How is pain managed in amyotrophic lateral sclerosis (ALS)?

Updated: Jan 02, 2020
  • Author: Divakara Kedlaya, MBBS; Chief Editor: Ryan O Stephenson, DO  more...
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Answer

Answer

Pain is quite common in patients with ALS; its prevalence is reported to be 67% in one population-based controlled study [26] and 72 % in another cross-sectional study. [27] Its occurrence is directly proportional to disease progression. [28] Pain can occur for many reasons, but in these patients, it is usually musculoskeletal in origin. Pain may be caused by muscle spasms, contractures, or altered joint biomechanics. Involvement of either peripheral or central sensory mechanisms in ALS causing pain is still under debate. [29]

First-line treatment for pain is with nonsteroidal anti-inflammatory drugs (NSAIDs). If the patient is intolerant to these medications, use acetaminophen. Muscle cramps occur frequently. Traditional treatment was with quinine, but this drug is no longer recommended because of its adverse effect profile. NSAIDs and acetaminophen may provide some benefit. Antispasticity medications discussed above are recommended for treatment of pain due to muscle spasm and spasticity and usually are effective.

In some instances, pain may be neuropathic in origin, and anticonvulsant medications such as gabapentin and pregabalin may be beneficial. Tricyclic antidepressants such as nortriptyline and serotonin norepinephrine reuptake inhibitors (SNRIs) such as duloxetine also are indicated for this type of pain.

For severe pain unresponsive to the above treatments, opioid pain medications are indicated. Use them with caution owing to their multiple adverse effects; they too can cause respiratory depression, especially at higher doses.


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