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Meanti R, Bresciani E, Rizzi L, Coco S, Zambelli V, Dimitroulas A, Molteni L, Omeljaniuk RJ, Locatelli V, Torsello A. Potential Applications for Growth Hormone Secretagogues Treatment of Amyotrophic Lateral Sclerosis. Curr Neuropharmacol 2023; 21:2376-2394. [PMID: 36111771 PMCID: PMC10616926 DOI: 10.2174/1570159x20666220915103613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 07/18/2022] [Accepted: 08/01/2022] [Indexed: 11/22/2022] Open
Abstract
Amyotrophic lateral sclerosis (ALS) arises from neuronal death due to complex interactions of genetic, molecular, and environmental factors. Currently, only two drugs, riluzole and edaravone, have been approved to slow the progression of this disease. However, ghrelin and other ligands of the GHS-R1a receptor have demonstrated interesting neuroprotective activities that could be exploited in this pathology. Ghrelin, a 28-amino acid hormone, primarily synthesized and secreted by oxyntic cells in the stomach wall, binds to the pituitary GHS-R1a and stimulates GH secretion; in addition, ghrelin is endowed with multiple extra endocrine bioactivities. Native ghrelin requires esterification with octanoic acid for binding to the GHS-R1a receptor; however, this esterified form is very labile and represents less than 10% of circulating ghrelin. A large number of synthetic compounds, the growth hormone secretagogues (GHS) encompassing short peptides, peptoids, and non-peptidic moieties, are capable of mimicking several biological activities of ghrelin, including stimulation of GH release, appetite, and elevation of blood IGF-I levels. GHS have demonstrated neuroprotective and anticonvulsant effects in experimental models of pathologies both in vitro and in vivo. To illustrate, some GHS, currently under evaluation by regulatory agencies for the treatment of human cachexia, have a good safety profile and are safe for human use. Collectively, evidence suggests that ghrelin and cognate GHS may constitute potential therapies for ALS.
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Affiliation(s)
- Ramona Meanti
- School of Medicine and Surgery, University of Milano-Bicocca, Via Cadore 48, Monza, 20900, Italy
| | - Elena Bresciani
- School of Medicine and Surgery, University of Milano-Bicocca, Via Cadore 48, Monza, 20900, Italy
| | - Laura Rizzi
- School of Medicine and Surgery, University of Milano-Bicocca, Via Cadore 48, Monza, 20900, Italy
| | - Silvia Coco
- School of Medicine and Surgery, University of Milano-Bicocca, Via Cadore 48, Monza, 20900, Italy
| | - Vanessa Zambelli
- School of Medicine and Surgery, University of Milano-Bicocca, Via Cadore 48, Monza, 20900, Italy
| | - Anna Dimitroulas
- Faculty of Health and Medical Sciences, University of Surrey, Stag Hill, Guildford, GU2 7XH, United Kingdom
| | - Laura Molteni
- School of Medicine and Surgery, University of Milano-Bicocca, Via Cadore 48, Monza, 20900, Italy
| | - Robert J. Omeljaniuk
- Department of Biology, Lakehead University, 955 Oliver Rd, Thunder Bay, Ontario, P7B 5E1, Canada
| | - Vittorio Locatelli
- School of Medicine and Surgery, University of Milano-Bicocca, Via Cadore 48, Monza, 20900, Italy
| | - Antonio Torsello
- School of Medicine and Surgery, University of Milano-Bicocca, Via Cadore 48, Monza, 20900, Italy
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Waheed W, Khan F, Naud S, Kasarskis E, Matthews D, Tandan R. Urine specific gravity to identify and predict hydration need in ALS. Amyotroph Lateral Scler Frontotemporal Degener 2022; 23:407-414. [PMID: 34918583 PMCID: PMC9887640 DOI: 10.1080/21678421.2021.2013894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Introduction: Multiple factors contribute to increased risk of dehydration in amyotrophic lateral sclerosis (ALS), which contributes to shortened survival independent of nutritional status. The assessment of hydration by doubly labeled water is restricted due to the limited availability of this gold standard technique for clinical use. This prompted us to examine the utility of urine-specific gravity (USG) as a predictor of hydration need in ALS subjects. Material and Methods: Using data from a multicenter study of 80 ALS subjects with 250 visits, we conducted a secondary analysis of the original data set from doubly labeled water experiments. We used a cross-section of the data (one visit per 75 subjects) in the model selection step ("test set"), and a repeated measures analysis in the validation step with data from 63 subjects and 142 follow-up visits. The sensitivity to detect inadequate water turnover rate (a surrogate for water intake) was the goal of the predictive model presented for clinical use. Results and discussion: The final predictive model to estimate water requirement included USG, gender, body mass index, and the ALSFRS gross motor subscale score. We developed a best-fit equation to estimate water intake from USG, determine hydration status, and improve clinical care of real-world ALS subjects.
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Affiliation(s)
- Waqar Waheed
- Department of Neurological Sciences, University of Vermont and the University of Vermont Medical Center, Burlington, VT
| | - Fatima Khan
- Department of Neurological Sciences, University of Vermont and the University of Vermont Medical Center, Burlington, VT
| | - Shelly Naud
- Department of Medical Biostatistics, University of Vermont, Burlington, VT, USA
| | - Edward Kasarskis
- Department of Neurology, University of Kentucky, Lexington, KY, USA
| | - Dwight Matthews
- Department of Chemistry, University of Vermont, Burlington, VT, USA
| | - Rup Tandan
- Department of Neurological Sciences, University of Vermont and the University of Vermont Medical Center, Burlington, VT
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Tandan R, Levy EA, Howard DB, Hiser J, Kokinda N, Dey S, Kasarskis EJ. Body composition in amyotrophic lateral sclerosis subjects and its effect on disease progression and survival. Am J Clin Nutr 2022; 115:1378-1392. [PMID: 35108352 PMCID: PMC9071423 DOI: 10.1093/ajcn/nqac016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 01/19/2022] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Motor neuron degeneration and malnutrition alter body composition in amyotrophic lateral sclerosis (ALS). Resulting losses of weight, fat mass (FM), and fat-free mass (FFM) shorten survival. Nutritional management relies on body weight or BMI; neither reliably indicates malnutrition nor differentiates body compartments. OBJECTIVES We aimed to 1) develop an equation to compute FM and FFM using clinical data, validated against DXA; and 2) examine the effect of computed FM and FFM on disease course and survival. METHODS We studied 364 ALS patients from 3 cohorts. In Cohort #1 we used logistic regression on clinical and demographic data to create an equation (test cohort). In Cohort #2 we validated FM and FFM computed using this equation against DXA (validation cohort). In Cohort #3, we examined the effect of computed body composition on disease course and survival. RESULTS In Cohort #1 (n = 29) the model incorporated sex, age, BMI, and bulbar-onset to create an equation to estimate body fat: % body fat = 1.73 - [19.80*gender (1 if male or 0 if female)] + [0.25*weight (kg)] + [0.95*BMI (kg/m2)] - (5.20*1 if bulbar-onset or *0 if limb-onset). In Cohort #2 (n = 104), body composition using this equation, compared to other published equations, showed the least variance from DXA values. In Cohort #3 (n = 314), loss of body composition over 6 mo was greater in males. Adjusted survival was predicted by low baseline FM (HR: 1.39; 95% CI: 1.07, 1.80), and loss of FM (HR: 1.87; 95% CI: 1.30, 2.69) and FFM (HR: 1.73; 95% CI: 1.20, 2.49) over 6 mo. CONCLUSIONS Our equation broadens the traditional nutritional evaluation in clinics and reliably estimates body composition. Measuring body composition could target FM as a focus for nutritional management to ensure adequate energy intake and complement measures, such as the ALS functional rating scale-revised score and forced vital capacity, currently used.
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Affiliation(s)
- Rup Tandan
- Department of Neurological Sciences, University of Vermont Medical Center and Robert Larner, MD College of Medicine, University of Vermont, Burlington, VT, USA
- General Clinical Research Center, University of Vermont Medical Center and Robert Larner, MD College of Medicine, University of Vermont, Burlington, VT, USA
| | - Evan A Levy
- Department of Neurological Sciences, University of Vermont Medical Center and Robert Larner, MD College of Medicine, University of Vermont, Burlington, VT, USA
- General Clinical Research Center, University of Vermont Medical Center and Robert Larner, MD College of Medicine, University of Vermont, Burlington, VT, USA
| | - Diantha B Howard
- General Clinical Research Center, University of Vermont Medical Center and Robert Larner, MD College of Medicine, University of Vermont, Burlington, VT, USA
- The Northern New England Clinical and Translational Research Network, Robert Larner, MD College of Medicine, University of Vermont, Burlington, VT, USA
- Maine Medical Center Research Institute, Portland, ME, USA
| | - John Hiser
- General Clinical Research Center, University of Vermont Medical Center and Robert Larner, MD College of Medicine, University of Vermont, Burlington, VT, USA
- The Northern New England Clinical and Translational Research Network, Robert Larner, MD College of Medicine, University of Vermont, Burlington, VT, USA
- Maine Medical Center Research Institute, Portland, ME, USA
| | - Nathan Kokinda
- General Clinical Research Center, University of Vermont Medical Center and Robert Larner, MD College of Medicine, University of Vermont, Burlington, VT, USA
- The Northern New England Clinical and Translational Research Network, Robert Larner, MD College of Medicine, University of Vermont, Burlington, VT, USA
- Maine Medical Center Research Institute, Portland, ME, USA
| | - Swatee Dey
- Department of Neurology, University of Kentucky, Lexington, KY, USA
- General Clinical Research Center, University of Kentucky, Lexington, KY, USA
| | - Edward J Kasarskis
- Department of Neurology, University of Kentucky, Lexington, KY, USA
- General Clinical Research Center, University of Kentucky, Lexington, KY, USA
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Jackson CE, Heiman-Patterson TD, Sherman M, Daohai YU, Kasarskis EJ. Factors associated with Noninvasive ventilation compliance in patients with ALS/MND. Amyotroph Lateral Scler Frontotemporal Degener 2021; 22:40-47. [PMID: 34348541 DOI: 10.1080/21678421.2021.1917617] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Background: Although noninvasive ventilation (NIV) improves survival and quality of life (QOL) in ALS, use of NIV is suboptimal. Objective: To determine compliance with "early" NIV initiation, requisite for the feasibility of a large study of early NIV initiation, and examine factors impacting compliance. Methods: Seventy-three ALS participants with forced vital capacities (FVC) >50% were enrolled. Participants with FVC over 80% (Group 1) were initiated on NIV early (FVC between 80 and 85%). Participants with FVC between 50 and 80% (Group 2) started NIV at FVC between 50 and 55%. Symptom surveys, QOL scores, and NIV compliance (machine download documenting use ≥4 hours/night >60% of time) were collected following NIV initiation. Results: 53.6% of Group 1 and 50% of Group 2 were compliant 28 days following NIV initiation, with increased compliance over time. Participants who were unmarried, had lower income, lower educational attainment, or limited caregiver availability were less likely to be compliant. Bothersome symptoms in non-compliant participants included facial air pressure, frequent arousals with difficulty returning to sleep, and claustrophobia. Both compliant and noncompliant participants felt improved QOL with NIV; improvement was significantly greater in compliant participants. Conclusions: These data suggest ALS patients can comply with NIV early in their disease, and potentially benefit as evidenced by improved QOL scores, supporting both feasibility and need for a study comparing early versus late NIV initiation. Moreover, modifiable symptoms were identified that could be optimized to improve compliance. Further studies are needed to determine the impact of "early" intervention on survival and QOL.
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Affiliation(s)
- C E Jackson
- University of Texas Health Science Center, San Antonio, TX, USA
| | | | - M Sherman
- MCG-Hearst Health, Drexel University College of Medicine, Philadelphia, PA, USA
| | - Y U Daohai
- Temple University Lewis Katz School of Medicine, Philadelphia, PA, USA
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Heiman-Patterson TD, Khazaal O, Yu D, Sherman ME, Kasarskis EJ, Jackson CE. Pulmonary function decline in amyotrophic lateral sclerosis. Amyotroph Lateral Scler Frontotemporal Degener 2021; 22:54-61. [PMID: 34348540 DOI: 10.1080/21678421.2021.1910713] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Background: There has been no comprehensive longitudinal study of pulmonary functions (PFTS) in ALS determining which measure is most sensitive to declines in respiratory muscle strength. Objective: To determine the longitudinal decline of PFTS in ALS and which measure supports Medicare criteria for NIV initiation first. Methods: Serial PFTs (maximum voluntary ventilation (MVV), maximum inspiratory pressure measured by mouth (MIP) or nasal sniff pressure (SNIP), maximum expiratory pressure (MEP), and Forced Vital Capacity (FVC)) were performed over 12 months on 73 ALS subjects to determine which measure showed the sentinel decline in pulmonary function. The rate of decline for each measure was determined as the median slope of the decrease over time. Medicare-based NIV initiation criteria were met if %FVC was ≤ 50% predicted or MIP was ≤ 60 cMH2O. Results: 65 subjects with at least 3 visits were included for analyses. All median slopes were significantly different than zero. MEP and sitting FVC demonstrated the largest rate of decline. Seventy subjects were analyzed for NIV initiation criteria, 69 met MIP criteria first; 11 FVC and MIP criteria simultaneously and none FVC criteria first. Conclusions: MEP demonstrated a steeper decline compared to other measures suggesting expiratory muscle strength declines earliest and faster and the use of airway clearance interventions should be initiated early. When Medicare criteria for NIV initiation are considered, MIP criteria are met earliest. These results suggest that pressure-based measurements are important in assessing the timing of NIV and the use of pulmonary clearance interventions.
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Affiliation(s)
| | - Ossama Khazaal
- Department of Neurology, University of Pennsylvania, Philadelphia, PA, USA
| | - Daohai Yu
- Department of Clinical Sciences, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | - Michael E Sherman
- Department of Medicine, MCG-Hearst Health, Drexel University College of Medicine, Philadelphia, PA, USA
| | - Edward J Kasarskis
- Department of Neurology, University of Kentucky, Lexington, KY, USA, and
| | - Carlayne E Jackson
- Department of Neurology, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
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Heiman-Patterson TD, Sherman MS, Yu D, Jackson CE, George A, Kasarskis EJ. Use of a new ALS specific respiratory questionnaire: the ARES score. Amyotroph Lateral Scler Frontotemporal Degener 2021; 22:48-53. [PMID: 34348538 DOI: 10.1080/21678421.2021.1910307] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Objective: To develop an ALS respiratory symptom scale (ARES) and evaluate how ARES compares to Medical Research Council Modified Dyspnea Scale (MRC), Borg dyspnea scale, and respiratory subscores from ALSFRS-R (ALSFRS-Resp) in detecting respiratory symptoms, correlation with pulmonary function and ALSFRS-R, and deterioration of pulmonary function and ALSFRS-R over time.Methods: The ARES scale consists of 9 questions addressing dyspnea during activities and 3 questions addressing symptoms of worsening pulmonary function. 153 subjects with ALS completed MRC, Borg, ALSFRS-R, and ARES questionnaires at baseline, 16, 32, and 48 weeks, and spirometry at baseline. 73 of these subjects had spirometry, maximum inspiratory (MIP) and expiratory pressures (MEP), nasal inspiratory pressure (SNIP), and maximum voluntary ventilation (MVV) measured at each visit. Sensitivity of each scale and correlations between symptom scores, pulmonary function, and ALSFRS-R were evaluated at baseline and over the study duration.Results and conclusions: ARES was more sensitive than MRC, Borg and ALSFRS-Resp scales at baseline and for detecting changes at 16 and 32 weeks. ARES and ALSFRS-Resp correlated significantly with vital capacity at baseline, but Borg and MRC did not. Only ALSFRS-Resp correlated with respiratory pressures. Changes in ALSFRS-Resp and ARES both correlated with vital capacity decline; however, changes in ARES had superior correlation with respiratory pressure decline. Comparisons between telephone and in-person administration of ARES met criteria for satisfactory test-retest correlation in different settings one week apart. These findings suggest that the ARES may be more useful in monitoring symptom progression in ALS than other available scales.
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Affiliation(s)
- Terry D Heiman-Patterson
- Department of Neurology, Lewis Katz School of Medicine, Temple University, Philadelphia, PA, USA
| | - Michael S Sherman
- MCG-Hearst Health and Department of Medicine, Drexel University College of Medicine, Philadelphia, PA, USA
| | - Daohai Yu
- Department of Neurology, Lewis Katz School of Medicine, Temple University, Philadelphia, PA, USA.,Department of Clinical Sciences, Lewis Katz School of Medicine, Temple University, Philadelphia, PA, USA
| | - Carlayne E Jackson
- Department of Clinical Sciences, Lewis Katz School of Medicine, Temple University, Philadelphia, PA, USA.,Department of Neurology, University of Texas, San Antonio, TX, USA
| | - Asha George
- Innovative Research Associates, Sharon Hill, Pa., USA
| | - Edward J Kasarskis
- Department of Neurology, University of Texas, San Antonio, TX, USA.,Department of Neurology, University of Kentucky, Lexington, KY, USA
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Fayemendy P, Marin B, Labrunie A, Boirie Y, Walrand S, Achamrah N, Coëffier M, Preux PM, Lautrette G, Desport JC, Couratier P, Jésus P. Hypermetabolism is a reality in amyotrophic lateral sclerosis compared to healthy subjects. J Neurol Sci 2020; 420:117257. [PMID: 33290920 DOI: 10.1016/j.jns.2020.117257] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 11/08/2020] [Accepted: 11/25/2020] [Indexed: 12/12/2022]
Abstract
RATIONALE Hypermetabolism (HM) in Amyotrophic lateral sclerosis (ALS) is the reflection of a high energy metabolic level, but this alteration seems controversial. The main objective of the study was to confirm the existence of HM during ALS compared to healthy subjects. METHODS A cohort of ALS patients was compared to a control group without metabolic disorder. The assessment included anthropometric criteria measurements, body composition by bioelectric impedance analysis and resting energy expenditure (REE) by indirect calorimetry. HM was defined as a variation > +10% between measured and calculated REE. Statistical analysis used Mann-Withney and Chi2 tests. Multivariate analysis included logistic regression. RESULTS 287 patients and 75 controls were included. The metabolic level was higher in ALS patients (1500 kcal/24 h [1290-1693] vs. 1230 kcal/24 h [1000-1455], p < 0.0001) as well as the REE/fat free mass ratio (33.5 kcal/kg/24 h [30.4-37.8] vs. 28.3 kcal/kg/24 h [26.1-33.6], p < 0.0001). 55.0% of ALS patients had HM vs. 13.3% of controls (p < 0.0001). HM was strongly and positively associated with ALS (OR = 9.50 [4.49-20.10], p < 0.0001). CONCLUSIONS HM in ALS is a reality, which affects more than half of the patients and is associated with ALS. This work confirms a very frequent metabolic deterioration during ALS. The identification of HM can allow a better adaptation of the patients' nutritional intake.
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Affiliation(s)
- Philippe Fayemendy
- Nutrition Unit, University Hospital of Limoges, Limoges, France; INSERM UMR 1094, Tropical Neuroepidemiology, Limoges, France.
| | - Benoit Marin
- INSERM UMR 1094, Tropical Neuroepidemiology, Limoges, France; Center for Epidemiology, Biostatistics and Methodology of Research, University Hospital of Limoges, France
| | - Anaïs Labrunie
- Center for Epidemiology, Biostatistics and Methodology of Research, University Hospital of Limoges, France
| | - Yves Boirie
- University Clermont Auvergne, INRA, UNH, Human Nutrition Unit, CRNH Auvergne, Clermont-Ferrand, France
| | - Stéphane Walrand
- University Clermont Auvergne, INRA, UNH, Human Nutrition Unit, CRNH Auvergne, Clermont-Ferrand, France
| | | | | | - Pierre-Marie Preux
- INSERM UMR 1094, Tropical Neuroepidemiology, Limoges, France; Center for Epidemiology, Biostatistics and Methodology of Research, University Hospital of Limoges, France
| | | | - Jean-Claude Desport
- Nutrition Unit, University Hospital of Limoges, Limoges, France; INSERM UMR 1094, Tropical Neuroepidemiology, Limoges, France
| | - Philippe Couratier
- INSERM UMR 1094, Tropical Neuroepidemiology, Limoges, France; ALS center, University Hospital of Limoges, France
| | - Pierre Jésus
- Nutrition Unit, University Hospital of Limoges, Limoges, France; INSERM UMR 1094, Tropical Neuroepidemiology, Limoges, France
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Ning P, Yang B, Li S, Mu X, Shen Q, Hu F, Tang Y, Yang X, Xu Y. Systematic review of the prognostic role of body mass index in amyotrophic lateral sclerosis. Amyotroph Lateral Scler Frontotemporal Degener 2019; 20:356-367. [PMID: 30931632 DOI: 10.1080/21678421.2019.1587631] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- Pingping Ning
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan Province, P.R. China,
| | - Baiyuan Yang
- Department of Neurology, Seventh People’s Hospital of Chengdu, Chengdu, Sichuan Province, P.R. China,
| | - Shuangjiang Li
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, P.R. China,
| | - Xin Mu
- Department of Neurology, Chengdu First People’s Hospital, Chengdu, Sichuan Province, P.R. China and
| | - Qiuyan Shen
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan Province, P.R. China,
| | - Fayun Hu
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan Province, P.R. China,
| | - Yao Tang
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan Province, P.R. China,
| | - Xinglong Yang
- Department of Geriatric Neurology, First Affiliated Hospital of Kunming Medical University, Kunming, Yunnan Province, P.R. China
| | - Yanming Xu
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan Province, P.R. China,
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Scagnelli CN, Howard DB, Bromberg MB, Kasarskis EJ, Matthews DE, Mitsumoto HM, Simmons Z, Tandan R. Hydration measured by doubly labeled water in ALS and its effects on survival. Amyotroph Lateral Scler Frontotemporal Degener 2017; 19:220-231. [PMID: 29243507 DOI: 10.1080/21678421.2017.1413117] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
We present a study of hydration in ALS patients and its effects on survival. This was a multicenter study over 48 weeks in 80 ALS patients who underwent 250 individual measurements using doubly labeled water (DLW). Total body water (TBW) and water turnover (a surrogate for water intake) were 3.4% and 8.6% lower, respectively, in patients compared to age- and gender-matched healthy controls, and both significantly decreased over study duration. In 20% of patients, water turnover measured over 10 d was 2 standard deviations below the mean value in healthy controls. In a separate clinic cohort of 208 patients, water intake estimated from a de novo equation created from common clinical endpoints was a prognostic indicator of survival. Regardless of nutritional state assessed by BMI, survival was two-fold longer in the group above the median for estimated water intake, suggesting that hydration may be a more important predictor of survival than malnutrition. Risk factors for poor hydration were identified. Water intake equations recommended by US Centers for Medicare and Medicaid Services in healthy elderly were inaccurate for use in ALS patients. We developed equations to estimate TBW and water intake in ALS patients for use in clinics to accurately estimate hydration and improve clinical care.
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Affiliation(s)
- Connor N Scagnelli
- a Department of Neurological Sciences , University of Vermont , Burlington , VT , USA
| | - Diantha B Howard
- b Clinical Research Center , University of Vermont College of Medicine , Burlington , VT , USA
| | - Mark B Bromberg
- c Department of Neurology , University of Utah , Salt Lake City , UT , USA
| | - Edward J Kasarskis
- d Department of Neurology , University of Kentucky , Lexington , KY , USA
| | - Dwight E Matthews
- e Departments of Chemistry and Medicine , University of Vermont , Burlington , VT , USA
| | | | - Zachary Simmons
- g Department of Neurology , Pennsylvania State University , Hershey , PA , USA
| | - Rup Tandan
- a Department of Neurological Sciences , University of Vermont , Burlington , VT , USA
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Raheja D, Stephens HE, Lehman E, Walsh S, Yang C, Simmons Z. Patient-reported problematic symptoms in an ALS treatment trial. Amyotroph Lateral Scler Frontotemporal Degener 2016; 17:198-205. [PMID: 26824413 DOI: 10.3109/21678421.2015.1131831] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
This study was undertaken to determine which symptoms are perceived to be most problematic for patients with ALS and how their severity changes over time. A retrospective study was performed of data from a randomized, double-blind, placebo-controlled trial of ceftriaxone in ALS. Participants completed the ALS Specific Quality of Life Instrument (ALSSQoL) at baseline and at intervals up to 96 weeks. Ten ALSSQoL items ask participants to rate how problematic symptoms are (the subjective feeling of burden of these symptoms), ranging from 0 (no problem) to 10 (tremendous problem). Six are non-bulbar (pain, fatigue, breathing, strength and ability to move, sleep, and bowel and bladder) and four are bulbar (eating, speaking, excessive saliva, and mucus). Results revealed that there were 82 subjects (56% males, mean age 53 ± 10.3 years) with ALSSQoL data for weeks 0 and 96. All 10 symptoms became more problematic over time. For non-bulbar symptoms, strength/ability to move and fatigue were the most problematic. Speaking was the most problematic bulbar symptom. In conclusion, although all the symptoms in the ALSSQoL were acknowledged as problematic, some had greater impact than others. All became more problematic over time. This should help prioritize research into symptom management, and assist individual clinicians in their approach to patient care.
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Affiliation(s)
- Divisha Raheja
- a Department of Neurology , The Pennsylvania State University College of Medicine , Hershey Pennsylvania
| | - Helen E Stephens
- a Department of Neurology , The Pennsylvania State University College of Medicine , Hershey Pennsylvania
| | - Erik Lehman
- b Department of Public Health Sciences , The Pennsylvania State University College of Medicine , Hershey Pennsylvania
| | - Susan Walsh
- c ALS Association Greater Philadelphia Chapter , Harrisburg Pennsylvania
| | - Chengwu Yang
- d Department of Public Health Sciences & Office for Scholarship in Learning and Education Research , Hershey Pennsylvania , USA , and
| | - Zachary Simmons
- e Departments of Neurology and Humanities , The Pennsylvania State University College of Medicine , Hershey Pennsylvania , USA
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Bedlack RS, Joyce N, Carter GT, Paganoni S, Karam C. Complementary and Alternative Therapies in Amyotrophic Lateral Sclerosis. Neurol Clin 2015; 33:909-36. [PMID: 26515629 PMCID: PMC4712627 DOI: 10.1016/j.ncl.2015.07.008] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Given the severity of their illness and lack of effective disease-modifying agents, it is not surprising that most patients with amyotrophic lateral sclerosis (ALS) consider trying complementary and alternative therapies. Some of the most commonly considered alternative therapies include special diets, nutritional supplements, cannabis, acupuncture, chelation, and energy healing. This article reviews these in detail. The authors also describe 3 models by which physicians may frame discussions about alternative therapies: paternalism, autonomy, and shared decision making. Finally, the authors review a program called ALSUntangled, which uses shared decision making to review alternative therapies for ALS.
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Affiliation(s)
- Richard S Bedlack
- Department of Neurology, Duke University Medical Center, Durham, NC 27702, USA.
| | - Nanette Joyce
- Department of Physical Medicine and Rehabilitation, University of California, Davis School of Medicine, 4860 Y Street Suite 3850, Sacramento, CA 95817, USA
| | - Gregory T Carter
- Department of Physical Medicine and Rehabilitation, St. Luke's Rehabilitation Institute, 711 South Cowley, Spokane, WA 99202, USA
| | - Sabrina Paganoni
- Spaulding Rehabilitation Hospital, Boston VA Health Care System, Harvard Medical School, Massachussets General Hospital, Boston, MA 02114, USA
| | - Chafic Karam
- Department of Neurology, University of North Carolina School of Medicine, 170 Manning Drive, Campus Box 7025, Chapel Hill, NC 27599-7025, USA
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Gibson SB, Kasarskis EJ, Hu N, Pulst SM, Mendiondo MS, Matthews DE, Mitsumoto H, Tandan R, Simmons Z, Kryscio RJ, Bromberg MB. Relationship of creatine kinase to body composition, disease state, and longevity in ALS. Amyotroph Lateral Scler Frontotemporal Degener 2015; 16:473-7. [PMID: 26312548 DOI: 10.3109/21678421.2015.1062516] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Our objective was to explore if creatine kinase (CK) levels correlate with survival in amyotrophic lateral sclerosis (ALS), and whether a correlation is independent of other well-studied predictors such as location of onset, gender, age, fat free mass, spasticity, cramps, and fasciculations. We analyzed data from 80 ALS patients from a 48-week non-interventional longitudinal multicenter nutrition study with long term follow-up. The overall mean CK was 214 ± 191.8 U/l (range 22-1992 U/l). Forty-five percent of patients had at least one high CK value (> 200 U/l), and about half maintained a high CK value, but there was no trend over the study period. Male gender and extremity onset were significantly associated with high CK. In univariate analysis, age, bioelectric impedance spectroscopy (BIS) fat free mass, spasticity, and fasciculations were not associated with CK level. There was an association between CK and muscle cramps (p < 0.001). In survival analysis, low CK (≤ 200 U/l) was associated with a longer overall survival (p = 0.02), when adjusting for location of onset, age, race, gender, BIS fat free mass, and study site. In conclusion, CK may be a useful marker for ALS survival, which has implications for clinical care and the design of future clinical trials.
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Affiliation(s)
- Summer B Gibson
- a Department of Neurology , University of Utah , Salt Lake City , Utah , USA
| | - Edward J Kasarskis
- b Department of Neurology , University of Kentucky , Lexington , Kentucky , USA.,c Neurology Service, Lexington VA Medical Center , Lexington , Kentucky , USA.,d Graduate Center for Nutrition, University of Kentucky , Lexington , Kentucky , USA.,e Graduate Center for Toxicology, University of Kentucky , Lexington , Kentucky , USA
| | - Nan Hu
- f Department of Internal Medicine , University of Utah , Salt Lake City , Utah , USA.,g Huntsman Cancer Institute , Salt Lake City , Utah , USA
| | - Stefan-M Pulst
- a Department of Neurology , University of Utah , Salt Lake City , Utah , USA
| | - Marta S Mendiondo
- h Department of Biostatistics , College of Public Health, University of Kentucky , Lexington , Kentucky , USA.,i Sanders Brown Center on Aging, University of Kentucky , Lexington , Kentucky , USA
| | - Dwight E Matthews
- j Departments of Chemistry and Medicine , University of Vermont , Burlington , Vermont , USA
| | - Hiroshi Mitsumoto
- k Department of Neurology , Columbia University , New York , NY , USA
| | - Rup Tandan
- l Department of Neurology , University of Vermont , Burlington , Vermont , USA
| | - Zachary Simmons
- m Department of Neurology , Pennsylvania State University , Hershey , Pennsylvania , USA
| | - Richard J Kryscio
- h Department of Biostatistics , College of Public Health, University of Kentucky , Lexington , Kentucky , USA.,i Sanders Brown Center on Aging, University of Kentucky , Lexington , Kentucky , USA.,n Department of Statistics , College of Arts and Science, University of Kentucky , Lexington , Kentucky , USA
| | - Mark B Bromberg
- a Department of Neurology , University of Utah , Salt Lake City , Utah , USA
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13
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Wills AM, Hubbard J, Macklin EA, Glass J, Tandan R, Simpson EP, Brooks B, Gelinas D, Mitsumoto H, Mozaffar T, Hanes GP, Ladha SS, Heiman-Patterson T, Katz J, Lou JS, Mahoney K, Grasso D, Lawson R, Yu H, Cudkowicz M. Hypercaloric enteral nutrition in patients with amyotrophic lateral sclerosis: a randomised, double-blind, placebo-controlled phase 2 trial. Lancet 2014; 383:2065-2072. [PMID: 24582471 PMCID: PMC4176708 DOI: 10.1016/s0140-6736(14)60222-1] [Citation(s) in RCA: 191] [Impact Index Per Article: 19.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Amyotrophic lateral sclerosis is a fatal neurodegenerative disease with few therapeutic options. Mild obesity is associated with greater survival in patients with the disease, and calorie-dense diets increased survival in a mouse model. We aimed to assess the safety and tolerability of two hypercaloric diets in patients with amyotrophic lateral sclerosis receiving enteral nutrition. METHODS In this double-blind, placebo-controlled, randomised phase 2 clinical trial, we enrolled adults with amyotrophic lateral sclerosis from participating centres in the USA. Eligible participants were aged 18 years or older with no history of diabetes or liver or cardiovascular disease, and who were already receiving percutaneous enteral nutrition. We randomly assigned participants (1:1:1) using a computer-generated list of random numbers to one of three dietary interventions: replacement calories using an isocaloric tube-fed diet (control), a high-carbohydrate hypercaloric tube-fed diet (HC/HC), or a high-fat hypercaloric tube-fed diet (HF/HC). Participants received the intervention diets for 4 months and were followed up for 5 months. The primary outcomes were safety and tolerability, analysed in all patients who began their study diet. This trial is registered with ClinicalTrials.gov, number NCT00983983. FINDINGS Between Dec 14, 2009, and Nov 2, 2012, we enrolled 24 participants, of whom 20 started their study diet (six in the control group, eight in the HC/HC group, and six in the HF/HC group). One patient in the control group, one in the HC/HC group, and two in the HF/HC group withdrew consent before receiving the intervention. Participants who received the HC/HC diet had a smaller total number of adverse events than did those in the other groups (23 in the HC/HC group vs 42 in the control group vs 48 in the HF/HC group; overall, p=0.06; HC/HC vs control, p=0.06) and significantly fewer serious adverse events than did those on the control diet (none vs nine; p=0.0005). Fewer patients in the HC/HC group discontinued their study diet due to adverse events (none [0%] of eight in the HC/HC group vs three [50%] of six in the control group). During the 5 month follow-up, no deaths occurred in the nine patients assigned to the HC/HC diet compared with three deaths (43%) in the seven patients assigned to the control diet (log-rank p=0.03). Adverse events, tolerability, deaths, and disease progression did not differ significantly between the HF/HC group and the control group. INTERPRETATION Our results provide preliminary evidence that hypercaloric enteral nutrition is safe and tolerable in patients with amyotrophic lateral sclerosis, and support the study of nutritional interventions in larger randomised controlled trials at earlier stages of the disease. FUNDING Muscular Dystrophy Association, National Center for Research Resources, National Institutes of Health, and Harvard NeuroDiscovery Center.
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Affiliation(s)
- Anne-Marie Wills
- Department of Neurology and the Neurological Clinical Research Institute, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
| | - Jane Hubbard
- Harvard Catalyst/Massachusetts General Hospital Clinical Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Eric A Macklin
- Biostatistics Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Rup Tandan
- University of Vermont, Burlington, VT, USA
| | | | - Benjamin Brooks
- Carolinas Medical Center Neuromuscular/ALS-MDA Center, Charlotte, NC, USA
| | | | | | | | | | - Shafeeq S Ladha
- Barrow Neurological Institute/St Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | | | - Jonathan Katz
- California Pacific Medical Center, University of California at San Francisco, San Francisco, CA, USA
| | - Jau-Shin Lou
- Oregon Health and Science University, Portland, OR, USA
| | - Katy Mahoney
- Department of Neurology and the Neurological Clinical Research Institute, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Daniela Grasso
- Department of Neurology and the Neurological Clinical Research Institute, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Robert Lawson
- Department of Neurology and the Neurological Clinical Research Institute, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Hong Yu
- Department of Neurology and the Neurological Clinical Research Institute, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Merit Cudkowicz
- Department of Neurology and the Neurological Clinical Research Institute, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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14
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Kasarskis EJ, Mendiondo MS, Matthews DE, Mitsumoto H, Tandan R, Simmons Z, Bromberg MB, Kryscio RJ. Estimating daily energy expenditure in individuals with amyotrophic lateral sclerosis. Am J Clin Nutr 2014; 99:792-803. [PMID: 24522445 PMCID: PMC3953880 DOI: 10.3945/ajcn.113.069997] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Patients with amyotrophic lateral sclerosis (ALS) experience progressive limb weakness, muscle atrophy, and dysphagia, making them vulnerable to insufficient energy intake. Methods to estimate energy requirements have not been devised for this patient group. OBJECTIVE The goal was to develop equations to estimate energy requirements of ALS patients. DESIGN We enrolled 80 ALS participants at varying stages of their illness and studied them every 16 wk over 48 wk. At each time, we determined total daily energy expenditure (TDEE) in the home setting over a 10-d period by using the doubly labeled water method. We then developed statistical models to estimate TDEE by using factors easily obtained during a routine clinical visit. RESULTS The most practical TDEE models used the Harris-Benedict, Mifflin-St Jeor, or Owen equations to estimate resting metabolic rate (RMR) and 6 questions from the revised ALS Functional Rating Scale (ALSFRS-R) that relate to physical activity. We developed a Web-based calculator to facilitate its use. In the research setting, measuring body composition with bioelectrical impedance spectroscopy enabled the estimation of RMR with the Rosenbaum equation and the same 6 questions from the ALSFRS-R to estimate TDEE. By using these models, the estimate of TDEE for nutritional maintenance was ±500 kcal/d across the spectrum of ALS progression. CONCLUSIONS Our results emphasize the importance of physical function and body composition in estimating TDEE. Our predictive equations can serve as a basis for recommending placement of a feeding gastrostomy in ALS patients who fail to meet their energy requirements by oral intake.
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Affiliation(s)
- Edward J Kasarskis
- Department of Neurology (EJK), the Graduate Center for Nutrition (EJK), and the Graduate Center for Toxicology (EJK); the Department of Biostatistics, College of Public Health (MSM); the Sanders Brown Center on Aging (MSM and RJK); and the Department of Statistics, College of Arts and Science (RJK), University of Kentucky, Lexington, KY; Neurology Service, Lexington VA Medical Center, Lexington, KY (EJK); the Departments of Chemistry and Medicine (DEM) and Neurology (RT), University of Vermont, Burlington, VT; the Department of Neurology, Columbia University, New York, NY (HM); the Department of Neurology, Pennsylvania State University, Hershey, PA (ZS); and the Department of Neurology, University of Utah, Salt Lake City, UT (MBB)
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Lehéricey G, Le Forestier N, Dupuis L, Gonzalez-Bermejo J, Meininger V, Pradat PF. Prise en charge nutritionnelle dans la sclérose latérale amyotrophique : un enjeu médical et éthique. Presse Med 2012; 41:560-74. [DOI: 10.1016/j.lpm.2011.09.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2011] [Revised: 08/12/2011] [Accepted: 09/08/2011] [Indexed: 11/16/2022] Open
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