Early clinical markers of aggressive multiple sclerosis
Authors: Malpas Charles B , Manouchehrinia Ali , Sharmin Sifat , Roos Izanne , Horakova Dana , Havrdova Eva Kubala , Trojano Maria , Izquierdo Guillermo , Eichau Sara , Bergamaschi Roberto , Sola Patrizia , Ferraro Diana , Lugaresi Alessandra , Prat Alexandre , Girard Marc , Duquette Pierre , Grammond Pierre , Grand’Maison Francois , Ozakbas Serkan , Van Pesch Vincent , Granella Franco , Hupperts Raymond , Pucci Eugenio , Boz Cavit , Sidhom Youssef , Gouider Riadh , Spitaleri Daniele , Soysal Aysun , Petersen Thor , Verheul Freek , Karabudak Rana , Turkoglu Recai , Ramo-Tello Cristina , Terzi Murat , Cristiano Edgardo , Slee Mark , McCombe Pamela , Macdonell Richard , Fragoso Yara , Olascoaga Javier , Altintas Ayse , Olsson Tomas , Butzkueven Helmut , Hillert Jan , Kalincik Tomas 
Published: February 2020

Patients with the ‘aggressive’ form of multiple sclerosis accrue disability at an accelerated rate, typically reaching Expanded Disability Status Score (EDSS) ≥ 6 within 10 years of symptom onset. Several clinicodemographic factors have been associated with aggressive multiple sclerosis, but less research has focused on clinical markers that are present in the first year of disease. The development of early predictive models of aggressive multiple sclerosis is essential to optimize treatment in this multiple sclerosis subtype. We evaluated whether patients who will develop aggressive multiple sclerosis can be identified based on early clinical markers. We then replicated this analysis in an independent cohort. Patient data were obtained from the MSBase observational study. Inclusion criteria were (i) first recorded disability score (EDSS) within 12 months of symptom onset; (ii) at least two recorded EDSS scores; and (iii) at least 10 years of observation time, based on time of last recorded EDSS score. Patients were classified as having ‘aggressive multiple sclerosis’ if all of the following criteria were met: (i) EDSS ≥ 6 reached within 10 years of symptom onset; (ii) EDSS ≥ 6 confirmed and sustained over ≥6 months; and (iii) EDSS ≥ 6 sustained until the end of follow-up. Clinical predictors included patient variables (sex, age at onset, baseline EDSS, disease duration at first visit) and recorded relapses in the first 12 months since disease onset (count, pyramidal signs, bowel-bladder symptoms, cerebellar signs, incomplete relapse recovery, steroid administration, hospitalization). Predictors were evaluated using Bayesian model averaging. Independent validation was performed using data from the Swedish Multiple Sclerosis Registry. Of the 2403 patients identified, 145 were classified as having aggressive multiple sclerosis (6%). Bayesian model averaging identified three statistical predictors: age &gt; 35 at symptom onset, EDSS ≥ 3 in the first year, and the presence of pyramidal signs in the first year. This model significantly predicted aggressive multiple sclerosis [area under the curve (AUC) = 0.80, 95% confidence intervals (CIs): 0.75, 0.84, positive predictive value = 0.15, negative predictive value = 0.98]. The presence of all three signs was strongly predictive, with 32% of such patients meeting aggressive disease criteria. The absence of all three signs was associated with a 1.4% risk. Of the 556 eligible patients in the Swedish Multiple Sclerosis Registry cohort, 34 (6%) met criteria for aggressive multiple sclerosis. The combination of all three signs was also predictive in this cohort (AUC = 0.75, 95% CIs: 0.66, 0.84, positive predictive value = 0.15, negative predictive value = 0.97). Taken together, these findings suggest that older age at symptom onset, greater disability during the first year, and pyramidal signs in the first year are early indicators of aggressive multiple sclerosis.