Safety and efficacy profile of a 90-day oral L-arginine hydrochloride intervention for patients with amyotrophic lateral sclerosis

Safety and efficacy profile of a 90-day oral L-arginine hydrochloride intervention for patients with amyotrophic lateral sclerosis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Safety and efficacy profile of a 90-day oral L-arginine hydrochloride intervention for patients with amyotrophic lateral sclerosis Hiroyuki Naito, Masahiro Nakamori, Megumi Toko, Yuki Hayashi, and 6 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4788914/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 07 Jan, 2025 Read the published version in Scientific Reports → Version 1 posted 16 You are reading this latest preprint version Abstract Weight loss, a key indicator of malnutrition in amyotrophic lateral sclerosis (ALS) patients, negatively impacts prognosis. However, effective nutritional interventions have not been adequately established. Previous research in ALS model mice has shown that L-arginine can prolong survival, yet no human intervention studies have been conducted. This study aimed to assess the safety, tolerability, and efficacy of L-arginine hydrochloride in ALS patients. ALS patients were administered 15 g/day L-arginine hydrochloride for 90 days. Safety was primarily evaluated on days 45 and 90. Efficacy measures included changes in nutritional status, ALS Functional Rating Scale scores, and the occurrence of events such as the initiation of tracheostomy positive pressure ventilation (TPPV) and death. The study included 20 patients (40% female; mean age, 62.0 ± 6.9 years; median disease duration, 1.9 years). Six participants (30%) experienced treatment-emergent adverse events (TEAEs), including elevated creatine kinase levels, liver function test abnormalities, glucose tolerance issues, hyperammonemia, anorexia, dysgeusia, and vasculitis. No serious TEAEs were associated with L-arginine hydrochloride. Over the course of three months, the average changes in body weight and body mass index (BMI) were − 0.37 kg and − 1.1 kg/m 2 , respectively, which are less than the typically observed natural reduction rates. There were no events requiring TPPV initiation or deaths. This study demonstrated that the oral administration of L-arginine hydrochloride across three months was well tolerated by ALS patients, with no serious TEAEs or deaths attributed to the study drug. Trial Registration number : Japan Registry of Clinical Trials (jRCTs061230001), first registered 11/04/2023 Health sciences/Health care Health sciences/Neurology Amyotrophic lateral sclerosis L-arginine hydrochloride nutrition body weight body mass index Figures Figure 1 Introduction Amyotrophic lateral sclerosis (ALS) is a progressive, fatal neurodegenerative disorder for which there is no effective cure. Moreover, malnutrition significantly impacts the prognosis and overall outcomes of this disease and worsens quality of life. Hence, the thorough assessment and appropriate management of nutritional status are critical components of ALS care. Despite extensive research, effective nutritional interventions have yet to be established. Most trials have focused predominantly on high-calorie, high-fat diets. Studies in ALS mouse models have reported that the administration of a high-calorie, high-fat diet leads to weight gain and disease progression inhibition 1 , contributing to prolonged survival 2 . However, clinical studies in humans, including one in which a high-calorie, high-fat diet (405 kcal/day, 45 g fat) was administered to ALS patients, did not show a survival advantage over a placebo 3 . These findings indicate that high-calorie, high-fat diets may not exert disease-modifying effects on ALS, highlighting the necessity of investigating alternative nutritional strategies. In ALS, one of the mechanisms contributing to motor neuron cell death is believed to be excessive activation of glutamate receptors due to abnormalities in amino acid metabolism. Riluzole, a drug that inhibits glutamate release, exemplifies the critical link between amino acid metabolism and ALS pathophysiology. It is postulated that L-arginine confers neuroprotection to motor neurons against glutamate toxicity and is a potential therapeutic target for ALS. Additionally, L-arginine is thought to enhance skeletal muscle glucose metabolism and sustain muscle energy production, which may protect against ALS progression. In vitro studies using mature C2C12 myotubes have demonstrated that L-arginine can protect against skeletal muscle cell atrophy through the activation of the mechanistic target of rapamycin complex 1 and enhanced synthesis of skeletal muscle proteins 4 . Observations indicate that serum L-arginine levels are typically low in ALS patients 5 , which is correlated with the malnutrition often observed in this population. Preclinical trials involving presymptomatic mtSOD1(G93A) mice, an animal model of ALS, have shown that administering L-arginine delays the onset of motor symptoms and prolongs survival 6 . Moreover, nitric oxide synthase (NOS), which is implicated in motor neuron degeneration in ALS models, was found to be downregulated following L-arginine supplementation in G93A ALS mice, underscoring its neuroprotective effects 7 . Despite these promising preclinical findings, clinical studies investigating L-arginine supplementation in ALS patients are lacking. To address this gap, we conducted a prospective clinical trial to evaluate the safety and efficacy of oral L-arginine supplementation in ALS patients. Results Background characteristics From May 2023 to October 2023, a total of 29 patients were screened for this study, 20 of whom were enrolled and received oral L-arginine hydrochloride. Six patients did not meet the inclusion criteria, and three did not provide consent. All 20 patients completed 45 days of intervention, and 19 completed 90 days, reflecting a discontinuation rate of 5% (Fig.1). One participant discontinued the study on day 75 due to the progression of ALS-related symptoms. Clinical and demographic data are presented in Table 1. The majority of patients (75%) were concurrently using riluzole, and most had not yet undergone PEG or received NPPV. Safety assessments During the study period, 4 patients (25%) experienced TEAEs within the first 45 days, and 6 patients (31.6%) experienced TEAEs within 90 days (Table 2). By day 45, the reported TEAEs included elevated creatinine kinase (CK) levels in 3 patients (CK level of 900, 350, and 648 U/L, respectively) and anorexia in 1 patient. By the end of the 90-day intervention, the reported TEAEs were elevated CK levels in 2 patients (384 and 584 U/L); liver function test abnormalities, including elevated aspartate aminotransferase (AST) and γ-glutamyl transpeptidase (γ-GTP) levels, in 1 patient (AST level of 123 U/L, γ-GTP level of 545 U/L); glucose tolerance abnormalities in 1 patient (fasting blood glucose level of 173 mg/dL and hemoglobin A1c level of 6.6%); hyperammonemia in 1 patient (ammonia level of 70 μg/dL); dysgeusia in 1 patient; and vasculitis in 1 patient. The investigator considered anorexia and dysgeusia to be related to the study drug. No AEs were severe, and there were no instances of study discontinuation or deaths due to AEs. Regarding clinical events, there was one instance where NPPV was initiated during the study. However, there were no cases of pneumonia, gastrostomy tube placement, TPPV initiation, or death. For the administration of L-arginine hydrochloride, the median number of missed doses was 1 (range: 0-43), with an adherence rate of 99.7%. Effect of L-arginine on clinical outcomes From the initiation of L-arginine hydrochloride administration to the end of the study, the average change in body weight was -0.37 kg, and the average change in BMI was -0.11 kg/m², which are less than the typically observed natural reduction rates. There were 12 patients (63.2%) in whom body weight was maintained or increased. The average change in muscle mass was -0.38 kg, while the average change in body fat mass was an increase of +0.17 kg. The MNA total score increased by 0.5 points on average. The ALSFRS-R score decreased by -1.7 points on average. Changes in muscle mass, fat mass, and MNA score were significantly correlated with changes in body weight (muscle mass, p =0.036; body fat mass, p =0.016; MNA score, p =0.033). No significant associations were found between the weight maintenance and weight loss groups regarding baseline data, changes in the ALSFRS-R score, body composition, or nutritional assessment (Table 3). Although no significant differences in baseline plasma or urinary arginine levels were detected between the groups, the proportions of individuals with high plasma and urinary arginine levels at 90 days after the start of the intervention and the urinary arginine ratio (day 90/baseline) were significantly greater in the weight maintenance group than in the weight loss group. Additionally, the urinary arginine ratio (day 45/baseline) was significantly greater in the weight maintenance group ( p =0.048). There were no significant differences in the frequency of events or TEAEs between the groups. Discussion In this study, we investigated the safety of L-arginine hydrochloride administered orally over a 90-day period in patients with ALS and explored its effects on nutritional status. L-arginine hydrochloride was generally well tolerated, as evidenced by a low rate of study discontinuation and high medication adherence, with no treatment-related serious AEs or deaths reported. Additionally, changes in body weight, an indicator of nutritional status in ALS patients, were found to correlate with the administration of L-arginine hydrochloride. Regarding the use of oral L-arginine formulations that combine L-arginine and L-arginine hydrochloride, AEs such as liver function abnormalities, nausea, vomiting, and diarrhea have been reported 8 . Additionally, arginine hydrochloride loading has been linked to renal dysfunction and glucose tolerance abnormalities. In this study, the reported TEAEs included elevated CK levels, liver function test abnormalities, glucose tolerance abnormalities, hyperammonemia, taste alterations, appetite loss, and vasculitis. Elevated CK levels were associated with the progression of ALS, while liver function test abnormalities and glucose tolerance abnormalities were related to comorbid conditions (alcoholic liver injury and type 2 diabetes, respectively). Given that L-arginine is used to treat hyperammonemia in patients with urea cycle disorders 9 , the occurrence of hyperammonemia in this study was considered unrelated to L-arginine hydrochloride administration. In previous safety studies in healthy individuals, L-arginine hydrochloride was administered at dosages of 0, 15, and 30 g/day, with safety confirmed up to 30 g/day 10 . However, considering the substantial load at 30 g/day, a dosage of 15 g/day was selected for this study. No serious AEs or deaths occurred during the study. One patient discontinued treatment due to ALS progression, and the study confirmed good tolerability given the high medication adherence rate. Weight loss, which is recognized as a marker of malnutrition in individuals with ALS, has been identified as a poor prognostic factor and is utilized for the longitudinal assessment of nutrition. In Japan, a prediagnosis rate of BMI reduction of 2-2.5 kg/m 2 /year has been reported as an indicator of poor prognosis 11,12 . Additionally, a decrease in BMI of 1.7 kg/m 2 /year or more from diagnosis to tracheostomy has been associated with poorer functional prognosis post-TPPV 13 . In ALS patients, weight loss is often driven by a combination of factors such as skeletal muscle atrophy, decreased fat mass, and increased respiratory muscle energy demands 14 , suggesting that BMI maintenance could improve life expectancy. In this study, three months of L-arginine administration in ALS patients who did not require TPPV resulted in a modest decrease in BMI of 0.11 kg/m 2 and a decrease in body weight of 0.37 kg. Previous studies have indicated that ALS patients typically experience monthly changes, with a decrease in BMI of -0.13 kg/m 2 and a weight loss of -0.28 kg 15 . Therefore, our findings suggest that the patients’ body weights were relatively maintained. Moreover, in the group that maintained body weight, the serum and urine L-arginine ratios were significantly greater than those in the group that lost weight, indicating the potential role of arginine in weight maintenance. L-arginine is known to improve skeletal muscle glucose metabolism 4 and protect motor neurons against glutamate toxicity through nitric oxide (NO) synthesis 7 . Recent studies have also used L-arginine in animal models of spinocerebellar ataxia and spinal muscular atrophy, in which polyglutamine aggregate formation was inhibited and motor symptoms were improved 16 . Additionally, arginine has been shown to inhibit abnormal aggregation of the RNA-binding Protein Fused in Sarcoma, which is implicated in ALS pathogenesis 17 , making it a promising target for ALS treatment. In this study, the ALSFRS-R score decreased by an average of 1.7 points over three months of L-arginine administration. Importantly, there were no deaths or new initiations of TPPV during the trial period. This study has several limitations. First, this was a single-site, single-group intervention trial that represents the first investigation into the safety of L-arginine hydrochloride in patients with ALS. As an exploratory trial aimed at examining the potential benefits of L-arginine hydrochloride for improving nutritional status and outcomes in ALS patients, no control group was established, and the study design involved a pre- and postintervention comparison within the same group. Future studies should consider employing randomized controlled trials, including a nonintervention group, to facilitate intergroup comparisons. Second, the limited number of participants represents a challenge. This study primarily focused on the safety of L-arginine hydrochloride; therefore, the sample size was determined based on the incidence rate of AEs related to L-arginine hydrochloride reported in clinical trials regarding its approval and postmarketing surveillance, as well as accounting for potential dropouts. Third, the study excluded patients who used TPPV and thus did not include those with advanced ALS. ALS is characterized by weight loss due to hypermetabolism in the early stages, but after the initiation of TPPV, metabolic changes often lead to weight gain 18 , necessitating different nutritional interventions. Comprehensive examination and analysis of the diverse clinical courses of ALS patients requires the inclusion of a greater number of patients. Therefore, the recruitment of a greater number of patients is necessary for future research. In conclusion, this study demonstrated that oral L-arginine hydrochloride administered over the course of 90 days was well tolerated, with no serious TEAEs or deaths related to the intervention. In ALS patients who received L-arginine hydrochloride, the maintenance of body weight—an indicator of nutritional status—was observed throughout the intervention period. This maintenance was suggested to correlate with the concentrations of L-arginine hydrochloride in the blood and urine. Clinically, randomized controlled trials comparing the treatment to placebos, as well as biological validation in basic experiments, are needed in the future. Methods Study design and protocol This study employed a single-arm, open-label comparative design to evaluate the effects of L-arginine hydrochloride supplementation (before and after treatment). The study was conducted at Hiroshima University Hospital and targeted ALS patients aged 18 years or older who met the Gold Coast criteria 19 and were capable of being observed for a minimum of three months. The exclusion criteria included patients with contraindications for arginine formulations, such as arginase deficiency or lysinuric protein intolerance; patients who were already on arginine formulations; patients who were using ventilators; and patients who were scheduled for surgery at the time of study registration. The primary endpoints were the safety and tolerability of oral L-arginine hydrochloride. Safety assessments included adverse events (AEs) such as any events occurring during the clinical trial period, total treatment-emergent adverse events (TEAEs) during the L-arginine hydrochloride administration period, serious TEAEs, TEAEs leading to death, TEAEs leading to the discontinuation of L-arginine hydrochloride, and TEAEs related to L-arginine hydrochloride (side effects). Patients were evaluated at 45 days (± 14 days) and 90 days (± 14 days) following the initiation of the treatment. The safety analysis population included all enrolled patients who received at least one dose of L-arginine hydrochloride. Tolerability was determined based on the incidence of AEs and the proportion of patients who discontinued the study drug due to TEAEs. As a secondary endpoint, efficacy was assessed by evaluating changes in nutritional status and outcomes in ALS patients. Nutritional status was assessed at baseline and after three months of treatment by measuring changes in body weight, body mass index (BMI), body fat mass, Mini Nutritional Assessment (MNA) scores 20 , the resting metabolic rate (RMR) calculated using the Harris-Benedict Eq. 2 1 , and the total energy expenditure (TEE) derived from the Shimizu formula 22 . Outcomes were evaluated using the revised ALS Functional Rating Scale (ALSFRS-R) 21 , and ALS-related events, including percutaneous endoscopic gastrostomy (PEG), pneumonia, noninvasive positive pressure ventilation (NPPV), tracheostomy positive pressure ventilation (TPPV), and death, were monitored. Ethics statement This study received ethical approval from the Certified Review Board at Hiroshima University, Hiroshima, Japan (approval ID: CRB2022-0013-01) and conformed to directives from the federal government in accordance with the ethical principles outlined in the 1964 Declaration of Helsinki. The trial is registered in the jRCT database (trail registration number: jRCTs061230001, first registerd 11/04/2023). The recruitment period from this study was from April 11, 2023 to November 30, 2023. Comprehensive written informed consent was obtained from all participants prior to their inclusion in the study. L-arginine intervention Patients received oral L-arginine hydrochloride (Ajinomoto Co., Inc., Tokyo, Japan) at a dose of 15 grams per day for 90 days. Two packets were dissolved in water and administered orally following breakfast and dinner. Patients who were capable of oral intake consumed oral L-arginine hydrochloride directly, while those receiving enteral nutrition received it through the enteral feeding route. Adherence to the treatment regimen was monitored using a medication diary. Data acquisition Clinical evaluation and diagnosis were conducted by three neurologists (HN, MN, and MT). The recorded data included age, sex, weight, BMI, muscle mass, body fat mass, time of symptom onset and current neurological symptoms, disease duration, weekly alcohol consumption, smoking habits, ALSFRS-R scores, MNA scores, current medications, and blood and urine test results. Physical measurements, physical examinations, and nutritional assessments, along with blood and urine tests, were performed at baseline, 45 days after treatment (± 14 days), 90 days after treatment (at completion) or at the time of discontinuation (± 14 days). Sample size Based on the frequency of AEs observed in clinical trials and postmarketing surveillance of arginine formulations (5 out of 40 cases and 18 out of 222 cases, respectively), the incidence rate of AEs associated with L-arginine hydrochloride was estimated to be 8.7%. To calculate the number of patients needed where the probability of observing no events, given the assumed rate of 8.7%, was less than 20%, a minimum of 18 patients was needed. Considering an anticipated dropout rate of approximately 10%, the target sample size for this study was 20 patients. Statistical analysis Categorical variables are presented as numbers and percentages, while continuous variables are presented as the means with standard deviations (SDs) or medians (minimum, maximum). The safety of L-arginine hydrochloride was evaluated using descriptive statistics, which included the number and incidence of AEs during the administration period, the detailed breakdown of each AE, and AE severity. To assess the efficacy of L-arginine hydrochloride, we compared the nutritional status and outcomes of each patient before the intervention with those recorded 90 days after the start of the intervention or at the time of discontinuation. Furthermore, we conducted statistical comparisons between groups in which body weight was maintained or increased postintervention and those in which body weight decreased. Appropriate statistical tests, such as the χ 2 test, Mann–Whitney U test, or unpaired t test, were utilized to evaluate differences between groups. A p value less than 0.05 was considered to indicate statistical significance. All analyses were conducted using JMP 17.0 software (SAS Institute, Inc., Cary, NC). Declarations Conflicts of interest MN received honoraria from Eisai. HM received honoraria from Eisai, Shionogi, Otsuka Pharmaceutical, and Sumitomo Pharma. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as potential conflicts of interest. Funding The author(s) declare that financial support was received for the research, authorship, and/or publication of this article. HN received funding from Grants-in-Aid for Scientific Research Author Contribution HN: Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Validation, Writing—original draft. MN: Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Validation, Writing—original draft. MT: Conceptualization, Data curation, Investigation, Methodology, Validation, Writing—original draft. YH: Data curation, Writing—original draft. TT: Conceptualization, Methodology. TW: Conceptualization, Methodology. KI: Data curation. KT: Data curation. YY: Conceptualization, Supervision, Writing—review & editing. HM: Conceptualization, Supervision, Validation, Writing—review & editing. Acknowledgement We thank the Clinical Research Center in Hiroshima at the Hiroshima University Hospital for their assistance. Data Availability The datasets used and/or analyzed during the current study are available from the first author upon reasonable request. References Dupuis, L. et al . Evidence for defective energy homeostasis in amyotrophic lateral sclerosis: benefit of a high-energy diet in a transgenic mouse model. Proc Natl Acad Sci U S A 101, 11159–11164. https://doi.org/10.1073/pnas.0402026101 (2004). Coughlan, K. S., Halang, L., Woods, I. & Prehn, J. H. A high-fat jelly diet restores bioenergetic balance and extends lifespan in the presence of motor dysfunction and lumbar spinal cord motor neuron loss in TDP-43A315T mutant C57BL6/J mice. Dis Model Mech 9, 1029–1037. https://doi.org/10.1242/dmm.024786 (2016). Ludolph, A. C. et al . Effect of High-Caloric Nutrition on Survival in Amyotrophic Lateral Sclerosis. Ann Neurol 87, 206–216. https://doi.org/10.1002/ana.25661 (2020). Ham, D. J., Caldow, M. K., Lynch, G. S. & Koopman, R. 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The measurement and estimation of total energy expenditure in Japanese patients with ALS: a doubly labelled water method study. Amyotroph Lateral Scler Frontotemporal Degener 18, 37–45. https://doi.org/10.1080/21678421.2016.1245756 (2017). Tables Table 1. Patient background information N=20 Age, years 662.0±6.9 Sex (female), n (%) 8 (40.0) Disease duration, years 1.9 (0.4, 4.8) Initial symptom, n (%) Bulbar onset 5 (25.0) Limb onset 14 (70.0) Respiratory failure 1 (5.0) ALSFRS-R score 38.4±6.5 Body weight, kg 59.7±12.5 Body mass index, kg/m 2 22.3±3.4 Soft lean mass, kg 40.1±10.0 Body fat mass, kg 17.0±5.0 MNA score 23.1±4.5 mREE, kcal 1294±221 TEE, kcal 1934±396 Plasma amino acids (arginine), nmol/ml 73.2±17.4 Urine amino acids (arginine), μmol/g・cre 20.0±15.3 Concomitant use of riluzole, n (%) 15 (75.0) Concomitant use of edaravone, n (%) 6 (30.0) PEG, n (%) 1 (5.0) NPPV, n (%) 1 (5.0) Abbreviations: ALSFRS-R, revised ALS Functional Rating Scale; MNA, Mini Nutritional Assessment; mREE, measured resting energy expenditure; TEE, total energy expenditure; PEG, percutaneous endoscopic gastrostomy; NPPV, noninvasive positive pressure ventilation. The data are expressed as the mean ± standard deviation or median (minimum, maximum) for continuous variables and as frequencies and percentages for discrete variables. Table 2. TEAEs, events, and compliance rates at 90 days or until discontinuation TEAE N = 20 Any TEAEs, n (%) 6 (30) Elevated creatinine kinase levels, n (%) 3 (15) Liver function test abnormalities, n (%) 1 (5) Glucose tolerance abnormalities, n (%) 1 (5) Hyperammonemia, n (%) 1 (5) Anorexia, n (%) 1 (5) Dysgeusia, n (%) 1 (5) Vasculitis, n (%) 1 (5) Event Pneumonia, n (%) 0 PEG, n (%) 0 NPPV, n (%) 1 (5) TPPV, n (%) 0 Death, n (%) 0 Medication intake Number of missed medication doses 1 (0, 43) Adherence rate (%) 99.7 (76.1, 100) Abbreviations: TEAE, treatment-emergent adverse event; PEG, percutaneous endoscopic gastrostomy; NPPV, noninvasive positive pressure ventilation; TPPV, tracheostomy positive pressure ventilation. Data are expressed as the mean ± standard deviation or median (minimum, maximum) for continuous variables and as frequencies and percentages for discrete variables. Table 3. Comparison between patients who maintained weight and those who experienced weight loss during L-arginine hydrochloride administration Weight maintenance (n = 7) Weight loss (n = 12) p value Age, years 62.6 ± 2.5 60.6 ± 1.9 0.534 Sex (female), n (%) 3 (42.9) 4 (33.3) 0.679 Disease duration, years 2.7 (0.8, 4.4) 1.3 (0.4, 4.8) 0.118 ALSFRS-R score 41.3 ± 4.2 37.9 ± 6.0 0.212 ΔALSFRS-R score 0 (-4, 2) 1 (-11, 1) 0.340 ΔBody mass index, kg/m 2 0.8 ± 0.7 -0.7 ± 0.5 <0.001* ΔSoft lean mass, kg 1.0 ± 2.7 -1.2 ± 1.8 0.054 ΔBody fat mass, kg 1.3 ± 3.0 -0.5 ± 2.3 0.147 ΔMNA score 1.9 ± 1.9 -0.3 ± 4.9 0.294 Plasma arginine at baseline, nmol/ml 82.5 ± 10.9 70.2 ± 17.5 0.114 Elevated plasma arginine level on day 90, n (%) 4 (57.1) 1 (8.3) 0.020* Plasma Arginine Ratio (Day 90/baseline) 2.3 ± 1.3 1.4 ± 0.6 0.051 Urinary arginine at baseline, μmol/g・cre 21.3 ± 12.2 19.5 ± 17.9 0.813 Elevated urinary arginine level on day 90, n (%) 4 (57.1) 1 (8.3) 0.020* Urinary Arginine Ratio (Day 90/baseline) 11.5 ± 11.9 2.4 ± 2.8 0.019* ALS-related events during the intervention period, n (%) 0 1 (8.3) 0.433 Any TEAEs, n (%) 3 (42.9) 3 (25) 0.423 Abbreviations: ALSFRS-R, revised ALS Functional Rating Scale; MNA, Mini Nutritional Assessment; TEAE, treatment emergent adverse event. Data are expressed as the mean ± standard deviation or median (minimum, maximum) for continuous variables and as frequencies and percentages for discrete variables. * p <0.05 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 07 Jan, 2025 Read the published version in Scientific Reports → Version 1 posted Editorial decision: Revision requested 01 Oct, 2024 Reviews received at journal 01 Oct, 2024 Reviews received at journal 18 Sep, 2024 Reviews received at journal 14 Sep, 2024 Reviewers agreed at journal 08 Sep, 2024 Reviewers agreed at journal 04 Sep, 2024 Reviewers agreed at journal 02 Sep, 2024 Reviews received at journal 18 Aug, 2024 Reviewers agreed at journal 06 Aug, 2024 Reviewers agreed at journal 06 Aug, 2024 Reviewers agreed at journal 06 Aug, 2024 Reviewers invited by journal 04 Aug, 2024 Editor assigned by journal 02 Aug, 2024 Editor invited by journal 29 Jul, 2024 Submission checks completed at journal 27 Jul, 2024 First submitted to journal 23 Jul, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4788914","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":343437669,"identity":"cce6579f-3296-415b-9131-58bd1121f98d","order_by":0,"name":"Hiroyuki Naito","email":"","orcid":"","institution":"Hiroshima University","correspondingAuthor":false,"prefix":"","firstName":"Hiroyuki","middleName":"","lastName":"Naito","suffix":""},{"id":343437670,"identity":"8cd2d471-acf9-4cde-b656-8c5afde8f447","order_by":1,"name":"Masahiro Nakamori","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA0ElEQVRIiWNgGAWjYHACZjDJxsx8AEhJyJCghZ0tAaSFh3gtDPw8BiCKsBbd2c2PDX7m2OTzMfN8fnWjxoKHgf3w0Q34tJjdOWac2LstzbKNmXebdc4xoMN40tJu4NVyI8H4AO+2wwZsQC3GOWxALRI8ZgS0pH8++BesheeZcc4/orTkGCdDbOFhfpzbRpyWYmPZbWlALWxmzLl9EjxshP2Svlny7TYbA/n+w48/53yrk+NnP3wMrxZkwCYBJolVDgLMH0hRPQpGwSgYBSMHAAAljECApRQM+AAAAABJRU5ErkJggg==","orcid":"","institution":"Hiroshima University","correspondingAuthor":true,"prefix":"","firstName":"Masahiro","middleName":"","lastName":"Nakamori","suffix":""},{"id":343437671,"identity":"ff5cfb59-8adb-400d-a5c5-806bc0d20bd1","order_by":2,"name":"Megumi Toko","email":"","orcid":"","institution":"Hiroshima University","correspondingAuthor":false,"prefix":"","firstName":"Megumi","middleName":"","lastName":"Toko","suffix":""},{"id":343437672,"identity":"178b33c4-0e7b-4560-aa0a-a9e38771ba35","order_by":3,"name":"Yuki Hayashi","email":"","orcid":"","institution":"Hiroshima University","correspondingAuthor":false,"prefix":"","firstName":"Yuki","middleName":"","lastName":"Hayashi","suffix":""},{"id":343437673,"identity":"4a036a8e-7d60-477d-875e-877685b0f44c","order_by":4,"name":"Taku Tazuma","email":"","orcid":"","institution":"Hiroshima University","correspondingAuthor":false,"prefix":"","firstName":"Taku","middleName":"","lastName":"Tazuma","suffix":""},{"id":343437674,"identity":"92221569-86c8-429f-913c-c0a0c7c5e433","order_by":5,"name":"Tomoaki Watanabe","email":"","orcid":"","institution":"Hiroshima University","correspondingAuthor":false,"prefix":"","firstName":"Tomoaki","middleName":"","lastName":"Watanabe","suffix":""},{"id":343437675,"identity":"f3463d6d-0bb5-44e1-a537-249bf293d237","order_by":6,"name":"Keito Ishihara","email":"","orcid":"","institution":"Hiroshima University","correspondingAuthor":false,"prefix":"","firstName":"Keito","middleName":"","lastName":"Ishihara","suffix":""},{"id":343437676,"identity":"70e47bce-c5f4-4c92-8902-f7e625ba5f85","order_by":7,"name":"Keisuke Tachiyama","email":"","orcid":"","institution":"Hiroshima University","correspondingAuthor":false,"prefix":"","firstName":"Keisuke","middleName":"","lastName":"Tachiyama","suffix":""},{"id":343437677,"identity":"cd1d573e-b2a1-4c33-8065-6f3b69012f4d","order_by":8,"name":"Yu Yamazaki","email":"","orcid":"","institution":"Hiroshima University","correspondingAuthor":false,"prefix":"","firstName":"Yu","middleName":"","lastName":"Yamazaki","suffix":""},{"id":343437678,"identity":"c9b0d63c-6063-4446-b9b9-cf68b1e4a7b3","order_by":9,"name":"Hirofumi Maruyama","email":"","orcid":"","institution":"Hiroshima University","correspondingAuthor":false,"prefix":"","firstName":"Hirofumi","middleName":"","lastName":"Maruyama","suffix":""}],"badges":[],"createdAt":"2024-07-23 12:54:50","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4788914/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4788914/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1038/s41598-024-84944-6","type":"published","date":"2025-01-07T15:57:12+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":63421303,"identity":"7e2a3aa5-4db9-44fa-9bb8-7941f6691575","added_by":"auto","created_at":"2024-08-28 02:45:42","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":29411,"visible":true,"origin":"","legend":"\u003cp\u003ePatient selection flow diagram\u003c/p\u003e\n\u003cp\u003eAbbreviations: Amyotrophic lateral sclerosis\u003c/p\u003e","description":"","filename":"Figure.png","url":"https://assets-eu.researchsquare.com/files/rs-4788914/v1/a80237236083afe8b2fa8ab4.png"},{"id":73694171,"identity":"c782118c-f71d-4d76-b9cf-6264bcc5eb52","added_by":"auto","created_at":"2025-01-13 16:11:51","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":660004,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4788914/v1/dd48705b-4d81-4b9c-80b4-9cb856892f07.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Safety and efficacy profile of a 90-day oral L-arginine hydrochloride intervention for patients with amyotrophic lateral sclerosis","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAmyotrophic lateral sclerosis (ALS) is a progressive, fatal neurodegenerative disorder\u0026nbsp;for which there is no\u0026nbsp;effective cure.\u0026nbsp;Moreover, malnutrition\u0026nbsp;significantly impacts the prognosis and overall outcomes of\u0026nbsp;this\u0026nbsp;disease\u0026nbsp;and\u0026nbsp;worsens quality of\u0026nbsp;life. Hence, the thorough assessment and appropriate management of nutritional status are critical components of ALS care. Despite extensive research, effective nutritional interventions have yet to be established. Most trials have focused\u0026nbsp;predominantly\u0026nbsp;on high-calorie, high-fat diets. Studies in ALS mouse models have reported that\u0026nbsp;the\u0026nbsp;administration of a high-calorie, high-fat diet\u0026nbsp;leads\u0026nbsp;to weight gain and disease progression inhibition\u003csup\u003e1\u003c/sup\u003e, contributing to prolonged survival\u003csup\u003e2\u003c/sup\u003e. However, clinical studies in humans, including one\u0026nbsp;in which\u0026nbsp;a high-calorie, high-fat diet (405 kcal/day,\u0026nbsp;45\u0026nbsp;g\u0026nbsp;fat)\u0026nbsp;was administered\u0026nbsp;to ALS patients, did not show a survival advantage over\u0026nbsp;a\u0026nbsp;placebo\u003csup\u003e3\u003c/sup\u003e. These findings indicate that high-calorie, high-fat diets may not exert disease-modifying effects\u0026nbsp;on\u0026nbsp;ALS, highlighting the necessity\u0026nbsp;of investigating\u0026nbsp;alternative nutritional strategies.\u003c/p\u003e\n\u003cp\u003eIn ALS, one of the mechanisms contributing to motor neuron cell death is believed to be excessive activation of glutamate receptors due to abnormalities in amino acid metabolism. Riluzole, a drug that inhibits glutamate release, exemplifies the critical link between amino acid metabolism and ALS pathophysiology. It is postulated that L-arginine confers neuroprotection to motor neurons against glutamate toxicity and is a potential therapeutic target for ALS. Additionally, L-arginine is thought to enhance skeletal muscle glucose metabolism and sustain muscle energy production, which may\u0026nbsp;protect against\u0026nbsp;ALS progression. In vitro studies using mature C2C12\u0026nbsp;myotubes have demonstrated that L-arginine can protect against skeletal muscle cell atrophy through the activation of the mechanistic target of rapamycin complex 1 and enhanced synthesis of skeletal muscle proteins\u003csup\u003e4\u003c/sup\u003e. Observations indicate that serum L-arginine levels are typically low in ALS patients\u003csup\u003e5\u003c/sup\u003e,\u0026nbsp;which is correlated\u0026nbsp;with the malnutrition often\u0026nbsp;observed\u0026nbsp;in this\u0026nbsp;population. Preclinical trials involving presymptomatic mtSOD1(G93A) mice, an animal model of ALS, have shown that administering L-arginine\u0026nbsp;delays\u0026nbsp;the onset of motor symptoms and\u0026nbsp;prolongs\u0026nbsp;survival\u003csup\u003e6\u003c/sup\u003e. Moreover, nitric oxide synthase (NOS), which is implicated in motor neuron degeneration in ALS models, was found to be downregulated following L-arginine supplementation in G93A\u0026nbsp;ALS mice, underscoring its neuroprotective\u0026nbsp;effects\u003csup\u003e7\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eDespite these promising preclinical findings, clinical studies investigating L-arginine supplementation in ALS patients are lacking. To address this gap, we conducted a prospective clinical trial to evaluate the safety and efficacy of oral L-arginine supplementation in ALS patients.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eBackground characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFrom May 2023 to October 2023, a total of 29 patients were screened for this study, 20 of whom were enrolled and received oral L-arginine hydrochloride. Six patients did not meet the inclusion criteria, and three did not provide consent. All 20 patients completed 45 days of intervention, and 19 completed 90 days, reflecting a discontinuation rate of 5% (Fig.1). One participant discontinued the study on day 75 due to the progression of ALS-related symptoms. Clinical and demographic data are presented in Table 1. The majority of patients (75%) were concurrently using riluzole, and most had not yet undergone PEG or received NPPV.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSafety assessments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDuring the study period, 4 patients (25%) experienced TEAEs within the first 45 days, and 6 patients (31.6%) experienced TEAEs within 90 days (Table 2). By day 45, the reported TEAEs included elevated creatinine kinase (CK) levels in 3 patients (CK level of 900, 350, and 648 U/L, respectively) and anorexia in 1 patient. By the end of the 90-day intervention, the reported TEAEs were elevated CK levels in 2 patients (384 and 584 U/L); liver function test abnormalities, including elevated aspartate aminotransferase (AST) and \u0026gamma;-glutamyl transpeptidase (\u0026gamma;-GTP) levels, in 1 patient (AST level of 123 U/L, \u0026gamma;-GTP level of 545 U/L); glucose tolerance abnormalities in 1 patient (fasting blood glucose level of 173 mg/dL and hemoglobin A1c level of 6.6%); hyperammonemia in 1 patient (ammonia level of 70 \u0026mu;g/dL); dysgeusia in 1 patient; and vasculitis in 1 patient. The investigator considered anorexia and dysgeusia to be related to the study drug. No AEs were severe, and there were no instances of study discontinuation or deaths due to AEs. Regarding clinical events, there was one instance where NPPV was initiated during the study. However, there were no cases of pneumonia, gastrostomy tube placement, TPPV initiation, or death. For the administration of L-arginine hydrochloride, the median number of missed doses was 1 (range: 0-43), with an adherence rate of 99.7%.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEffect of L-arginine on clinical outcomes\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFrom the initiation of L-arginine hydrochloride administration to the end of the study, the average change in body weight was -0.37 kg, and the average change in BMI was -0.11 kg/m\u0026sup2;, which are less than the typically observed natural reduction rates. There were 12\u0026nbsp;patients\u0026nbsp;(63.2%)\u0026nbsp;in whom\u0026nbsp;body weight was maintained or increased. The average change in muscle mass was -0.38 kg, while the average change in body fat mass was an increase of +0.17 kg. The MNA total score increased by 0.5 points on average. The ALSFRS-R score decreased by -1.7 points on average. Changes in muscle mass, fat mass, and MNA score\u0026nbsp;were significantly correlated with changes\u0026nbsp;in body weight (muscle mass, \u003cem\u003ep\u003c/em\u003e=0.036; body fat mass, \u003cem\u003ep\u003c/em\u003e=0.016; MNA score, \u003cem\u003ep\u003c/em\u003e=0.033). No significant associations were found between the weight maintenance and weight loss groups regarding baseline data, changes in\u0026nbsp;the\u0026nbsp;ALSFRS-R\u0026nbsp;score, body composition, or nutritional assessment (Table 3).\u0026nbsp;Although\u0026nbsp;no significant differences in baseline plasma\u0026nbsp;or\u0026nbsp;urinary arginine levels were\u0026nbsp;detected\u0026nbsp;between the groups, the\u0026nbsp;proportions of individuals with\u0026nbsp;high plasma and urinary arginine levels at 90 days\u0026nbsp;after the\u0026nbsp;start of the intervention and the urinary arginine ratio (day\u0026nbsp;90/baseline) were significantly\u0026nbsp;greater\u0026nbsp;in the weight maintenance group\u0026nbsp;than in\u0026nbsp;the weight loss group. Additionally, the urinary arginine ratio (day\u0026nbsp;45/baseline) was significantly\u0026nbsp;greater\u0026nbsp;in the weight maintenance group (\u003cem\u003ep\u003c/em\u003e=0.048). There were no significant differences in the frequency of events or TEAEs between the groups.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this study, we investigated the safety of L-arginine hydrochloride administered orally over a 90-day period in patients with ALS and explored its effects on nutritional status. L-arginine hydrochloride was generally well tolerated, as evidenced by a low rate of study discontinuation and high medication adherence, with no treatment-related serious AEs or deaths reported. Additionally, changes in body weight, an indicator of nutritional status in ALS patients, were found to correlate with the administration of L-arginine hydrochloride.\u003c/p\u003e \u003cp\u003eRegarding the use of oral L-arginine formulations that combine L-arginine and L-arginine hydrochloride, AEs such as liver function abnormalities, nausea, vomiting, and diarrhea have been reported\u003csup\u003e8\u003c/sup\u003e. Additionally, arginine hydrochloride loading has been linked to renal dysfunction and glucose tolerance abnormalities. In this study, the reported TEAEs included elevated CK levels, liver function test abnormalities, glucose tolerance abnormalities, hyperammonemia, taste alterations, appetite loss, and vasculitis. Elevated CK levels were associated with the progression of ALS, while liver function test abnormalities and glucose tolerance abnormalities were related to comorbid conditions (alcoholic liver injury and type 2 diabetes, respectively). Given that L-arginine is used to treat hyperammonemia in patients with urea cycle disorders\u003csup\u003e9\u003c/sup\u003e, the occurrence of hyperammonemia in this study was considered unrelated to L-arginine hydrochloride administration. In previous safety studies in healthy individuals, L-arginine hydrochloride was administered at dosages of 0, 15, and 30 g/day, with safety confirmed up to 30 g/day\u003csup\u003e10\u003c/sup\u003e. However, considering the substantial load at 30 g/day, a dosage of 15 g/day was selected for this study. No serious AEs or deaths occurred during the study. One patient discontinued treatment due to ALS progression, and the study confirmed good tolerability given the high medication adherence rate.\u003c/p\u003e \u003cp\u003eWeight loss, which is recognized as a marker of malnutrition in individuals with ALS, has been identified as a poor prognostic factor and is utilized for the longitudinal assessment of nutrition. In Japan, a prediagnosis rate of BMI reduction of 2-2.5 kg/m\u003csup\u003e2\u003c/sup\u003e/year has been reported as an indicator of poor prognosis\u003csup\u003e11,12\u003c/sup\u003e. Additionally, a decrease in BMI of 1.7 kg/m\u003csup\u003e2\u003c/sup\u003e/year or more from diagnosis to tracheostomy has been associated with poorer functional prognosis post-TPPV \u003csup\u003e13\u003c/sup\u003e. In ALS patients, weight loss is often driven by a combination of factors such as skeletal muscle atrophy, decreased fat mass, and increased respiratory muscle energy demands\u003csup\u003e14\u003c/sup\u003e, suggesting that BMI maintenance could improve life expectancy. In this study, three months of L-arginine administration in ALS patients who did not require TPPV resulted in a modest decrease in BMI of 0.11 kg/m\u003csup\u003e2\u003c/sup\u003e and a decrease in body weight of 0.37 kg. Previous studies have indicated that ALS patients typically experience monthly changes, with a decrease in BMI of -0.13 kg/m\u003csup\u003e2\u003c/sup\u003e and a weight loss of -0.28 kg\u003csup\u003e15\u003c/sup\u003e. Therefore, our findings suggest that the patients\u0026rsquo; body weights were relatively maintained. Moreover, in the group that maintained body weight, the serum and urine L-arginine ratios were significantly greater than those in the group that lost weight, indicating the potential role of arginine in weight maintenance. L-arginine is known to improve skeletal muscle glucose metabolism\u003csup\u003e4\u003c/sup\u003e and protect motor neurons against glutamate toxicity through nitric oxide (NO) synthesis\u003csup\u003e7\u003c/sup\u003e. Recent studies have also used L-arginine in animal models of spinocerebellar ataxia and spinal muscular atrophy, in which polyglutamine aggregate formation was inhibited and motor symptoms were improved\u003csup\u003e16\u003c/sup\u003e. Additionally, arginine has been shown to inhibit abnormal aggregation of the RNA-binding Protein Fused in Sarcoma, which is implicated in ALS pathogenesis\u003csup\u003e17\u003c/sup\u003e, making it a promising target for ALS treatment. In this study, the ALSFRS-R score decreased by an average of 1.7 points over three months of L-arginine administration. Importantly, there were no deaths or new initiations of TPPV during the trial period.\u003c/p\u003e \u003cp\u003eThis study has several limitations. First, this was a single-site, single-group intervention trial that represents the first investigation into the safety of L-arginine hydrochloride in patients with ALS. As an exploratory trial aimed at examining the potential benefits of L-arginine hydrochloride for improving nutritional status and outcomes in ALS patients, no control group was established, and the study design involved a pre- and postintervention comparison within the same group. Future studies should consider employing randomized controlled trials, including a nonintervention group, to facilitate intergroup comparisons. Second, the limited number of participants represents a challenge. This study primarily focused on the safety of L-arginine hydrochloride; therefore, the sample size was determined based on the incidence rate of AEs related to L-arginine hydrochloride reported in clinical trials regarding its approval and postmarketing surveillance, as well as accounting for potential dropouts. Third, the study excluded patients who used TPPV and thus did not include those with advanced ALS. ALS is characterized by weight loss due to hypermetabolism in the early stages, but after the initiation of TPPV, metabolic changes often lead to weight gain\u003csup\u003e18\u003c/sup\u003e, necessitating different nutritional interventions. Comprehensive examination and analysis of the diverse clinical courses of ALS patients requires the inclusion of a greater number of patients. Therefore, the recruitment of a greater number of patients is necessary for future research.\u003c/p\u003e \u003cp\u003eIn conclusion, this study demonstrated that oral L-arginine hydrochloride administered over the course of 90 days was well tolerated, with no serious TEAEs or deaths related to the intervention. In ALS patients who received L-arginine hydrochloride, the maintenance of body weight\u0026mdash;an indicator of nutritional status\u0026mdash;was observed throughout the intervention period. This maintenance was suggested to correlate with the concentrations of L-arginine hydrochloride in the blood and urine. Clinically, randomized controlled trials comparing the treatment to placebos, as well as biological validation in basic experiments, are needed in the future.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eStudy design and protocol\u003c/h2\u003e \u003cp\u003eThis study employed a single-arm, open-label comparative design to evaluate the effects of L-arginine hydrochloride supplementation (before and after treatment). The study was conducted at Hiroshima University Hospital and targeted ALS patients aged 18 years or older who met the Gold Coast criteria\u003csup\u003e19\u003c/sup\u003e and were capable of being observed for a minimum of three months. The exclusion criteria included patients with contraindications for arginine formulations, such as arginase deficiency or lysinuric protein intolerance; patients who were already on arginine formulations; patients who were using ventilators; and patients who were scheduled for surgery at the time of study registration. The primary endpoints were the safety and tolerability of oral L-arginine hydrochloride. Safety assessments included adverse events (AEs) such as any events occurring during the clinical trial period, total treatment-emergent adverse events (TEAEs) during the L-arginine hydrochloride administration period, serious TEAEs, TEAEs leading to death, TEAEs leading to the discontinuation of L-arginine hydrochloride, and TEAEs related to L-arginine hydrochloride (side effects). Patients were evaluated at 45 days (\u0026plusmn;\u0026thinsp;14 days) and 90 days (\u0026plusmn;\u0026thinsp;14 days) following the initiation of the treatment. The safety analysis population included all enrolled patients who received at least one dose of L-arginine hydrochloride. Tolerability was determined based on the incidence of AEs and the proportion of patients who discontinued the study drug due to TEAEs. As a secondary endpoint, efficacy was assessed by evaluating changes in nutritional status and outcomes in ALS patients. Nutritional status was assessed at baseline and after three months of treatment by measuring changes in body weight, body mass index (BMI), body fat mass, Mini Nutritional Assessment (MNA) scores\u003csup\u003e20\u003c/sup\u003e, the resting metabolic rate (RMR) calculated using the Harris-Benedict Eq.\u0026nbsp;2\u003csup\u003e1\u003c/sup\u003e, and the total energy expenditure (TEE) derived from the Shimizu formula\u003csup\u003e22\u003c/sup\u003e. Outcomes were evaluated using the revised ALS Functional Rating Scale (ALSFRS-R)\u003csup\u003e21\u003c/sup\u003e, and ALS-related events, including percutaneous endoscopic gastrostomy (PEG), pneumonia, noninvasive positive pressure ventilation (NPPV), tracheostomy positive pressure ventilation (TPPV), and death, were monitored.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eEthics statement\u003c/h2\u003e \u003cp\u003e This study received ethical approval from the Certified Review Board at Hiroshima University, Hiroshima, Japan (approval ID: CRB2022-0013-01) and conformed to directives from the federal government in accordance with the ethical principles outlined in the 1964 Declaration of Helsinki. The trial is registered in the jRCT database (trail registration number: jRCTs061230001, first registerd 11/04/2023). The recruitment period from this study was from April 11, 2023 to November 30, 2023. Comprehensive written informed consent was obtained from all participants prior to their inclusion in the study.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eL-arginine intervention\u003c/h2\u003e \u003cp\u003ePatients received oral L-arginine hydrochloride (Ajinomoto Co., Inc., Tokyo, Japan) at a dose of 15 grams per day for 90 days. Two packets were dissolved in water and administered orally following breakfast and dinner. Patients who were capable of oral intake consumed oral L-arginine hydrochloride directly, while those receiving enteral nutrition received it through the enteral feeding route. Adherence to the treatment regimen was monitored using a medication diary.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eData acquisition\u003c/h2\u003e \u003cp\u003eClinical evaluation and diagnosis were conducted by three neurologists (HN, MN, and MT). The recorded data included age, sex, weight, BMI, muscle mass, body fat mass, time of symptom onset and current neurological symptoms, disease duration, weekly alcohol consumption, smoking habits, ALSFRS-R scores, MNA scores, current medications, and blood and urine test results. Physical measurements, physical examinations, and nutritional assessments, along with blood and urine tests, were performed at baseline, 45 days after treatment (\u0026plusmn;\u0026thinsp;14 days), 90 days after treatment (at completion) or at the time of discontinuation (\u0026plusmn;\u0026thinsp;14 days).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eSample size\u003c/h2\u003e \u003cp\u003eBased on the frequency of AEs observed in clinical trials and postmarketing surveillance of arginine formulations (5 out of 40 cases and 18 out of 222 cases, respectively), the incidence rate of AEs associated with L-arginine hydrochloride was estimated to be 8.7%. To calculate the number of patients needed where the probability of observing no events, given the assumed rate of 8.7%, was less than 20%, a minimum of 18 patients was needed. Considering an anticipated dropout rate of approximately 10%, the target sample size for this study was 20 patients.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eCategorical variables are presented as numbers and percentages, while continuous variables are presented as the means with standard deviations (SDs) or medians (minimum, maximum). The safety of L-arginine hydrochloride was evaluated using descriptive statistics, which included the number and incidence of AEs during the administration period, the detailed breakdown of each AE, and AE severity. To assess the efficacy of L-arginine hydrochloride, we compared the nutritional status and outcomes of each patient before the intervention with those recorded 90 days after the start of the intervention or at the time of discontinuation. Furthermore, we conducted statistical comparisons between groups in which body weight was maintained or increased postintervention and those in which body weight decreased. Appropriate statistical tests, such as the χ\u003csup\u003e2\u003c/sup\u003e test, Mann\u0026ndash;Whitney U test, or unpaired \u003cem\u003et\u003c/em\u003e test, were utilized to evaluate differences between groups. A \u003cem\u003ep\u003c/em\u003e value less than 0.05 was considered to indicate statistical significance. All analyses were conducted using JMP 17.0 software (SAS Institute, Inc., Cary, NC).\u003c/p\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eConflicts of interest\u003c/h2\u003e \u003cp\u003eMN received honoraria from Eisai. HM received honoraria from Eisai, Shionogi, Otsuka Pharmaceutical, and Sumitomo Pharma. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as potential conflicts of interest.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThe author(s) declare that financial support was received for the research, authorship, and/or publication of this article. HN received funding from Grants-in-Aid for Scientific Research\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eHN: Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Validation, Writing\u0026mdash;original draft. MN: Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Validation, Writing\u0026mdash;original draft. MT: Conceptualization, Data curation, Investigation, Methodology, Validation, Writing\u0026mdash;original draft. YH: Data curation, Writing\u0026mdash;original draft. TT: Conceptualization, Methodology. TW: Conceptualization, Methodology. KI: Data curation. KT: Data curation. YY: Conceptualization, Supervision, Writing\u0026mdash;review \u0026amp; editing. HM: Conceptualization, Supervision, Validation, Writing\u0026mdash;review \u0026amp; editing.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eWe thank the Clinical Research Center in Hiroshima at the Hiroshima University Hospital for their assistance.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the first author upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eDupuis, L. \u003cem\u003eet al\u003c/em\u003e. Evidence for defective energy homeostasis in amyotrophic lateral sclerosis: benefit of a high-energy diet in a transgenic mouse model. 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Overview of the MNA\u0026ndash;Its history and challenges. J Nutr Health Aging 10, 456\u0026ndash;463 (2006).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCedarbaum, J, M. \u003cem\u003eet al\u003c/em\u003e. The ALSFRS-R: a revised ALS functional rating scale that incorporates assessments of respiratory function. BDNF ALS Study Group (Phase III). J Neurol Sci 169, 13\u0026ndash;21. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/s0022-510x(99)00210-5\u003c/span\u003e\u003cspan address=\"10.1016/s0022-510x(99)00210-5\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e (1999).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShimizu, T. \u003cem\u003eet al\u003c/em\u003e. The measurement and estimation of total energy expenditure in Japanese patients with ALS: a doubly labelled water method study. Amyotroph Lateral Scler Frontotemporal Degener 18, 37\u0026ndash;45. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1080/21678421.2016.1245756\u003c/span\u003e\u003cspan address=\"10.1080/21678421.2016.1245756\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e (2017).\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1.\u0026nbsp;\u003c/strong\u003ePatient background information\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"510\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"62.94117647058823%\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"37.05882352941177%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eN=20\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"62.94117647058823%\" valign=\"top\"\u003e\n \u003cp\u003eAge, years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"37.05882352941177%\" valign=\"top\"\u003e\n \u003cp\u003e662.0\u0026plusmn;6.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"62.94117647058823%\" valign=\"top\"\u003e\n \u003cp\u003eSex (female), n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"37.05882352941177%\" valign=\"top\"\u003e\n \u003cp\u003e8 (40.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"62.94117647058823%\" valign=\"top\"\u003e\n \u003cp\u003eDisease duration, years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"37.05882352941177%\" valign=\"top\"\u003e\n \u003cp\u003e1.9 (0.4, 4.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"62.94117647058823%\" valign=\"top\"\u003e\n \u003cp\u003eInitial symptom, n (%)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"37.05882352941177%\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"62.94117647058823%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; Bulbar onset\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"37.05882352941177%\" valign=\"top\"\u003e\n \u003cp\u003e5 (25.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"62.94117647058823%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; Limb onset\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"37.05882352941177%\" valign=\"top\"\u003e\n \u003cp\u003e14 (70.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"62.94117647058823%\" valign=\"top\"\u003e\n \u003cp\u003eRespiratory failure\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"37.05882352941177%\" valign=\"top\"\u003e\n \u003cp\u003e1 (5.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"62.94117647058823%\" valign=\"top\"\u003e\n \u003cp\u003eALSFRS-R score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"37.05882352941177%\" valign=\"top\"\u003e\n \u003cp\u003e38.4\u0026plusmn;6.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"62.94117647058823%\" valign=\"top\"\u003e\n \u003cp\u003eBody weight, kg\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"37.05882352941177%\" valign=\"top\"\u003e\n \u003cp\u003e59.7\u0026plusmn;12.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"62.94117647058823%\" valign=\"top\"\u003e\n \u003cp\u003eBody mass index, kg/m\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"37.05882352941177%\" valign=\"top\"\u003e\n \u003cp\u003e22.3\u0026plusmn;3.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"62.94117647058823%\" valign=\"top\"\u003e\n \u003cp\u003eSoft lean mass, kg\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"37.05882352941177%\" valign=\"top\"\u003e\n \u003cp\u003e40.1\u0026plusmn;10.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"62.94117647058823%\" valign=\"top\"\u003e\n \u003cp\u003eBody fat mass, kg\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"37.05882352941177%\" valign=\"top\"\u003e\n \u003cp\u003e17.0\u0026plusmn;5.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"62.94117647058823%\" valign=\"top\"\u003e\n \u003cp\u003eMNA score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"37.05882352941177%\" valign=\"top\"\u003e\n \u003cp\u003e23.1\u0026plusmn;4.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"62.94117647058823%\" valign=\"top\"\u003e\n \u003cp\u003emREE, kcal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"37.05882352941177%\" valign=\"top\"\u003e\n \u003cp\u003e1294\u0026plusmn;221\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"62.94117647058823%\" valign=\"top\"\u003e\n \u003cp\u003eTEE, kcal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"37.05882352941177%\" valign=\"top\"\u003e\n \u003cp\u003e1934\u0026plusmn;396\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"62.94117647058823%\" valign=\"top\"\u003e\n \u003cp\u003ePlasma amino acids (arginine), nmol/ml\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"37.05882352941177%\" valign=\"top\"\u003e\n \u003cp\u003e73.2\u0026plusmn;17.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"62.94117647058823%\" valign=\"top\"\u003e\n \u003cp\u003eUrine amino acids (arginine), \u0026mu;mol/g・cre\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"37.05882352941177%\" valign=\"top\"\u003e\n \u003cp\u003e20.0\u0026plusmn;15.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"62.94117647058823%\" valign=\"top\"\u003e\n \u003cp\u003eConcomitant use of riluzole, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"37.05882352941177%\" valign=\"top\"\u003e\n \u003cp\u003e15 (75.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"62.94117647058823%\" valign=\"top\"\u003e\n \u003cp\u003eConcomitant use of edaravone, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"37.05882352941177%\" valign=\"top\"\u003e\n \u003cp\u003e6 (30.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"62.94117647058823%\" valign=\"top\"\u003e\n \u003cp\u003ePEG, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"37.05882352941177%\" valign=\"top\"\u003e\n \u003cp\u003e1 (5.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"62.94117647058823%\" valign=\"top\"\u003e\n \u003cp\u003eNPPV, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"37.05882352941177%\" valign=\"top\"\u003e\n \u003cp\u003e1 (5.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eAbbreviations: ALSFRS-R, revised ALS Functional Rating Scale; MNA, Mini Nutritional Assessment; mREE, measured resting energy expenditure; TEE, total energy expenditure;\u0026nbsp;PEG, percutaneous endoscopic gastrostomy; NPPV, noninvasive positive pressure ventilation.\u003c/p\u003e\n\u003cp\u003eThe data are expressed as the mean \u0026plusmn; standard deviation or median (minimum, maximum) for continuous variables and as frequencies and percentages for discrete variables.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2.\u0026nbsp;\u003c/strong\u003eTEAEs, events, and compliance\u0026nbsp;rates\u0026nbsp;at\u0026nbsp;90 days or until discontinuation\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"539\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"59.66542750929368%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTEAE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"40.33457249070632%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eN = 20\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"59.66542750929368%\" valign=\"top\"\u003e\n \u003cp\u003eAny TEAEs, n (%)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"40.33457249070632%\" valign=\"top\"\u003e\n \u003cp\u003e6 (30)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"59.66542750929368%\" valign=\"top\"\u003e\n \u003cp\u003eElevated creatinine kinase levels, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"40.33457249070632%\" valign=\"top\"\u003e\n \u003cp\u003e3 (15)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"59.66542750929368%\" valign=\"top\"\u003e\n \u003cp\u003eLiver function test abnormalities, n (%)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"40.33457249070632%\" valign=\"top\"\u003e\n \u003cp\u003e1 (5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"59.66542750929368%\" valign=\"top\"\u003e\n \u003cp\u003eGlucose tolerance abnormalities, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"40.33457249070632%\" valign=\"top\"\u003e\n \u003cp\u003e1 (5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"59.66542750929368%\" valign=\"top\"\u003e\n \u003cp\u003eHyperammonemia, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"40.33457249070632%\" valign=\"top\"\u003e\n \u003cp\u003e1 (5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"59.66542750929368%\" valign=\"top\"\u003e\n \u003cp\u003eAnorexia, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"40.33457249070632%\" valign=\"top\"\u003e\n \u003cp\u003e1 (5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"59.66542750929368%\" valign=\"top\"\u003e\n \u003cp\u003eDysgeusia, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"40.33457249070632%\" valign=\"top\"\u003e\n \u003cp\u003e1 (5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"59.66542750929368%\" valign=\"top\"\u003e\n \u003cp\u003eVasculitis, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"40.33457249070632%\" valign=\"top\"\u003e\n \u003cp\u003e1 (5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"59.66542750929368%\" valign=\"top\"\u003e\n \u003cp\u003eEvent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"40.33457249070632%\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"59.66542750929368%\" valign=\"top\"\u003e\n \u003cp\u003ePneumonia, n (%)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"40.33457249070632%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"59.66542750929368%\" valign=\"top\"\u003e\n \u003cp\u003ePEG, n (%)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"40.33457249070632%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"59.66542750929368%\" valign=\"top\"\u003e\n \u003cp\u003eNPPV, n (%)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"40.33457249070632%\" valign=\"top\"\u003e\n \u003cp\u003e1 (5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"59.66542750929368%\" valign=\"top\"\u003e\n \u003cp\u003eTPPV, n (%)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"40.33457249070632%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"59.66542750929368%\" valign=\"top\"\u003e\n \u003cp\u003eDeath, n (%)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"40.33457249070632%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"59.66542750929368%\" valign=\"top\"\u003e\n \u003cp\u003eMedication intake\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"40.33457249070632%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"59.66542750929368%\" valign=\"top\"\u003e\n \u003cp\u003eNumber of missed medication doses\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"40.33457249070632%\" valign=\"top\"\u003e\n \u003cp\u003e1 (0, 43)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"59.66542750929368%\" valign=\"top\"\u003e\n \u003cp\u003eAdherence rate (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"40.33457249070632%\" valign=\"top\"\u003e\n \u003cp\u003e99.7 (76.1, 100)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eAbbreviations: TEAE, treatment-emergent adverse event; PEG, percutaneous endoscopic gastrostomy; NPPV, noninvasive positive pressure ventilation; TPPV, tracheostomy positive pressure ventilation. Data are expressed as the mean \u0026plusmn; standard deviation or median (minimum, maximum) for continuous variables and as frequencies and percentages for discrete variables.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3.\u0026nbsp;\u003c/strong\u003eComparison between patients\u0026nbsp;who\u0026nbsp;maintained weight and\u0026nbsp;those who\u0026nbsp;experienced weight loss during L-arginine hydrochloride administration\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"917\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.23991275899673%\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"20.610687022900763%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eWeight maintenance\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n = 7)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.610687022900763%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eWeight loss\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n = 12)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.538713195201744%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ep\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003evalue\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.23991275899673%\"\u003e\n \u003cp\u003eAge, years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.610687022900763%\"\u003e\n \u003cp\u003e62.6 \u0026plusmn; 2.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.610687022900763%\"\u003e\n \u003cp\u003e60.6 \u0026plusmn; 1.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.538713195201744%\"\u003e\n \u003cp\u003e0.534\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.23991275899673%\"\u003e\n \u003cp\u003eSex (female), n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.610687022900763%\"\u003e\n \u003cp\u003e3 (42.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.610687022900763%\"\u003e\n \u003cp\u003e4 (33.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.538713195201744%\"\u003e\n \u003cp\u003e0.679\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.23991275899673%\"\u003e\n \u003cp\u003eDisease duration, years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.610687022900763%\"\u003e\n \u003cp\u003e2.7 (0.8, 4.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.610687022900763%\"\u003e\n \u003cp\u003e1.3 (0.4, 4.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.538713195201744%\"\u003e\n \u003cp\u003e0.118\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.23991275899673%\"\u003e\n \u003cp\u003eALSFRS-R score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.610687022900763%\"\u003e\n \u003cp\u003e41.3 \u0026plusmn; 4.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.610687022900763%\"\u003e\n \u003cp\u003e37.9 \u0026plusmn; 6.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.538713195201744%\"\u003e\n \u003cp\u003e0.212\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.23991275899673%\"\u003e\n \u003cp\u003e\u0026Delta;ALSFRS-R score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.610687022900763%\"\u003e\n \u003cp\u003e0 (-4, 2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.610687022900763%\"\u003e\n \u003cp\u003e1 (-11, 1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.538713195201744%\"\u003e\n \u003cp\u003e0.340\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.23991275899673%\"\u003e\n \u003cp\u003e\u0026Delta;Body mass index, kg/m\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.610687022900763%\"\u003e\n \u003cp\u003e0.8 \u0026plusmn; 0.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.610687022900763%\"\u003e\n \u003cp\u003e-0.7 \u0026plusmn; 0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.538713195201744%\"\u003e\n \u003cp\u003e\u0026lt;0.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.23991275899673%\"\u003e\n \u003cp\u003e\u0026Delta;Soft lean mass, kg\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.610687022900763%\"\u003e\n \u003cp\u003e1.0 \u0026plusmn; 2.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.610687022900763%\"\u003e\n \u003cp\u003e-1.2 \u0026plusmn; 1.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.538713195201744%\"\u003e\n \u003cp\u003e0.054\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.23991275899673%\"\u003e\n \u003cp\u003e\u0026Delta;Body fat mass, kg\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.610687022900763%\"\u003e\n \u003cp\u003e1.3 \u0026plusmn; 3.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.610687022900763%\"\u003e\n \u003cp\u003e-0.5 \u0026plusmn; 2.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.538713195201744%\"\u003e\n \u003cp\u003e0.147\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.23991275899673%\"\u003e\n \u003cp\u003e\u0026Delta;MNA score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.610687022900763%\"\u003e\n \u003cp\u003e1.9 \u0026plusmn; 1.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.610687022900763%\"\u003e\n \u003cp\u003e-0.3 \u0026plusmn; 4.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.538713195201744%\"\u003e\n \u003cp\u003e0.294\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.23991275899673%\"\u003e\n \u003cp\u003ePlasma arginine at baseline, nmol/ml\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.610687022900763%\"\u003e\n \u003cp\u003e82.5 \u0026plusmn; 10.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.610687022900763%\"\u003e\n \u003cp\u003e70.2 \u0026plusmn; 17.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.538713195201744%\"\u003e\n \u003cp\u003e0.114\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.23991275899673%\"\u003e\n \u003cp\u003eElevated plasma arginine level on day 90, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.610687022900763%\"\u003e\n \u003cp\u003e4 (57.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.610687022900763%\"\u003e\n \u003cp\u003e1 (8.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.538713195201744%\"\u003e\n \u003cp\u003e0.020*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.23991275899673%\"\u003e\n \u003cp\u003ePlasma Arginine Ratio (Day 90/baseline)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.610687022900763%\"\u003e\n \u003cp\u003e2.3 \u0026plusmn; 1.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.610687022900763%\"\u003e\n \u003cp\u003e1.4 \u0026plusmn; 0.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.538713195201744%\"\u003e\n \u003cp\u003e0.051\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.23991275899673%\"\u003e\n \u003cp\u003eUrinary arginine at baseline,\u0026nbsp;\u0026mu;mol/g・cre\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.610687022900763%\"\u003e\n \u003cp\u003e21.3 \u0026plusmn; 12.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.610687022900763%\"\u003e\n \u003cp\u003e19.5 \u0026plusmn; 17.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.538713195201744%\"\u003e\n \u003cp\u003e0.813\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.23991275899673%\"\u003e\n \u003cp\u003eElevated urinary arginine level on day 90, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.610687022900763%\"\u003e\n \u003cp\u003e4 (57.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.610687022900763%\"\u003e\n \u003cp\u003e1 (8.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.538713195201744%\"\u003e\n \u003cp\u003e0.020*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.23991275899673%\"\u003e\n \u003cp\u003eUrinary Arginine Ratio (Day 90/baseline)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.610687022900763%\"\u003e\n \u003cp\u003e11.5 \u0026plusmn; 11.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.610687022900763%\"\u003e\n \u003cp\u003e2.4 \u0026plusmn; 2.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.538713195201744%\"\u003e\n \u003cp\u003e0.019*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.23991275899673%\"\u003e\n \u003cp\u003eALS-related events during the intervention period, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.610687022900763%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.610687022900763%\"\u003e\n \u003cp\u003e1 (8.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.538713195201744%\"\u003e\n \u003cp\u003e0.433\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.23991275899673%\"\u003e\n \u003cp\u003eAny TEAEs, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.610687022900763%\"\u003e\n \u003cp\u003e3 (42.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.610687022900763%\"\u003e\n \u003cp\u003e3 (25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.538713195201744%\"\u003e\n \u003cp\u003e0.423\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eAbbreviations: ALSFRS-R, revised ALS Functional Rating Scale; MNA, Mini Nutritional Assessment; TEAE, treatment emergent adverse event.\u003c/p\u003e\n\u003cp\u003eData are expressed as\u0026nbsp;the\u0026nbsp;mean \u0026plusmn; standard deviation or median (minimum, maximum) for continuous variables and as frequencies and percentages for discrete variables.\u0026nbsp;*\u003cem\u003ep\u003c/em\u003e \u0026lt;0.05\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Amyotrophic lateral sclerosis, L-arginine hydrochloride, nutrition, body weight, body mass index","lastPublishedDoi":"10.21203/rs.3.rs-4788914/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4788914/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eWeight loss, a key indicator of malnutrition in amyotrophic lateral sclerosis (ALS) patients, negatively impacts prognosis. However, effective nutritional interventions have not been adequately established. Previous research in ALS model mice has shown that L-arginine can prolong survival, yet no human intervention studies have been conducted. This study aimed to assess the safety, tolerability, and efficacy of L-arginine hydrochloride in ALS patients. ALS patients were administered 15 g/day L-arginine hydrochloride for 90 days. Safety was primarily evaluated on days 45 and 90. Efficacy measures included changes in nutritional status, ALS Functional Rating Scale scores, and the occurrence of events such as the initiation of tracheostomy positive pressure ventilation (TPPV) and death. The study included 20 patients (40% female; mean age, 62.0\u0026thinsp;\u0026plusmn;\u0026thinsp;6.9 years; median disease duration, 1.9 years). Six participants (30%) experienced treatment-emergent adverse events (TEAEs), including elevated creatine kinase levels, liver function test abnormalities, glucose tolerance issues, hyperammonemia, anorexia, dysgeusia, and vasculitis. No serious TEAEs were associated with L-arginine hydrochloride. Over the course of three months, the average changes in body weight and body mass index (BMI) were \u0026minus;\u0026thinsp;0.37 kg and \u0026minus;\u0026thinsp;1.1 kg/m\u003csup\u003e2\u003c/sup\u003e, respectively, which are less than the typically observed natural reduction rates. There were no events requiring TPPV initiation or deaths. This study demonstrated that the oral administration of L-arginine hydrochloride across three months was well tolerated by ALS patients, with no serious TEAEs or deaths attributed to the study drug.\u003c/p\u003e \u003cp\u003e \u003cb\u003eTrial Registration number\u003c/b\u003e: Japan Registry of Clinical Trials (jRCTs061230001), first registered 11/04/2023\u003c/p\u003e","manuscriptTitle":"Safety and efficacy profile of a 90-day oral L-arginine hydrochloride intervention for patients with amyotrophic lateral sclerosis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-08-28 02:45:37","doi":"10.21203/rs.3.rs-4788914/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-10-01T08:22:34+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-10-01T05:45:09+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-09-18T11:14:13+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-09-15T03:01:30+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"332707361014383304793341735828673369960","date":"2024-09-08T19:11:24+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"140467027719160417045954000510325546757","date":"2024-09-04T18:31:39+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"291595490351805468184403023125378668307","date":"2024-09-02T16:12:58+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-08-18T06:44:01+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"319770568330644482170383351843320469629","date":"2024-08-07T01:37:46+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"134556502488093500142218868061070070755","date":"2024-08-06T19:06:30+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"213974097926672442655157810287991754090","date":"2024-08-06T15:07:18+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-08-04T19:48:24+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-08-02T15:23:35+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-07-29T16:40:08+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-07-27T06:58:49+00:00","index":"","fulltext":""},{"type":"submitted","content":"Scientific Reports","date":"2024-07-23T12:53:36+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"0fd8d0fa-b396-4283-adc3-57183be6a3a1","owner":[],"postedDate":"August 28th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":36390537,"name":"Health sciences/Health care"},{"id":36390538,"name":"Health sciences/Neurology"}],"tags":[],"updatedAt":"2025-01-13T16:05:23+00:00","versionOfRecord":{"articleIdentity":"rs-4788914","link":"https://doi.org/10.1038/s41598-024-84944-6","journal":{"identity":"scientific-reports","isVorOnly":false,"title":"Scientific Reports"},"publishedOn":"2025-01-07 15:57:12","publishedOnDateReadable":"January 7th, 2025"},"versionCreatedAt":"2024-08-28 02:45:37","video":"","vorDoi":"10.1038/s41598-024-84944-6","vorDoiUrl":"https://doi.org/10.1038/s41598-024-84944-6","workflowStages":[]},"version":"v1","identity":"rs-4788914","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4788914","identity":"rs-4788914","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}