What are the alternatives to Riluzole (Rilutek) for treating Amyotrophic Lateral Sclerosis (ALS)?

Alternatives to Riluzole for ALS Treatment

Edaravone (intravenous) is the primary FDA-approved alternative to riluzole for treating ALS, and these two medications can be used in combination to potentially maximize disease-modifying effects. 1

Current FDA-Approved Disease-Modifying Therapies

• Edaravone is administered intravenously and has been shown to halt the progression of ALS in clinical studies, representing the only other FDA-approved disease-modifying treatment besides riluzole 1

• Riluzole remains the gold standard despite newer approvals, as it was the first FDA-approved drug for ALS in 1995 and continues to be the foundational therapy 2, 3

Combination Therapy Approach

• Both riluzole and edaravone can be used together, as they work through different mechanisms—riluzole blocks glutamatergic neurotransmission while edaravone provides antioxidant neuroprotection 1, 3

• Real-world evidence suggests riluzole extends survival by 6-19 months (substantially more than the 2-3 months shown in randomized trials), making it difficult to justify complete discontinuation even when adding alternatives 2, 4

Alternative Riluzole Formulations for Dysphagia

If the issue is tolerability or administration difficulty rather than seeking a different drug class:

• Riluzole oral suspension (ROS) allows administration in patients with dysphagia and can be used through percutaneous endoscopic gastrostomy tubes 2

• Riluzole oral film (ROF) requires minimal swallowing capacity and is bioequivalent to tablets, offering an option when tablets become inadequate 2

• Avoid crushing tablets, as this leads to drug loss and aspiration risk, jeopardizing riluzole's survival benefits 2

Critical Limitations to Understand

• Modest efficacy is inherent to ALS treatment—riluzole prolongs tracheostomy-free survival by only 2-3 months in controlled trials, though real-world data suggests greater benefit 3, 5, 4

• No alternative offers dramatic improvement over riluzole's modest disease modification; ALS remains a fatal disease with 2-5 year survival from symptom onset regardless of treatment 1, 3

• Edaravone requires intravenous administration, which presents logistical challenges compared to oral riluzole 1

Safety Monitoring for Riluzole

• Monitor liver enzymes regularly, as 10% of patients develop transaminase elevation (typically a threefold increase in ALT), though this is usually manageable 2, 5

• Gastrointestinal side effects are the main limiting adverse effects but are generally non-severe 2