ALS Untangled®

ALSUntangled® reviews alternative and off label treatments (AOTs), with the goal of helping people with ALS make more informed decisions about them.

Mechanistic plausibility - C

Ayahuasca

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Ayahuasca has interesting mechanisms that could potentially be useful in treating human ALS. We found one person who appears to have experienced an ALS reversal following exposure to a single dose of ayahuasca and several other AOTs. We do not believe that a single dose of ayahuasca could trigger a mechanism that would reverse ALS. There are more plausible explanations for this case, including an unrecognised ALS mimic syndrome. Importantly, there are several documented harms associated with ayahuasca use, including hospitalisation, intubation, and death. There are also serious theoretical risks, including hypertensive crisis, serotonin syndrome, and birth defects. Given this information, at this time, we do not endorse the use of ayahuasca to slow, stop or reverse ALS progression.

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Gluten-Free Diet

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Theoretically, gluten-induced autoimmunity could trigger ALS. However, the data supporting this link are weak, consisting of two association studies and a single case-report. Further studies are needed to confirm the relationship between GRDs and ALS, and the utility of the GFD in patients with both conditions. In spite of the fact that GFD is reasonably safe, it is a complex undertaking and is more expensive than a standard diet. While we wait for better data, it would be reasonable to screen PALS who have GI symptoms, iron-deficiency anemia, or an abnormal brain MRI for the antibodies associated with GFDs. Those with elevated antibodies could be referred to a gastroenterologist for further work-up, and if this is consistent with a GRD, then GFD could be tried under the guidance and monitoring of a dietician.‌‌‌‌

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Lunasin

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Lunasin has interesting mechanisms of action that might be useful in treating ALS, and it appears reasonably safe although some forms of it are expensive. While some PALS have reported improvements on lunasin, we have thus far found only one in which we were able to independently validate these improvements. This patient had atypical features for ALS including a history of myasthenia gravis, which can produce weakness that improves spontaneously. At this time there is not enough evidence to recommend that PALS take lunasin. A reasonable next step would be a small pilot trial of lunasin with validated ALS diagnoses and outcome measures.

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TUDCA

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Ursodiol has interesting mechanisms of action, appears reasonably safe and well-tolerated, has anecdotal reports of benefit in 6/21 of patients who report taking it, and a form of it (Yoo’s solution) was associated with slightly slower ALS progression in one out of three outcome measures within a poorly designed study that did not account for large numbers of drop-outs. However, analyses of ursodiol data from the well-conducted randomized, double-blind ceftriaxone trial show that ursodiol 300 mg twice a day is no better than placebo at prolonging survival or slowing ALS progression. Based upon this review, ALSUntangled does not recommend off-label use of ursodiol as a treatment for ALS, at least at doses of 300 mg twice a day. Determining whether higher doses or different formulations are effective will require further well-designed studies.

Vitamin D

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At this time, there is evidence that PALS, like those with other chronic illnesses, are at increased risk for vitamin D deficiency. It is, therefore, reasonable to screen PALS for this. If vitamin D deficiency is found, it seems reasonable to supplement vitamin D according to established guidelines (31) in order to avoid medical complications of vitamin D deficiency. It is not yet clear, however, that vitamin D supplementation can slow disease progression, improve muscle strength, or reduce falls in PALS. We support further studies to answer these questions.

Propofol

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Propofol has mechanisms of action that may be relevant in treating ALS, although the short action of the drug makes it unlikely that a single infusion could influence ALS pathophysiology in a meaningful way. On ALS.net, six patients with ALS reported wide-ranging subjective benefits coincident with propofol use. Unfortunately, none of these benefits has been verified on validated ALS outcome measures. Only one of 235 patients with confirmed ALS who received propofol for PEG at an ALS center, or in the PRO-ACT database, or in a stem cell trial, improved objectively. The improvements in this patient were much slower to begin, and longer in duration, compared to those reported by the cohort on ALS.net, suggesting that they were more likely due to other longer-acting medications the patient received (such as immunosuppression), the stem cell treatment, or an unusual reversible form of ALS (27–30). While we cannot conclusively rule out a very brief benefit from propofol in rare patients with ALS, the risks and costs involved do not appear to justify its use. We strongly discourage the off label use of propofol in ALS patients at this time. Patients with ALS who are going to have propofol on label for a procedure or surgery may wish to have their ALS neurologist measure an ALSFRS-R and FVC before and in the first few days after propofol exposure and to send these results to ALSUntangled for a possible follow-up review.

Apoaequorin (Prevagen)

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There is a rationale by which the calcium binding protein apoaequorin could work to slow ALS progression. Unfortunately, at this time there is insufficient information available to determine whether it does. The one small case series referred to above utilized a cocktail of therapies and is further weakened by the loss of its standardized outcome measurements. Information from the manufacturer suggests that apoaequorin is reasonably safe and well tolerated but there is no independent, systematic confirmation of this; two PatientsLikeMe members reported serious adverse events while taking it and it is fairly expensive.

At this time ALSUntangled does not recommend that patients with ALS take apoaequorin. Reasonable next steps would include a controlled study of apoaequorin in an ALS animal model and/or a small series of well-characterized patients with ALS using validated outcome measures and including serum and CSF pharmacokinetics.

Cannabis

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Cannabis has biological properties including immunomodulation and effects on excitototoxicity that suggest it could be useful in ALS. Evidence from small, non-randomized, unblinded animal studies suggest that it could potentially slow ALS progression, and anecdotal reports suggest that it could ameliorate troubling ALS symptoms. Given all this, ALSUntangled supports further careful study of cannabis and cannabinoids, the active ingredients contained therein. Natural cannabis, as a single agent, provides advantages similar to a multiple drug trial given its numerous mechanisms of action. A possible next step would be a small case series of well-characterized PALS using cannabis at controlled dosages that could potentially be monitored by blood levels of cannabinoids, compared to matched controls, performed in a geographic area where it would be legal.