The outcome spectrum of multiple sclerosis: disability, mortality, and a cluster of predictors from onset

Disease-modifying treatment, long-term outcomes and transition to progressive multiple sclerosis: data based on the New York State MS Consortium

BACKGROUND

The impact of disease-modifying treatments (DMTs) on multiple sclerosis (MS) long-term outcomes is continuously evolving. Retrospective analyses of large and long-term registries could provide information regarding general disease trajectories and risk factors that are commonly not investigated in shorter clinical trial settings.

METHODS

Retrospective observational study of people with MS (pwMS) registered in New York State MS Consortium (NYSMSC) since 1996. Disability outcomes of reaching sustained Expanded Disability Status Scale (EDSS) scores of 4.0, 6.0 and transition to secondary-progressive MS (SPMS) were confirmed at follow-up. Four DMT categories were determined (1) continuous DMT use, (2) discontinued DMT, (3) (re)started DMT and (4) never treated with DMT. Patient-reported outcomes (PRO) were acquired using LIFEware system. Kaplan-Meier survival curves and adjusted analysis of covariance (ANCOVA) were used to determine the rate and factors related to disability progression.

RESULTS

Total of 1893 pwMS were included with baseline average age of 43.2 years (SD = 10.4), 9.6 years of disease duration (SD = 8.8), median EDSS of 3.0 (IQR 2.0-3.5) and average follow-up time of 6.9 years (SD = 4.9). In addition to being male, older, more disabled and reporting worse PROs at baseline, pwMS who discontinued DMT had more than 5.5 times greater risk of reaching sustained EDSS of 4.0 (OR = 5.56, 95% CI 2.78-11.0, p < 0.001). Similarly, pwMS who discontinued DMT during the NYSMSC follow-up had 3.8- and 4.7-times greater risk to reach sustained EDSS 6.0 (OR = 3.86, 95% CI 2.12-7.02, p < 0.001), and to transition to SPMS (OR = 4.77, 95% CI 2.9-7.87, p < 0.001). Propensity matching analysis confirmed the worse clinical outcomes.

CONCLUSIONS

In addition to known predictors of long-term clinical outcomes, pwMS who discontinue DMT have worse long-term disability trajectory when compared to both early and late DMT starters. PRO-based indicators may suggest worse clinical outcomes.

Contemporary study of multiple sclerosis disability in South East Wales

BACKGROUND

A contemporary understanding of disability evolution in multiple sclerosis (MS) is an essential tool for individual disease management and planning of interventional studies. We have used prospectively collected longitudinal data to analyse disability progression and variation in a British MS cohort.

METHODS

Cox proportional hazards regression was used to estimate hazard of Expanded Disability Status Scale (EDSS) 4.0 and 6.0. A continuous Markov model was used to estimate transitional probabilities for individual EDSS scores. Models were adjusted for age at MS onset, sex and disease-modifying treatments (DMTs) exposure.

RESULTS

2135 patients were included (1487 (70%) female, 1922 (89%) relapsing onset). 865 (41%) had used DMTs. Median time to EDSS 4.0 and 6.0 was 18.2 years (95% CI 16.3 to 20.2) and 22.1 years (95% CI 20.5 to 24.5). In the Markov model, the median time spent at EDSS scores of <6 (0.40-0.98 year) was shorter than the time spent at EDSS scores of ≥6 (0.87-4.11 year). Hazard of change in EDSS was greatest at EDSS scores <6 (HR for increasing EDSS: 1.02-1.33; decreasing EDSS: 0.34-1.27) compared with EDSS scores ≥6 (HR for increasing EDSS: 0.08-0.61; decreasing EDSS: 0.18-0.54).

CONCLUSIONS

These data provide a detailed contemporary model of disability outcomes in a representative population-based MS cohort. They support a trend of increasing time to disability milestones compared with historical reference populations, and document disability variation with the use of transitional matrices. In addition, they provide essential information for patient counselling, clinical trial design, service planning and offer a comparative baseline for assessment of therapeutic interventions.

When to initiate palliative care in neurology

Life-limiting and life-threatening neurologic conditions often progress slowly. Patients live with a substantial symptom burden over a long period of time, and there is often a high degree of functional and cognitive impairment. Because of this, the most appropriate time to initiate neuropalliative care is often difficult to identify. Further challenges to the incorporation of neuropalliative care include communication barriers, such as profound dysarthria or language impairments, and loss of cognitive function and decision-making capacity that prevent shared decision making and threaten patient autonomy. As a result, earlier initiation of at least some components of palliative care is paramount to ensuring patient-centered care while the patient is still able to communicate effectively and participate as fully as possible in their medical care. For these reasons, neuropalliative care is also distinct from palliative care in oncology, and there is a growing evidence base to guide timely initiation and integration of neuropalliative care. In this chapter, we will focus on when to initiate palliative care in patients with life-limiting, life-threatening, and advanced neurologic conditions. We will address three main questions, which patients with neurologic conditions will benefit from initiation of palliative care, what aspects of neurologic illness are most amenable to neuropalliative care, and when to initiate neuropalliative care?

The impairment of the functional system and fatigue at the onset of the disease predict reaching disability milestones in relapsing-remitting multiple sclerosis differently in female and male patients

Multiple sclerosis (MS) is a chronic demyelinating disease of the central nervous system with variable types of disability progression (DP). Previous studies, defining different disability milestones (DMs), have reported symptoms at MS onset to be the predictors of DP and sex as a risk factor. Meanwhile, accounting for sex differences in MS, predictors in female and male patients might differ. To investigate whether the symptoms at MS onset predict reaching DMs in patients with relapsing-remitting (RR) MS and whether the predictors vary between different DMs and female and male patients. Data from 128 RR MS patients (84 females, 44 males) was retrospectively studied. EDSS scores 4 and 6 (associated with impaired ambulation) were taken as DMs. Association between symptoms at MS onset and time to reach DMs was assessed with Cox multiple regression model. Pyramidal symptoms and fatigue at MS onset predicted the progression to EDSS 4 in the whole study population (HR 1.84, 95% CI 1.07-3.2, p = 0.028 and HR 2.01, 95% CI 1.12-3.4, p = 0.011, correspondingly). The same symptoms predicted reaching DM in female, but not male patients. Bowel/bladder symptoms predicted reaching EDSS 6 in the whole study population (HR 4.31, 95% CI 1.47-12.6, p = 0.008) and female patients only (HR 3.93, 95% CI 1.04-14.8, p = 0.043). In female patients, fatigue was also the predictor of reaching EDSS 6 (HR 3.54, 95% CI 1.16-10.8, p = 0.026). Impairment of functional symptoms at MS onset can predict reaching DMs in patients with RR-MS, but the predictors for EDSS 4 and EDSS 6 differ in female and male patients.

Evidence for and against subclinical disease activity and progressive disease in MOG antibody disease and neuromyelitis optica spectrum disorder

Myelin oligodendrocyte glycoprotein antibody disease (MOGAD) and aquaporin-4 IgG seropositive neuromyelitis optica spectrum disorder (AQP4-IgG+ NMOSD) are generally considered to be relapsing disorders, without clinical progression or subclinical disease activity outside of clinical relapses, in contrast to multiple sclerosis (MS). With advances in the diagnosis and treatment of these conditions, prolonged periods of remission without relapses can be achieved, and the question of whether progressive disease courses can occur has re-emerged. In this review, we focus on studies exploring evidence for and against relapse-independent clinical progression and/or subclinical disease activity in patients with MOGAD and AQP4-IgG+ NMOSD.

The relationship between dysphagia, respiratory functions and anthropometry in patients with multiple sclerosis

BACKGROUND

It is known that many body systems are affected as a result of dysphagia. The aim of this study is to investigate the relationship between clinical features, respiratory functions, anthropometric measurements and dysphagia in patients with multiple sclerosis (MS).

METHOD

Seventy-five MS patients and 50 healthy controls were included in this prospective case-control study. Disability was assessed with expanded disability status scale (EDSS), and swallowing was assessed with questionnaire for the assessment of dysphagia (solid, liquid and total) for disease. Respiratory functions were demonstrated with computerized spirometry device. Body weight, height, waist, hip, and mid-arm circumference are measured. Body mass index and body fat percentage were calculated. The relationship of all these parameters with disease activity and dysphagia was investigated.

RESULTS

There were 75 MS patients with a mean age of 38.40 ± 11.27 years, and 50 (66.70%) were female in the study. The all type of dysphagia scores were higher in MS patients than control group (p = 0.001). Many respiratory function test scores and only hip circumference were lower in MS patients. However, especially low forced expiratory volume-1st second (FEV1), forced vital capacity (FVC) and peak expiratory flow (PEF) values were associated with disability. In addition, dysphagia scores were higher in progressive MS patients with severe disability and high frequency attacks (p = 0.001). Increased severity of dysphagia are associated with many lower anthropometric measurements (not height-especially mid-arm circumference) and respiratory function test scores.

CONCLUSION

MS affects swallowing and respiratory systems functions. They are associated with MS disease activity. Dysphagia and its severity are associated with many anthropometric measurements and respiratory functions test scores.

Onset Symptom Clusters in Multiple Sclerosis: Characteristics, Comorbidities, and Risk Factors

Background: Multiple sclerosis (MS) symptoms are expected to aggregate in specific patterns across different stages of the disease. Here, we studied the clustering of onset symptoms and examined their characteristics, comorbidity patterns and associations with potential risk factors.

Methods: Data stem from the Swiss Multiple Sclerosis Registry, a prospective study including 2,063 participants by November 2019. MS onset symptoms were clustered using latent class analysis (LCA). The latent classes were further examined using information on socio-demographic characteristics, MS-related features, potential risk factors, and comorbid diseases.

Results: The LCA model with six classes (frequencies ranging from 12 to 24%) was selected for further analyses. The latent classes comprised a multiple symptoms class with high probabilities across several symptoms, contrasting with two classes with solitary onset symptoms: vision problems and paresthesia. Two gait classes emerged between these extremes: the gait-balance class and the gait-paralysis class. The last class was the fatigue-weakness-class, also accompanied by depression symptoms, memory, and gastro-intestinal problems. There was a moderate variation by sex and by MS types. The multiple symptoms class yielded increased comorbidity with other autoimmune disorders. Similar to the fatigue-weakness class, the multiple symptoms class showed associations with angina, skin diseases, migraine, and lifetime prevalence of smoking. Mononucleosis was more frequently reported in the fatigue-weakness and the paresthesia class. Familial aggregation did not differ among the classes.

Conclusions: Clustering of MS onset symptoms provides new perspectives on the heterogeneity of MS. The clusters comprise different potential risk factors and comorbidities. They point toward different risk mechanisms.

Evaluation of respiratory functions and quality of life in multiple sclerosis patients

The aim of this study was to evaluate respiratory muscle strength, respiratory functions and quality of life in multiple sclerosis (MS) patients and compare the results with the healthy volunteers. The study included a group of 24 patients diagnosed with MS (16 women, 8 men) with an EDSS score of ≤ 5, who were without clinical respiratory impairment. MS patients were compared with the healthy volunteer group (16 women, 8 men). Respiratory muscle strength and respiratory functions were evaluated with specific devices. Maximal inspiratory pressure (MIP) and maximal expiratory pressure (MEP) parameters were measured for the muscle strength. Forced vital capacity (FVC), forced expiratory volume (FEV1), FEV1/FVC, peak expiratory flow, and forced expiratory flow (FEF_25-75) parameters were measured for the respiratory functions. Questionnaire SF-36 was applied to evaluate health-related quality of life. A total of 24 MS patients' respiratory function test results were compared with healthy volunteers and significant changes were found at MIP, MEP, and FEV1 parameters. Quality of life was compared between the groups and there was a significant difference in parameters related with physical performance and physical-health-related role limitations. There is an early involvement of the respiratory muscles in patients with MS, yet clinical symptoms appear in later stages. Respiratory functions should be evaluated at the earlier stage of the disease so that rehabilitation can be planned in order to reduce respiratory complications and improve the quality of life in patients.

Prediction of long-term disability in Chinese patients with multiple sclerosis: A prospective cohort study

BACKGROUND

Much information about outcomes of multiple sclerosis (MS) has been studied in Caucasian cohorts. However, little is known about the predictors of long-term disability in Chinese patients with MS. The aim of this prospective, observational study is to identify the prognostic factors associated with long-term disability progression (expanded disability status scale, EDSS=6.0) in Chinese patients with relapsing-onset MS.

METHODS

Based on data from the MSNMOBase registry within the neurology department of Peking Union Medical College Hospital (PUMCH) in China, this hospital-based cohort study was conducted to estimate the median time of attaining disability endpoint (EDSS = 6.0) by Kaplan-Meier curves, and identify factors that associated with disability progression by Cox proportional regression analysis.

RESULTS

A total of 415 consecutive, eligible patients with MS were registered in the MSNMOBase of PUMCH and prospectively followed from 2011 to 2019. Of these patients, 365 patients with relapsing-onset MS were analyzed. The median time to reach an EDSS of 6.0 was 22.0 (95% CI 16.5-27.5) years. Age at disease onset greater than 50 years (HR 3.846, 95% CI 1.240-11.932, P=0.020), incomplete recovery from first attack (HR 2.107, 95% CI 1.168-3.800, P=0.013), and ≥2 relapses during the first 2 years after onset (HR 2.217, 95% CI 1.148-4.281, P=0.018) significantly associated with a higher hazard ratio to reach an EDSS of 6.0.

CONCLUSIONS

Our results confirm the importance of age at onset, recovery from the first attack, and number of relapses during the first 2 years after disease onset as predictors of disability progression in Chinese patients with relapsing-onset MS.

Do disease-modifying drugs (DMD) have a positive impact on the occurrence of secondary progressive multiple sclerosis? Comment

Very recent data from cohorts, such as that of the French Observatory of Multiple Sclerosis (OFSEP) and the MSBase cohort, are the subject of new statistical analyses using propensity scores that enable the matching of relapses frequency, EDSS, age, and sex ratio in patient populations for comparisons with each other, which reduces selection biases. The first data from these cohorts revealed a decline in transition to secondary progressive MS with the most effective disease-modifying drugs currently available, especially when these drugs were used early in the disease. However, these studies remain limited regarding the number of patients, the duration of follow-up, the use of imperfect methodologies, and the level of evidence remains low. The Gothenburg cohort in Sweden, which has been followed since the 1950s, found that 14% of benign non-progressive multiple sclerosis (MS) never evolved to secondary progression after more than 45 years of evolution. EDSS 7 was reached after 48 years of disease (median), and 50% evolved to secondary progressive MS after 15 years (consistent with data from the historic London, Ontario cohort). These data demonstrate that most people living with MS evolve without treatment to a significant long-term disability and that this evolution is closely linked to secondary progression (more than the relapse frequency). Benign forms appear as MS that never passes into secondary progressive MS. Recent data demonstrate that the delay until transition to secondary progression (more than 30 years in the MSBase cohort) and the delay in reaching EDSS 6 decreased since the introduction of disease-modifying drugs 20 years ago. However, randomized placebo-controlled trials do not last more than 2 or 3 years, and many biases may be involved in long-term follow-up studies: worsening patients who are lost to follow-up ("informative censoring" bias: only good responders to treatment remain primarily under the same long-term treatment and are followed); changes in the populations in the most recent studies with a lower rate of relapse and lower progression of disability at the beginning of the disease prior to initiating treatments; and environmental changes that remain largely misunderstood and may contribute to a natural evolution towards less severe disease.

The long-term outcomes of CIS patients in the Barcelona inception cohort: Looking back to recognize aggressive MS

Objective:

To explore the long-term outcomes of patients with clinically isolated syndromes from the Barcelona cohort.

Methods:

We selected patients with a follow-up longer than 10 years to (1) estimate the risks of multiple sclerosis (MS) and disability accumulation according to the baseline number of T2 lesions and to compare treated versus untreated patients and early versus delayed treatment, and (2) to study baseline features of patients with aggressive MS (Expanded Disability Status Scale (EDSS) ⩾6.0 at 10 years).

Results:

In all, 401 patients were included (mean follow-up of 14.4 (standard deviation of 2.9) years). A higher number of T2 lesions was associated with an earlier MS diagnosis and an earlier risk of irreversible disability. Early treatment was associated with a decreased risk of EDSS of 3.0: adjusted hazard ratio = 0.4, 95% confidence interval = (0.2, 0.7). Patients with aggressive MS differed in their baseline brain magnetic resonance images: The median (interquartile range) number of T2 lesions and contrast-enhancing lesions (CEL) was 71 (28–95) versus 7 (1–19) and 3 (1–24) versus 0 (0–1), respectively. The cut-offs that better classified patients with aggressive MS were 20 for T2 lesions and 2 for CEL.

Conclusion:

Although MS natural history is changing, a high lesion load at onset is helpful to identify patients at risk of presenting an aggressive MS.

Risk of secondary progressive multiple sclerosis: A longitudinal study

Background:

The risk factors for conversion from relapsing-remitting to secondary progressive multiple sclerosis remain highly contested.

Objective:

The aim of this study was to determine the demographic, clinical and paraclinical features that influence the risk of conversion to secondary progressive multiple sclerosis.

Methods:

Patients with adult-onset relapsing–remitting multiple sclerosis and at least four recorded disability scores were selected from MSBase, a global observational cohort. The risk of conversion to objectively defined secondary progressive multiple sclerosis was evaluated at multiple time points per patient using multivariable marginal Cox regression models. Sensitivity analyses were performed.

Results:

A total of 15,717 patients were included in the primary analysis. Older age (hazard ratio (HR) = 1.02, p < 0.001), longer disease duration (HR = 1.01, p = 0.038), a higher Expanded Disability Status Scale score (HR = 1.30, p < 0.001), more rapid disability trajectory (HR = 2.82, p < 0.001) and greater number of relapses in the previous year (HR = 1.07, p = 0.010) were independently associated with an increased risk of secondary progressive multiple sclerosis. Improving disability (HR = 0.62, p = 0.039) and disease-modifying therapy exposure (HR = 0.71, p = 0.007) were associated with a lower risk. Recent cerebral magnetic resonance imaging activity, evidence of spinal cord lesions and oligoclonal bands in the cerebrospinal fluid were not associated with the risk of conversion.

Conclusion:

Risk of secondary progressive multiple sclerosis increases with age, duration of illness and worsening disability and decreases with improving disability. Therapy may delay the onset of secondary progression.

A focus on secondary progressive multiple sclerosis (SPMS): challenges in diagnosis and definition

Secondary progressive multiple sclerosis (SPMS) is the second most common form of multiple sclerosis (MS). One in two relapse remitting multiple sclerosis (RRMS) patients will develop SPMS within 15 years and up to two-thirds after 30 years, leading to a progressive decrease of neurological function and limitation of daily activities. Nevertheless, the SPMS diagnosis is often established retrospectively and delayed up to 3 years due to several patient- and clinician-related factors. Definitive clinical diagnostic criteria are lacking and research is currently ongoing to identify imaging and biochemical biomarkers. As new therapies are introduced, early SPMS diagnosis may represent a window of opportunity for intervention. New approaches, endpoints or technologies could help physicians establishing a diagnosis. Here, we review SPMS in relation to its diagnostic and definition challenges and current screening techniques and tools.

A focus on secondary progressive multiple sclerosis (SPMS): challenges in diagnosis and definition

Secondary progressive multiple sclerosis (SPMS) is the second most common form of multiple sclerosis (MS). One in two relapse remitting multiple sclerosis (RRMS) patients will develop SPMS within 15 years and up to two-thirds after 30 years, leading to a progressive decrease of neurological function and limitation of daily activities. Nevertheless, the SPMS diagnosis is often established retrospectively and delayed up to 3 years due to several patient- and clinician-related factors. Definitive clinical diagnostic criteria are lacking and research is currently ongoing to identify imaging and biochemical biomarkers. As new therapies are introduced, early SPMS diagnosis may represent a window of opportunity for intervention. New approaches, endpoints or technologies could help physicians establishing a diagnosis. Here, we review SPMS in relation to its diagnostic and definition challenges and current screening techniques and tools.

Two Sides to Every Story: Perspectives from Four Patients and a Healthcare Professional on Multiple Sclerosis Disease Progression

Abstract

Multiple sclerosis (MS) is a chronic progressive disease and many patients transition from an initial relapsing–remitting course to a secondary progressive pattern. Accurate classification of disease status is critical to ensure that patients are treated appropriately and kept informed of their prognosis. Consensus terms defining the different forms of MS are available but were developed primarily for healthcare professionals (HCPs) and may be of limited value to patients. This article provides direct insights from four patients with MS, at different points in their disease trajectory, regarding their understanding of, and attitudes toward, MS progression. We also examine the utility of the current classification systems from the perspectives of patients and HCPs. Responses collected during in-depth, structured interviews and questionnaires portrayed the difficulties patients face accepting their MS diagnosis and treatment, revealed how understanding of the term “disease progression” varies considerably, and highlighted the challenges surrounding the period of transition to secondary progressive MS (SPMS). The terms describing different MS types were considered confusing and can make patients feel “compartmentalized” or “labeled”. Patients also struggled to relate these terms to their reality of living with MS, were reluctant to discuss progression with their HCPs, and feared being diagnosed with SPMS owing to concerns about treatment access. These insights highlight the need to develop patient-friendly language to describe MS progression; it may also be preferable for HCPs to describe MS as a disease spectrum in discussions with their patients.

Funding

Novartis Pharmaceuticals Corporation.

Plain Language Summary

Plain language summary available for this article.

Short-term prediction of secondary progression in a sliding window: A test of a predicting algorithm in a validation cohort

Introduction

The Multiple Sclerosis Prediction Score (MSPS, www.msprediction.com) estimates, for any month during the course of relapsing–remitting multiple sclerosis (MS), the individual risk of transition to secondary progression (SP) during the following year.

Objective

Internal verification of the MSPS algorithm in a derivation cohort, the Gothenburg Incidence Cohort (GIC, n =  144) and external verification in the Uppsala MS cohort (UMS, n = 145).

Methods

Starting from their second relapse, patients were included and followed for 25 years. A matrix of MSPS values was created. From this matrix, a goodness-of-fit test and suitable diagnostic plots were derived to compare MSPS-calculated and observed outcomes (i.e. transition to SP).

Results

The median time to SP was slightly longer in the UMS than in the GIC, 15 vs. 11.5 years (p = 0.19). The MSPS was calibrated with multiplicative factors: 0.599 for the UMS and 0.829 for the GIC; the calibrated MSPS provided a good fit between expected and observed outcomes (chi-square p = 0.61 for the UMS), which indicated the model was not rejected.

Conclusion

The results suggest that the MSPS has clinically relevant generalizability in new cohorts, provided that the MSPS was calibrated to the actual overall SP incidence in the cohort.

Interplay Between Age and Neuroinflammation in Multiple Sclerosis: Effects on Motor and Cognitive Functions

Aging is one of the main risk factors for the development of many neurodegenerative diseases. Emerging evidence has acknowledged neuroinflammation as potential trigger of the functional changes occurring during normal and pathological aging. Two main determinants have been recognized to cogently contribute to neuroinflammation in the aging brain, i.e., the systemic chronic low-grade inflammation and the decline in the regulation of adaptive and innate immune systems (immunosenescence, ISC). The persistence of the inflammatory status in the brain in turn may cause synaptopathy and synaptic plasticity impairments that underlie both motor and cognitive dysfunctions. Interestingly, such inflammation-dependent synaptic dysfunctions have been recently involved in the pathophysiology of multiple sclerosis (MS). MS is an autoimmune neurodegenerative disease, typically affecting young adults that cause an early and progressive deterioration of both cognitive and motor functions. Of note, recent controlled studies have clearly shown that age at onset modifies prognosis and exerts a significant effect on presenting phenotype, suggesting that aging is a significant factor associated to the clinical course of MS. Moreover, some lines of evidence point to the different impact of age on motor disability and cognitive deficits, being the former most affected than the latter. The precise contribution of aging-related factors to MS neurological disability and the underlying molecular and cellular mechanisms are still unclear. In the present review article, we first emphasize the importance of the neuroinflammatory dependent mechanisms, such as synaptopathy and synaptic plasticity impairments, suggesting their potential exacerbation or acceleration with advancing age in the MS disease. Lastly, we provide an overview of clinical and experimental studies highlighting the different impact of age on motor disability and cognitive decline in MS, raising challenging questions on the putative age-related mechanisms involved.

Natural Course of Clinically Isolated Syndrome: A Longitudinal Analysis Using a Markov Model

Clinically isolated syndrome (CIS) refers to the initial clinical episode with symptoms suggestive of multiple sclerosis (MS). Due to limited number of long-term follow-up studies, progression pattern from CIS to more advanced stages remains unclear. In the current study, we constructed a Markov model to simulate the natural course of CIS. The model estimated the probabilities of transition from CIS to more advanced disease stages and the duration needed for the progression. The analysis showed: (1) CIS is a solid disease identity: more than 85% of the subjects with a diagnosis of CIS progress to RRMS or more advanced stages within 20 years; (2) the reduction of life expectancy in subjects with CIS is marginal.

Multiple Sclerosis Re-Examined: Essential and Emerging Clinical Concepts

Multiple sclerosis (MS) is a chronic autoimmune disease of the central nervous system characterized by exacerbations of neurological dysfunction due to inflammatory demyelination. Neurologic symptoms typically present in young adulthood and vary based on the site of inflammation, although weakness, sensory impairment, brainstem dysfunction, and vision loss are common. MS occurs more frequently in women and its development is complex-genetics, hormones, geography, vitamin D, and viral exposure all play roles. Early MS is characterized by relapsing-remitting course and inflammation of the white matter, although as patients age, the disease often transitions to a pathologically distinct secondary progressive phase with gradual disability accrual affecting gait, coordination, and bladder function. A minority of patients (10%) have disease that is progressive at onset. In the past decade, there has been a remarkable expansion in disease-modifying therapy for MS, but treatment of progressive disease remains a challenge. This article reviews foundational concepts in MS and emerging work that has reshaped understanding of the disease, providing new insight for therapeutic advance.

Onset of secondary progressive multiple sclerosis is not influenced by current relapsing multiple sclerosis therapies

BACKGROUND

Disease-modifying therapies are thought to reduce the conversion rate to secondary progressive multiple sclerosis.

OBJECTIVE

To explore the rate, chronology, and contributing factors of conversion to the progressive phase in treated relapsing-remitting multiple sclerosis patients.

METHODS

Our study included 204 patients treated for relapsing-remitting multiple sclerosis between 1995 and 2002, prospectively followed to date. Kaplan-Meier analysis was applied to estimate the time until secondary progressive multiple sclerosis conversion, and multivariate survival analysis with a Cox regression model was used to analyse prognostic factors.

RESULTS

Relapsing-remitting multiple sclerosis patients were continuously treated for 13 years (SD 4.5); 36.3% converted to secondary progressive multiple sclerosis at a mean age of 42.6 years (SD 10.6), a mean time of 8.2 years (SD 5.2) and an estimated mean time of 17.2 years (range 17.1-18.1). A multifocal relapse, age older than 34 years at disease onset and treatment failure independently predicted conversion to secondary progressive multiple sclerosis but did not influence the time to reach an Expanded Disability Status Scale of 6.0.

CONCLUSIONS

The favourable influence of disease-modifying therapies on long-term disability in relapsing-remitting multiple sclerosis is well established. However, the time to progression onset and the subsequent clinical course in treated patients seem similar to those previously reported in natural history studies. More studies are needed to clarify the effect of disease-modifying therapies once the progressive phase has been reached.

Diffusion tensor imaging in multiple sclerosis at different final outcomes

OBJECTIVES

Methods to evaluate the relative contributions of demyelination vs axonal degeneration over the long-term course of MS are urgently needed. We used magnetic resonance diffusion tensor imaging (DTI) to estimate degrees of demyelination and axonal degeneration in the corpus callosum (CC) in cases of MS with different final outcomes.

MATERIALS AND METHODS

We determined DTI measures mean diffusivity (MD), fractional anisotropy (FA), and axial (AD) and radial (RD) diffusivities in the CC of 31 MS patients, of whom 13 presented a secondary progressive course, 11 a non-progressive course, and seven a monophasic course. The study participants were survivors from an incidence cohort of 254 attack-onset MS patients with 50 years of longitudinal follow-up. As reference, we included five healthy individuals without significant morbidity.

RESULTS

In patients with secondary progression, compared to all other groups, the corpus callosum showed increased RD and reduced FA, but no change in AD. None of the parameters exhibited differences among non-progressive and monophasic course groups and controls.

CONCLUSION

Increased RD was observed in secondary progressive MS, indicating significant myelin loss. Normal RD values observed in the clinically isolated syndrome and non-progressive groups confirm their benign nature. AD was not a characterizing parameter for long-term outcome. Demyelination revealed by increased RD is a distinguishing trait for secondary progression.

Early predictive factors of disability in CIDP

The objective of this study was to identify early clinical, biochemical and electrophysiological prognostic factors of disability in CIDP. We evaluated a dataset from 60 CIDP patients that included sex, age of onset, type of onset, phenotype, disease duration, response to treatment, disability at the time of diagnosis assessed using the modified Rankin Scale (baseline mRS), cerebrospinal fluid protein levels and electrophysiological data. All patients had clinical assessment of disability through the mRS within the last 6 months (last mRS) before enrollment in the study. Stepwise forward logistic regression model was applied to evaluate the impact of clinical, biochemical and electrophysiological parameters on the last mRS, considered as binary outcome (absence or presence of severe disability, i.e., <4/≥4 mRS). Moreover, we used Spearman's rank correlation coefficient to evaluate the relationship between disease duration and last mRS. We observed a significant relationship between last mRS and baseline mRS [p = 0.015, z = 2.44, OR 5.15 (CI 1.38-19.22)] and age of onset [p = 0.017, z = 2.39, OR 1.13 (CI 1.02-1.27) per additional year of age of onset]. There was no correlation between disease duration and last mRS. Our data suggest that a worse clinical status at the beginning of disease and an older age at onset may be negative prognostic factors of long-term disability independent from disease duration.

Definition, prevalence and predictive factors of benign multiple sclerosis

Background

Multiple sclerosis (MS) is characterized by a great inter-individual variability in disease course and severity. Some patients experience a rather mild course, controversially called 'benign MS' (BMS). The usefulness of this entity in clinical practice remains unclear.

Methods

We performed a literature search in PubMed, Web of Science and Cochrane Library databases from November 1980 to December 2015, using the following key words: benign multiple sclerosis, diagnosis, imaging, prognosis, predictive, natural history and predefined inclusion criteria.

Results

Our search yielded 26 publications. Most definitions were based on the Expanded Disease Status Scale (EDSS), which is heavily weighted towards physical disability. Between 30 and 80% of relapsing-remitting MS patients have EDSS < 3 or 4 at 10 years after onset. Having only one relapse in the first 5 years and EDSS ≤ 2 at 5 years or EDSS ≤ 3 at 10 years appears to be predictive for a prolonged benign disease course, without protecting against disease progression at a later stage. Evidence on the predictive value of MRI parameters remains limited.

Conclusions

Current BMS definitions have some predictive value for future physical disability, but do not take into account the age at EDSS and the potentially disrupting effects of non-EDSS symptoms and cognitive impairment. It appears to correspond to mild RRMS in the first decades and its prevalence varies. Since early and accurate prediction of BMS is not yet possible, the clinical relevance is limited. Research approaches are suggested.

Long-term evolution of multiple sclerosis disability in the treatment era

Objective

To characterize the accrual of long‐term disability in a cohort of actively treated multiple sclerosis (MS) patients and to assess whether clinical and magnetic resonance imaging (MRI) data used in clinical trials have long‐term prognostic value.

Methods

This is a prospective study of 517 actively managed MS patients enrolled at a single center.

Results

More than 91% of patients were retained, with data ascertained up to 10 years after the baseline visit. At this last assessment, neurologic disability as measured by the Expanded Disability Status Scale (EDSS) was stable or improved compared to baseline in 41% of patients. Subjects with no evidence of disease activity (NEDA) by clinical and MRI criteria during the first 2 years had long‐term outcomes that were no different from those of the cohort as a whole. 25‐OH vitamin D serum levels were inversely associated with short‐term MS disease activity; however, these levels had no association with long‐term disability. At a median time of 16.8 years after disease onset, 10.7% (95% confidence interval [CI] = 7.2–14%) of patients reached an EDSS ≥ 6, and 18.1% (95% CI = 13.5–22.5%) evolved from relapsing MS to secondary progressive MS (SPMS).

Interpretation

Rates of worsening and evolution to SPMS were substantially lower when compared to earlier natural history studies. Notably, the NEDA 2‐year endpoint was not a predictor of long‐term stability. Finally, the data call into question the utility of annual MRI assessments as a treat‐to‐target approach for MS care. Ann Neurol 2016;80:499–510

Multiple sclerosis risk loci and disease severity in 7,125 individuals from 10 studies

OBJECTIVE

We investigated the association between 52 risk variants identified through genome-wide association studies and disease severity in multiple sclerosis (MS).

METHODS

Ten unique MS case data sets were analyzed. The Multiple Sclerosis Severity Score (MSSS) was calculated using the Expanded Disability Status Scale at study entry and disease duration. MSSS was considered as a continuous variable and as 2 dichotomous variables (median and extreme ends; MSSS of ≤5 vs >5 and MSSS of <2.5 vs ≥7.5, respectively). Single nucleotide polymorphisms (SNPs) were examined individually and as both combined weighted genetic risk score (wGRS) and unweighted genetic risk score (GRS) for association with disease severity. Random-effects meta-analyses were conducted and adjusted for cohort, sex, age at onset, and HLA-DRB1*15:01.

RESULTS

A total of 7,125 MS cases were analyzed. The wGRS and GRS were not strongly associated with disease severity after accounting for cohort, sex, age at onset, and HLA-DRB1*15:01. After restricting analyses to cases with disease duration ≥10 years, associations were null (p value ≥0.05). No SNP was associated with disease severity after adjusting for multiple testing.

CONCLUSIONS

The largest meta-analysis of established MS genetic risk variants and disease severity, to date, was performed. Results suggest that the investigated MS genetic risk variants are not associated with MSSS, even after controlling for potential confounders. Further research in large cohorts is needed to identify genetic determinants of disease severity using sensitive clinical and MRI measures, which are critical to understanding disease mechanisms and guiding development of effective treatments.

Secondary Progression in Multiple Sclerosis: Neuronal Exhaustion or Distinct Pathology?

Prevention of progression in neurological diseases, particularly in multiple sclerosis (MS) but also in neurodegenerative diseases, remains a significant challenge. MS patients switch from a relapsing-remitting to a progressive disease course, but it is not understood why and how this conversion occurs and why some patients never experience disease progression. Do aging and accumulation of neuronal damage induce progression, or do cognitive symptoms and accelerated grey matter (GM) atrophy point to distinct processes affecting networks? This review weighs accepted dogma against real data on the secondary progressive phase of the disease, highlighting current challenges in this important field and directions towards development of treatment strategies to slow or prevent progression of disability.

Disability profile of multiple sclerosis in New Zealand

New Zealand is a high risk region for multiple sclerosis (MS). The aim of this study was to investigate demographic, clinical and temporal factors associated with disability status in the New Zealand National Multiple Sclerosis Prevalence Study (NZNMSPS) cohort. Data were obtained from the 2006 NZNMSPS with MS diagnosis based on the 2005 McDonald criteria. Disability was assessed using the Expanded Disability Status Scale (EDSS). Disability profiles were generated using multiple linear regression analysis. A total of 2917 persons with MS was identified, of whom disability data were available for 2422 (75% females). The overall disability was EDSS 4.4±standard deviation 2.6. Higher disability was associated with older age, longer disease duration, older and younger ages of onset, spinal cord syndromes with motor involvement at onset, and a progressive onset type. Lower disability was associated with sensory symptoms at onset and a relapsing onset type. Overall, the factors studied explained about one-third of the variation in disability, and of this, about two-thirds was accounted for by age, age of onset and disease duration and one-third by the nature of first symptoms and type of disease onset (progressive or relapsing). Current age, age at onset and disease duration all had independent associations with disability and their effects also interacted in contributing to higher disability levels over the course of the disease.

Prevalence of Multiple Sclerosis in Tuscany (Central Italy): A Study Based on Validated Administrative Data

BACKGROUND

Multiple Sclerosis (MS) epidemiology in Italy is mainly based on population-based prevalence studies. Administrative data are an additional source of information, when available, in prevalence studies of chronic diseases such as MS. The aim of our study is to update the prevalence rate of MS in Tuscany (central Italy) as at 2011 using a validated case-finding algorithm based on administrative data.

METHODS

The prevalence was calculated using an algorithm based on the following administrative data: hospital discharge records, drug-dispensing records, disease-specific exemptions from copayment to health care, home and residential long-term care and inhabitant registry. To test algorithm sensitivity, we used a true-positive reference cohort of MS patients from the Tuscan MS register. To test algorithm specificity, we used another cohort of individuals who were presumably not affected by MS.

RESULTS

As at December 31, 2011, we identified 6,890 cases (4,738 females and 2,152 males) with a prevalence of 187.9 per 100,000. The sensitivity of algorithm was 98% and the specificity was 99.99%.

CONCLUSIONS

We found a prevalence higher than the rates present in literature. Our algorithm, based on administrative data, can accurately identify MS patients; moreover, the resulting cohort is suitable to monitor disease care pathways.