Patient case (clinical description): A 47-year-old man comes to the clinic for the follow up of his neuromuscular disease. He experienced gradual, progressive weakness of the left upper extremity over the last year.  Over the last few months, he has also noticed weakness in the right upper extremity.  BP is 120/75, PR is 80 and temperature is 37 C. Reflexes are brisk in the upper extremities, and the plantar responses are extensor.  Mild gait ataxia is present. The patient is under treatment of Riluzole 50 mg BID with the diagnosis of ALS.

Patient's own account: I've been suffering from a neuromuscular disease for a while now, and I went to my doctor's office. I'm now a 47-year-old man and over the past year I experienced a progressive and gradual weakness of my left upper extremity, and over the past month, I also noticed a weakness over my right upper extremity. My heart rate was 120/75, and my  PR was 80 with 37°C for temperature. My reflexes are not good in my upper extremities, and I have trouble with my balance. I'm also under Exservan 50 mg for my sclerosis.

Clinical trial: Effects of Oral Levosimendan (ODM-109) on Respiratory Function in Patients With ALS

Eligibility criteria:
Inclusion Criteria:

          -  Written or verbal informed consent (IC) for participation in the study

          -  Male or female subjects with diagnosis of laboratory supported probable, probable or
             definite ALS according to El Escorial revised criteria. Full electromyogram (EMG)
             report available consistent with ALS (but not necessarily fulfilling the
             electrodiagnostic criteria for ALS) from an experienced neurophysiologist

          -  Able to swallow study treatment capsules, and in the opinion of the investigator, is
             expected to continue to do so during the study

          -  Sitting SVC between 60-90% of the predicted value for age, height and sex at screening
             visit

          -  Disease duration from symptom onset (defined by first muscle weakness or dysarthria)
             12-48 months at the time of visit 1 (baseline)

          -  Able to perform supine SVC in an adequate and reliable way at screening and baseline
             visits as judged by the investigator

          -  Subjects with or without riluzole and/or edaravone. If using riluzole (any daily dose
             up to 100 mg), the dose must have been stable for at least 4 weeks before the
             screening visit and should not be changed during the study. If using edaravone, the
             treatment should have been started at least 4 weeks before the screening visit (at
             least one 28-day treatment cycle as indicated) and should not be changed during the
             study. If not on riluzole and/or edaravone, the respective treatments should not be
             started during the study

        Exclusion Criteria:

          -  Subject in whom other causes of neuromuscular weakness have not been excluded

          -  Subject with a diagnosis of another neurodegenerative disease (e.g. Parkinson's or
             Alzheimer's disease)

          -  Assisted ventilation of any type within 3 months before the screening visit or at
             screening

          -  Any use of a diaphragm pacing system (DPS) within 3 months before the screening visit

          -  Any form of stem cell or gene therapy for the treatment of ALS

          -  Known hypersensitivity to levosimendan

          -  Administration of levosimendan within 3 months before the screening visit or previous
             participation in the present phase III study or earlier study with oral levosimendan
             in ALS patients (LEVALS)

          -  Any use of tirasemtiv or reldesemtiv within 1 month before the screening visit.

          -  Participation in a clinical trial with any experimental treatment within 30 days or
             within 5 half-lives of that treatment (whichever is longer) before the screening visit

          -  Any botulinum toxin use within 3 months before the screening visit

          -  Recorded diagnosis or evidence of major psychiatric diagnosis, significant cognitive
             impairment or clinically evident dementia that may interfere with the patient's
             ability to comply with study procedures

          -  Pulmonary illness (e.g. asthma or COPD) requiring regular treatment

          -  Haemodynamically significant uncorrected valve disease or hypertrophic cardiomyopathy
             or restrictive cardiomyopathy

          -  Any cardiovascular event (e.g. myocardial infarction, HF, arrhythmia or stroke)
             requiring hospitalisation within 3 months before the screening visit

          -  History of Torsades de Pointes (TdP) or diagnosed long QT-syndrome

          -  History of life-threatening ventricular arrhythmia, unless treated with reliable
             measures to prevent recurrence (e.g. with placement of implantable cardioverter
             defibrillator [ICD] or catheter ablation)

          -  History of second or third degree atrioventricular (AV) block or sinus node disease at
             screening, if not treated with pacemaker

          -  HR repeatedly > 100 bpm in the 12-lead ECG after a 5-minute rest at screening. If the
             HR is > 100 bpm in the first recording, then the second recording must be done after
             another 5 min rest to confirm HR > 100 bpm

          -  Systolic blood pressure (SBP) < 90 mmHg at screening

          -  Potassium < 3.7 mmol/l or > 5.5 mmol/l at screening

          -  Severe renal impairment (creatinine clearance < 30 ml/min at screening), creatinine >
             170 μmol/l at screening or on dialysis

          -  Blood haemoglobin < 10 g/dl at screening or blood donation or loss of significant
             amount of blood within 60 days before the screening visit

          -  Clinically significant hepatic impairment at the discretion of the investigator

          -  Body mass index (BMI) ≤ 18.5kg/m2 (BMI = weight/height2)

          -  Women who are lactating or of reproductive age without a negative pregnancy test and
             without a commitment to using a highly effective method of contraception (e.g. oral
             hormonal contraceptives associated with inhibition of ovulation, intrauterine devices
             and long acting progestin agents), if sexually active during the study, and for 1
             month after the last dose of the study treatment. Women who are postmenopausal (1 year
             since last menstrual cycle), surgically sterilised or who have undergone a
             hysterectomy are considered not to be reproductive and can be included

          -  Patient judged to be actively suicidal by the investigator during 3 months before the
             screening visit

          -  Patients with known history of human immunodeficiency virus (HIV) infection

          -  Any other clinically significant cardiovascular, gastrointestinal, hepatic, renal,
             neurological or psychiatric disorder or any other major concurrent illness that in the
             opinion of the investigator could interfere with the interpretation of the study
             results or constitute a health risk for the subject if he/she took part in the study
No condition on gender to be admitted to the trial.
No healthy subjects accepted to join the trial.
Subject must be at least 18 Years old.
Subject must be at most 120 Years

Eligibility (NLI label): Entailment