran, MSW, Coordinator, LupusLine and Charla de Lupus Programs (formerly Myositis Group Facilitator) and Diana Benzaia. Reviewed by Theodore Fields, MD, and Sotiria Everett, MS, RD, CDN, CSSD

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