Progression is independent of relapse activity in early multiple sclerosis: a real-life cohort study
Authors: Portaccio Emilio , Bellinvia Angelo , Fonderico Mattia , Pastò Luisa , Razzolini Lorenzo , Totaro Rocco , Spitaleri Daniele , Lugaresi Alessandra , Cocco Eleonora , Onofrj Marco , Di Palma Franco , Patti Francesco , Maimone Davide , Valentino Paola , Confalonieri Paolo , Protti Alessandra , Sola Patrizia , Lus Giacomo , Maniscalco Giorgia Teresa , Brescia Morra Vincenzo , Salemi Giuseppe , Granella Franco , Pesci Ilaria , Bergamaschi Roberto , Aguglia Umberto , Vianello Marika , Simone Marta , Lepore Vito , Iaffaldano Pietro , Filippi Massimo , Trojano Maria , Amato Maria Pia 
Published: March 2022

Abstract
Disability accrual in multiple sclerosis may occur as relapse-associated worsening or progression independent of relapse activity. The role of progression independent of relapse activity in early multiple sclerosis is yet to be established. The objective of this multicentre, observational, retrospective cohort study was to investigate the contribution of relapse-associated worsening and progression independent of relapse activity to confirmed disability accumulation in patients with clinically isolated syndrome and early relapsing-remitting multiple sclerosis, assessed within one year from onset and with follow-up ≥5 years (n = 5169). Data were extracted from the Italian Multiple Sclerosis Register. Confirmed disability accumulation was defined by an increase in Expanded Disability Status Scale score confirmed at 6 months, and classified per temporal association with relapses. Factors associated with progression independent of relapse activity and relapse-associated worsening were assessed using multivariable Cox regression models. Over a follow-up period of 11.5 ± 5.5 years, progression independent of relapse activity occurred in 1427 (27.6%) and relapse-associated worsening in 922 (17.8%) patients. Progression independent of relapse activity was associated with older age at baseline [hazard ratio (HR) = 1.19; 95% confidence interval (CI) 1.13–1.25, P &lt; 0.001], having a relapsing–remitting course at baseline (HR = 1.44; 95% CI 1.28–1.61, P &lt; 0.001), longer disease duration at baseline (HR = 1.56; 95% CI 1.28–1.90, P &lt; 0.001), lower Expanded Disability Status Scale at baseline (HR = 0.92; 95% CI 0.88–0.96, P &lt; 0.001) and lower number of relapses before the event (HR = 0.76; 95% CI 0.73–0.80, P &lt; 0.001). Relapse-associated worsening was associated with younger age at baseline (HR = 0.87; 95% CI 0.81–0.93, P &lt; 0.001), having a relapsing–remitting course at baseline (HR = 1.55; 95% CI 1.35–1.79, P &lt; 0.001), lower Expanded Disability Status Scale at baseline (HR = 0.94; 95% CI 0.89–0.99, P = 0.017) and a higher number of relapses before the event (HR = 1.04; 95% CI 1.01–1.07, P &lt; 0.001). Longer exposure to disease-modifying drugs was associated with a lower risk of both progression independent of relapse activity and relapse-associated worsening (P &lt; 0.001). This study provides evidence that in an early relapsing-onset multiple sclerosis cohort, progression independent of relapse activity was an important contributor to confirmed disability accumulation. Our findings indicate that insidious progression appears even in the earliest phases of the disease, suggesting that inflammation and neurodegeneration can represent a single disease continuum, in which age is one of the main determinants of disease phenomenology.