413 - Negative Impact of Atropine in Amyotrophic Lateral Sclerosis - Provider Be Aware: A Case Report

Case Diagnosis: Amyotrophic Lateral Sclerosis

Case Description: A 51-year-old male with newly diagnosed Amyotrophic Lateral Sclerosis (ALS), Hypertension and Post-Traumatic Stress Disorder was transferred to the spinal cord injury (SCI) unit for management and to assist with disposition. He was diagnosed with ALS based on El Escorial and Awaji electrodiagnostic criteria. He was started on riluzole and was treated by SCI for his ambulation impairments and inability to perform daily activities. He was started on sublingual atropine for sialorrhea with clinical improvement. Consequently, his bowel movements became composed primarily of mucous, with episodes of nausea, and increasing abdominal distention. Abdominal X-rays revealed constipation. He received oral bowel medications and intermittent placement of a rectal tube without significant improvement. CT scan of the abdomen revealed a mild small bowel ileus with no evidence of obstruction. Given its anticholinergic side effects, atropine was discontinued. Follow up abdominal X Rays showed improvement of his abdominal distension and his symptoms improved.

Discussions: Sialorrhea in ALS is due to tongue muscular spasticity and failure to control the orofacial and palatine-lingual muscles rather than an excess of saliva production. Progressive sialorrhea can increase the risk of aspiration syndromes, as well as significantly decrease quality of life, thus should be managed. Anticholinergic drugs are considered first line in the treatment of sialorrhea. However, as described here, their side effects including decreased gastrointestinal motility must be taken into consideration when used in patient populations at risk of neurogenic bowel.

Conclusions: Gastrointestinal side effects while on anticholinergics for sialorrhea warrant close monitoring of symptoms and serial examinations to determine whether to discontinue. Other treatments for sialorrhea in the ALS population to be considered include botulinum toxin and salivary gland irradiation.