ALS (amyotrophic lateral sclerosis) has no cure, but treatment today combines medications that slow the disease, therapies that manage specific symptoms, and supportive care that can meaningfully extend both survival and quality of life. The approach is broad because ALS affects so many body systems: movement, breathing, swallowing, speech, and sometimes emotions. Here’s what each layer of treatment involves and what it actually does.
Medications That Slow Progression
Riluzole was the first drug approved for ALS and remains a standard part of treatment. It works by reducing the activity of a chemical messenger called glutamate, which in excess can damage motor neurons. Taken as a pill twice daily, riluzole extends median survival by roughly two to three months and increases the chance of living an additional year by about 9%. That may sound modest, but across a large population of patients it represents a consistent, measurable benefit, and it’s typically started soon after diagnosis.
Edaravone (sold as Radicava) takes a different approach, acting as an antioxidant to reduce cellular damage. The original formulation requires intravenous infusions on a cycling schedule: daily infusions for 14 consecutive days in the first month, then 10 infusion days per month afterward, each cycle followed by a two-week break. An oral suspension is also available now. In its pivotal trial, patients on edaravone lost about 2.5 fewer points on a 48-point functional scale over six months compared to placebo. That translates to a slower decline in everyday abilities like writing, dressing, and climbing stairs.
Gene-Targeted Therapy for SOD1 Mutations
A small percentage of ALS cases are caused by mutations in a gene called SOD1. For those patients, tofersen (Qalsody) is the first gene-targeted treatment. It’s delivered by spinal injection and works by reducing levels of the toxic protein the mutated gene produces. In its clinical trial, tofersen lowered the SOD1 protein in spinal fluid substantially, though the primary measure of functional decline at 28 weeks did not reach statistical significance. Longer-term data from the open-label extension were more encouraging, which is why the FDA granted accelerated approval. Genetic testing is required to confirm a SOD1 mutation before this treatment can be prescribed, so if you have a family history of ALS, ask about testing early.
Breathing Support
Respiratory care is one of the most impactful parts of ALS treatment. As the muscles involved in breathing weaken, a device called BiPAP (bilevel positive airway pressure) helps by pushing air into the lungs with gentle pressure. It’s typically introduced when lung function tests drop below 50% of predicted capacity, or when you notice new breathlessness that regularly disrupts sleep or daily activity.
The survival benefit is striking. In one large study, people who used BiPAP lived a median of 21 months after diagnosis compared to about 14 months for those who didn’t, an increase of roughly 8 months, or 52%. Beyond survival, BiPAP improves sleep quality, reduces morning headaches caused by carbon dioxide buildup, and helps maintain energy during the day. Most people start using it at night and gradually increase use as needed.
When non-invasive ventilation is no longer sufficient, some patients choose invasive ventilation through a tracheostomy. This is a deeply personal decision that involves weighing extended survival against the level of care required, and it’s best discussed with your care team well before it becomes urgent.
Nutritional Support and Feeding Tubes
Swallowing difficulty is common as ALS progresses, leading to weight loss, dehydration, and the risk of food entering the lungs. A feeding tube placed through the abdomen (called a PEG tube) can maintain nutrition safely. Both the American Academy of Neurology and the European Federation of Neurological Societies recommend considering PEG placement after more than 10% body weight loss and before lung capacity drops below 50%. Timing matters because the procedure is safer when breathing muscles are still relatively strong. A PEG tube doesn’t prevent you from eating by mouth if you’re still able to swallow some foods safely. It serves as a reliable backup to keep weight and hydration stable.
Managing Muscle Cramps and Spasticity
Painful muscle cramps and stiffness are among the most common daily complaints in ALS. Baclofen and gabapentin are widely prescribed, with surveys of ALS specialists showing these are the two most frequently used medications for cramps and spasticity. However, neither has strong clinical trial evidence specifically in ALS. Mexiletine, taken at 150 mg twice daily, is the only medication shown in a placebo-controlled trial to reduce both the frequency and severity of muscle cramps in ALS. It worked within the first two weeks of treatment and was generally well tolerated. Physical therapy and stretching also help manage stiffness and maintain range of motion for as long as possible.
Treating Excess Saliva
When swallowing weakens, saliva pools in the mouth, creating drooling that can be both uncomfortable and socially distressing. First-line treatments are medications that reduce saliva production: scopolamine patches, sublingual atropine drops, amitriptyline, and glycopyrrolate. Scopolamine patches are effective in about 85% of people treated. When these medications aren’t enough, botulinum toxin injections into the salivary glands offer a more targeted option. Injections into the parotid glands reduce drooling and improve quality of life for up to four months per treatment session, with noticeable improvement within a week.
Involuntary Laughing or Crying
Up to half of people with ALS experience pseudobulbar affect, episodes of laughing or crying that are sudden, exaggerated, and disconnected from how they actually feel. It’s caused by damage to the brain circuits that regulate emotional expression, not by depression. Nuedexta (a combination of dextromethorphan and quinidine) is the only FDA-approved treatment for this condition in ALS. In clinical trials, it reduced the rate of laughing and crying episodes by about 47 to 49% compared to placebo. For many people, controlling these episodes makes a significant difference in social comfort and relationships.
Communication Technology
As speech becomes harder, assistive communication devices help maintain the ability to express thoughts and needs. Early on, simple tools like alphabet boards or speech-amplifying apps on a phone or tablet may be enough. As motor function declines further, eye-tracking systems become essential. These devices use cameras to follow eye movements across a screen, letting you select letters, words, or phrases just by looking at them. Eye-gaze and eye-tracking approaches together account for the majority of high-tech communication solutions studied for ALS. Some systems combine multiple input methods (eye blinks, head movements, and gaze tracking) to improve accuracy. Working with a speech-language pathologist early helps you learn the technology while communication is still relatively easy, making the transition smoother later.
Why Multidisciplinary Clinics Matter
Where you receive care can be just as important as which treatments you use. Specialized ALS clinics bring together neurologists, respiratory therapists, physical and occupational therapists, speech-language pathologists, dietitians, and social workers in a single coordinated visit. A population-based study found that patients treated at a multidisciplinary ALS clinic survived a median of 7.5 months longer than those seen in general neurology settings. One-year mortality dropped by nearly 30%. The benefit was even larger for people with bulbar-onset ALS (the type that first affects speech and swallowing), who gained an average of 9.6 months of survival through clinic-based care.
The advantage comes from catching problems earlier. A respiratory therapist notices declining lung function before you feel short of breath. A dietitian flags weight loss before it becomes dangerous. A speech therapist introduces communication tools before you’ve lost the ability to speak. Each intervention builds on the others, and the cumulative effect is substantial.