Multiple Sclerosis Journal - October 2017 - 1488

681197
research-article2016

MSJ0010.1177/1352458516681197Multiple Sclerosis JournalA Manouchehrinia, O Beiki

MULTIPLE
SCLEROSIS
JOURNAL

MSJ

Original Research Paper

Clinical course of multiple sclerosis:
A nationwide cohort study

Multiple Sclerosis Journal
2017, Vol. 23(11) 1488-1495
DOI: 10.1177/
https://doi.org/10.1177/1352458516681197
1352458516681197
https://doi.org/10.1177/1352458516681197
© The Author(s), 2016.
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Ali Manouchehrinia, Omid Beiki and Jan Hillert

Abstract
Background: The course of multiple sclerosis (MS) has been studied in several cohorts; however, results
have varied significantly.
Objective: To describe the clinical course of MS in a nationwide cohort of patients.
Method: Data from the Swedish MS register (SMSreg) were used to estimate the median time to the sustained Expanded Disability Status Scale (EDSS) scores 3.0, 4.0 and 6.0, onset of secondary progressive
multiple sclerosis (SPMS) and death using Kaplan-Meier method. A possible effect of first-line treatments on age at EDSS 6.0 and SPMS was estimated.
Results: In all, 12,703 patients were included. Median ages at EDSS scores 3.0, 4.0 and 6.0 were 55.4
(95% confidence interval (CI): 54.8−55.8), 60.7 (95% CI: 60.1−61.2) and 64.3 (95% CI: 63.6−64.7),
respectively. Median age at SPMS was 57.4 (95% CI: 56.9−57.9). The median age at the time of death was
80.5 (95% CI: 79.9−81.1). Males and progressive-onset patients showed higher risks of disability worsening. On average, treated patients gained 1.6 years (95% CI: 0.2−3) to EDSS 6.0 as a result of treatment.
Conclusion: Ages at disability milestones in this population-based cohort were higher than previously
described in clinic- and regional-based samples. Nevertheless, MS patients die at younger age and live at
an average almost 20 years with moderate and 30 years with severe disability.

Correspondence to:
J Hillert
Department of Clinical
Neuroscience, Karolinska
Institutet, Widerströmska
huset, Tomtebodavägen 18A,
Floor 5, 171 77 Stockholm,
Sweden.
Jan.Hillert@ki.se
Ali Manouchehrinia
Jan Hillert
Department of Clinical
Neuroscience, Karolinska
Institutet, Stockholm,
Sweden
Omid Beiki
Department of Clinical
Neuroscience, Karolinska
Institutet, Stockholm,
Sweden/Kermanshah
University of Medical
Sciences, Kermanshah, Iran

Keywords: Multiple sclerosis, disease course, disability progression
Date received: 31 August 2016; revised: 14 October 2016; accepted: 21 October 2016

Introduction
The course and progression of multiple sclerosis (MS)
vary strikingly between patients, and the future of an
individual patient is difficult to predict.1 The clinical
course of MS has often been studied by estimating
the time from birth and onset of the disease to the
Expanded Disability Status Scale (EDSS) milestone
scores 3.0, 4.0, 6.0 and 8.0 or conversion to secondary
progressive multiple sclerosis (SPMS). Not surprisingly, and despite seemingly simple analytical prerequisites, results have varied between the best known
'natural course cohorts' such as the ones from Lyon in
France, London Ontario, British Columbia in Canada
and Gothenburg in Sweden. For example, the reported
median time to EDSS score 6.0 from onset of MS has
varied up to 15 years between studies.2
Since the mid-1990s, disease-modifying treatments
(DMTs) have been available for the treatment of

1488

relapsing MS. Availability of DMTs may have
impacted characteristics of today's MS populations
through treatment effects and more importantly
patients' behaviour as a result of treatment availability (e.g. over presentation of severe patients). At present, it is not entirely clear whether the characteristics
and clinical course of today's MS patients presenting
at MS clinics have changed due to changes in the
management of the disease. Therefore, analysis of a
contemporary population-based cohort can offer valuable knowledge.
The aim of this study was to use a populationbased cohort of adequate coverage and follow-up
to estimate the time to major MS disability and
clinical milestones and all-cause mortality. It is
applicable to today's MS patients' situation when a
significant number of bout-onset patients have
received DMTs.

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