Management of amyotrophic lateral sclerosis

Amyotrophic lateral sclerosis (ALS) is a neurodegenerative disease affecting the motor neurons, in both the spinal cord and medulla (lower motor neurons) and cerebral cortex (upper motor neurons). Even though ALS remains fatal, several advances have been made during the last decade in improving the consequences of motor dysfunction, quality of life and survival time of patients. Treatment of ALS cannot be restricted to riluzole, the only molecule that has been proved to modify the evolution of the disease. Symptomatic treatments have an important role in controlling the major consequences of the disease, such as pain, sleep disorders, spasticity, hypersialhorroea, emotional lability, depression and digestive disorders (constipation and reflux). All these symptoms need to be recognized and their possible causes identified in order to provide the most appropriate management of patients with ALS. However, an advance in the daily care of patients is the identification of two important phenomena that occur during the evolution of the disease: swallowing difficulties and the occurrence of diaphragmatic dysfunction. For both, specific medical interventions have been developed to allow correction of the consequences (i.e. weight loss and respiratory insufficiency). Although no controlled trials have been performed, observational studies suggest that gastrostomy and non-invasive ventilation may improve at least quality of life and survival. All of these various approaches, pharmaceutical and non-pharmaceutical therapies, are prescribed according to individual symptoms and require the involvement of a large range of health professionals. This multidisciplinary approach in ALS clinics is considered to be one of the more important factors impacting on survival rate and appears to be the gold standard of medical care of ALS patients. Important findings have been made in understanding the nature of the degenerative process that affects the motor neurons. All these data have allowed new therapeutic molecules to be tested alone or in combination with riluzole. Despite the negative results obtained until now, we hope to demonstrate very soon a greater improvement in therapy.