Amyotrophic Lateral Sclerosis: Lou Gehrigs disease

Amyotrophic lateral sclerosis (ALS) a devastating neuromuscular disease that

strikes adults in the prime of life has puzzled physicians since it was first described in
medical literature more than 100 years ago. ALS was made famous by baseball legend
Lou Gehrig but anyone can get this disease. ALS is a fatal disorder that causes
progressive muscle paralysis. ALS is a terminal neurological disorder that robs patients
of their ability to dress themselves, eat, walk, and speak. Patients generally survive three
to five years after being diagnosed, with death generally occurring due to respiratory
failure. The cause of the deadly disease was and is still a mystery today.

The pathogenesis is unclear, but there are three general types of ALS: sporadic,
familial and guamanian. (Neurology Channel, 2004) Sporadic is the most common in
the United States with the cause believed to be excess levels of a neurotransmitter called
glutamate. Glutamate in high levels acts as a neurotoxin that damages and kills nerve
cells. Familial ALS (FALS) is linked to a genetic defect of chromosome 21. Mutated
superoxide dismutase (SOD) causes motor neuron problems seen in ALS. (Brown, 2001)
Guamanian ALS, first seen in Guam in the 1950s and 1960s, is suspected to be caused
by the Cycad Cyas circinalis seed used to make flour, although not all researchers agree
with this explanation. (Muscular Dystrophy Association, 2003) More recent research
proposes a theory that bats, a delicacy of native Guamanians, who eat the nuts of the
cycad tree, are cause of high rates of ALS in that country. If this holds true, then an
environmental toxin in the diet may cause ALS and further investigation is needed.
(Muscular Dystrophy Association Research, 2002)

Amyotrophic lateral sclerosis or Lou Gehrigs disease is a progressive disease that

attacks motor neurons, components of the nervous system that connect the brain with the
skeletal muscles, or voluntary muscles. The principle pathologic feature of ALS is
lower and upper motor neuron degeneration, although without inflammation. (Boss,
1998) In less than two percent of patients ALS is caused by a mutation of the gene
encoding the superoxide dismutase SOD1 that controls oxidative stress. Ninety-eight
percent of ALS cases are of unknown causes. (Hum-molgen, 2001) The motor neurons
affected by ALS are also known as anterior horn cells since they are located in the
anterior, or front, of the spinal cord. The anterior horn cells are the nerves that send
messages from the spinal cord to the muscles. The corticospinal tract is a series of
structures that start in the brain and descend into the spinal cord to the anterior horn cells;
it is part of the nervous system that sends messages regarding movement of the voluntary
muscles. (Hole, 1981)

In ALS, the motor neurons deteriorate and eventually die causing the muscles to
waste away from disuse. Weakness may begin in any or all muscles of the body with
paresis usually beginning in a single muscle group. Corresponding muscle groups are
asymmetrically affected in a mottled distribution. Gradual involvement occurs in all
striated muscles except extraocular muscles and the heart. A person in the late stages of
Lou Gehrigs disease progresses to paralysis with no remissions. Even though a persons
brain is fully functional and alert, the command to move never reaches the muscles. (ALS
& ALSA, 2004)

Diagnosis is based on characteristic signs of progressive weakness, atrophy,

fasiculations, and hyperreflexia affecting several regions of the body. (Walling, 1999)
Diagnosis is made after repeated regular physical exams to document involvement of
upper and lower motor neurons. The outward signs of ALS are progressive weakness and
deterioration of the muscles (amytrophic) beginning in limbs, usually on one side of the
body (lateral). Inside the body, the nerves controlling motor function die off after their
cell bodies become hardened and shriveled (sclerosis) leaving the patient increasingly
helpless.

There is an estimated 30,000 Americans with ALS. Since it is impossible to predict

how long the disease has been active before being diagnosed, many patients last less than
a year. However, life span can be five years after diagnosis and a small percentage
survive ten years. Older persons and those with bulbar form tend to have a worse
prognosis. About five to ten percent of ALS victims have an inherited disease, which
strikes at a younger age and consecutive generations. Non-inherited ALS develops
between 40 to 70 years of age and does not have racial, ethnic, or socioeconomic
boundaries. (Mayo Clinic, 2004)

Etiology may be multifactorial or result from different neuronal insults. Several theories
have been introduced over the years to try to explain ALS. The first is an abnormality of
calcium and glutamate, which is essential to neurotransmission. Pathologic changes
occur with cell metabolism damage with entry of the compounds in excessive amounts.
Other causes are hypothesized to be from neurotoxicity of various metals, foods, or
chemicals. (Walling, 1999) Approximately one third of neurons are destroyed before
atrophy occurs. Patients do not know what is going on with their bodies other than the
symptoms are progressively getting worse. The first symptoms are spastic gait and
manual dexterity involvement. Functions not affected by ALS are extraoccular muscle
movement, bladder and bowel control, sensory function and usually skin integrity.
(Walling, 1999) As the disease progresses, the muscles that control swallowing, chewing,
and breathing are affected. When the respiratory muscles weaken, some sort of
mechanical breathing support may be needed. Respiratory problems are irreversible and
once developed, a respirator is usually needed for the rest of the patients life.

There has been no treatment since the disorder was first identified more than 125
years ago until now. The first drug to slow the diseases progression (riluzole or Rilutek)
was approved by the Food and Drug Administration in 1995. Rilutek may slow
progression for some patients and prolong life for a few months (Mayo Clinic, 2004)
With no cure for ALS in sight; the primary care provider will try to control the
manifestations of the disease. Anti-oxidants (vitamins E, C, and beta-carotene, nerve
growth factor, gabapentin, myotrophin, and thyrotropin releasing hormone are being
tested in therapeutic trials but reports are not encouraging. (Dambro, 2000)

Riluteks mode of action is unknown but properties that may be related to effects
include: 1) an inhibitory effect on glutamate release, 2) inactivation of voltage-dependent
sodium channels, and 3) the ability to interfere with intracellular events that follow
transmitter binding at excitatory amino acid receptors. (The 2005 Physicians Desk
Reference Electronic Library) The drug is metabolized in the liver and excreted in the
urine and feces. Precautions need to be utilized in patients with liver and/or renal
insufficiency. There have been no clinical trials to evaluate drug interaction; however, if
hepatotoxic drugs are being taken, caution must be used with Rilutek. Adverse reactions
during trials included nausea, dizziness, decreased lung function, diarrhea, abdominal
pain, pneumonia, vomiting, vertigo, circumoral parathesis, anorexia, and somnolence.
Nausea, dizziness, anorexia, vertigo, somnolence, and circumoral paresthesia are dose
related. (The 2005 Physicians Desk Reference Electronic Library) These adverse
reactions were similar between genders and were independent of age. Recommended
dose is 50 mg every 12 hours taken one hour before or two hours after a meal.

Symptomatic treatment for ALS depends on the individual and possible benefits of
treatment. There are three drugs used to relieved spasticity: baclofen (Lioresal) 10 to 25
mg three times a day, diazepam (Valium) 2 to 15 mg three times a day, or dantrolene
(Dantrium) titrated dose 50 to 100 mg four times a day. Adverse effects of these drugs
are increased weakness, sedation, and dizziness. (Walling, 1999)

Painful muscle cramps can be treated with nonsteroidal anti-inflammatory agents and
anticonvulsive medications including carbamazepine (Tegretol) dose up to 200 mg three
times a day, or phenytoin (Dilantin) 300 mg at bedtime. In early ALS, amitriptyline
(Elavil) 50 to 100 mg at bedtime or nortriptyline (Pamelor) 50 to 75 mg at bedtime helps
to potentiate analgesic medications. (Walling, 1999)

One of the most distressing symptoms for ALS patients with bulbar type is drooling
which can cause bronchospasm. Anticholinergic drugs like Atropine 0.4 mg four times a
day or scopolamine (Transderm-Scop) 0.5 mg patch every third day application help to
suppress sialorrhea. (Walling, 1999)

There are several tricyclic antidepressants requiring a balancing of effects and adverse
effects that are used in the treatment of ALS. Amitriptyline (Elavil), doxepin (Sinequan),
and imipramine (Tofranil) have similar effects in providing antidepressant and
antisialorrheic actions and provide nocturnal sedation, help potentiate analgesia and
possible weight gain. These agents have the potential to produce hypotensive, cardiac,
sedative, and anticholinergic side effects. (Walling, 1999)

Individualized therapy is required for the depression and anxiety common to all ALS
patients. Fluoxetine (Prozac), a selective serotonin reuptake inhibitor, 20 mg once or
twice daily is effective but can cause agitation and insomnia. Anxiety and insomnia may
be relieved by benzodiazepines but daytime sedation may be caused. (Walling, 1999)

Each patient and family is unique while experiencing ALS. Various health
professionals are utilized to deal with the adjustment, mental health, disability, and
financial concerns required with this disabling disease. (Walling, 1999) Families require
access to the latest information. Written instructions need to be assessed and available
regarding respiratory failure and end-of-life decisions. Prior to respiratory failure, if a
decision is made to not use a ventilator, the provider needs to be aware of this decision
and a Do Not Resuscitate (DNR)

Bibliography:
ALSA: ALS and ALSA (2004). Understanding ALS: Facts about ALS. Retrieved
January 23, 2005, from http://www.alsa.org/als/facts.cfm
Boss, B. (1998). Alterations of neurologic function. In K.L. McCance & S.E. Huether
(Eds.), Pathophysiology: The biologic basis for disease in adults and children (pp. 562-
563). St. Louis: Mosby.
Brown, R., Jr. (2001). Amyotrophic lateral sclerosis and other motor neuron diseases. In
E. Braunwald, A.S. Fauci, D.L. Kasper, S.L. Hauser, D.L. Longo, & J.L. Jameson (Eds.),
Harrisons principles of internal medicine (pp. 2412-2415). New York: McGraw-Hill.
Dambro, M. (Ed.). (2000). Amyotrophic lateral sclerosis. In Griffiths 5-minute clinical
consult. (Pp. 36-37). Philadelphia: Lipincott, Williams, & Wilkins.
Hole, J. Jr. (Ed.). (1981). The nervous system. In Human Anatomy and Physiology (2nd
ed. pp. 290-294). Dubuque, IA: Wm C. Brown Company Publishers.
HUM-MOLGEN bulletin board. (June 1, 2001). Motor neuron survival and Lou
Gehrigs disease. Retrieved January 23, 2005, from
http://hum-molgen.org/NewsGen/06-2001/msg01.html
Mayo Clinic (December 3, 2004). What is ALS? Retrieved January 24, 2005, from
http://www.mayoclinic.com/invoke.cfm?id=DS00359
MDA Research (2002). Guamanian ALS: A tough nut finally cracked? Retrieved
January 20, 2005, from http://www.mdausa.org/research/020401batsALS.html
Muscular Dystrophy Association (2003). Facts about amyotrophic lateral sclerosis
(ALS). Retrieved January 19, 2005, from http://www.mdausa.org/publications/fa-
als.html
Neurology Channel (2004). Amyotrophic Lateral Sclerosis. Retrieved January 22, 2005,
from http://www.neurologychannel.com/als/
The 2005 Physicians Desk Reference Electronic Library. (2005), Medical Economics
Company, Inc. Retrieved from CD-ROM database (CD-ROM, 2005 release)
Walling, A. D. (1999). Amyotrophic lateral sclerosis: Lou Gehrigs disease. American
Family Physician. March 15, 1999. Retrieved January 21, 2005, from
http://www.aafp.org/afp/990315ap/1489.html