AAN Releases New ALS Care Guidelines

by Margaret Wahl on Sun, 2009-11-01 14:07

The American Academy of Neurology released its new guidelines on patient care in ALS on Oct. 13, 2009. Several MDA-affiliated physicians were involved in their development.

Aimed at physicians, the guidelines are based on evidence that certain treatments are effective in the care of people with ALS. People with ALS who are not attending an MDA clinic or MDA ALS Research and Clinical Centers may wish to inform their physicians of the availability of the new guidelines to ensure they’re getting the best care possible.

In developing the guidelines, the AAN used the language “strong evidence” to mean that more than one high-quality study supports the proposed treatment or test. “Good evidence” means at least one high-quality study or two or more lesser-quality studies support the guideline. “Weak evidence” means there are supportive studies that are deficient in their design.

There’s evidence that attending a multidisciplinary ALS clinic (such as an MDA/ALS center) increases survival time and improves quality of life.

Strong evidence

The AAN recommends riluzole, the only drug approved by the U.S. Food and Drug Administration (FDA), to treat ALS. It has a modest effect on slowing the rate at which the disease worsens. Strong evidence shows riluzole can prolong survival.

Good evidence

There is good evidence that the drugs dextromethorphan and quinidine (combined) can lessen the severity and frequency of episodes of uncontrolled laughing or crying that sometimes occur in ALS. (See “Zenvia for PBA” in the Clinical Trials section of MDA’s Web site for information about clinical testing of this drug combination.)

There is good evidence that drooling can be controlled using the drug botulinum toxin type B, injected into the glands near the jaw that make saliva.

Maintaining adequate nutrition is difficult when swallowing function deteriorates severely. There is good evidence that a percutaneous endoscopic gastrostomy (PEG) tube or a radiologically inserted gastrostomy (RIG) tube —  commonly called a “feeding tube” —  stabilizes body weight and prolongs survival.

It’s important to undergo tests to detect breathing problems even before they become apparent. If a breathing problem is detected, good evidence shows that a noninvasive ventilation (NIV) device is likely to lengthen survival and slow the rate at which the ability to breathe deteriorates.

Good evidence shows that people with ALS should be screened for possible problems with thinking ability.

There is good evidence that visiting a multidisciplinary ALS clinic (one with many types of health professionals, such as an MDA/ALS center) can help people with ALS get the best possible care. Good evidence also shows that people with ALS who visit a multidisciplinary ALS clinic live longer than those who don’t.

Weak evidence

There is weak evidence that suggests that quality of life improves for people with ALS if they attend a multidisciplinary ALS clinic, and if they use a noninvasive ventilation device.

There also is weak evidence that small amounts of radiation therapy may help with drooling.

MDA’s role

Neurologist Valerie Cwik, MDA’s medical director and executive vice president for research, was part of the AAN Practice Parameter Task Force that developed the physician guidelines. Several authors of the physician guidelines are directors of MDA/ALS centers throughout the United States and/or have received MDA research support.

The guidelines for physicians were published Oct. 13, 2009, in the journal Neurology, and also are available on the American Academy of Neurology Web site (click on "Practice"). A patient-directed version of the guidelines is available at The Brain Matters.

Margaret Wahl
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