Do you start Riluzole on all patients diagnosed with ALS?

No. I discuss riluzole with all patients and explain that it prolongs survival in ALS by a variable amount of time, usually around 3-4 months- therefore, if the patient wants to use anything available to prolong their life, they should take it. I also explain, however, that riluzole will not stop disease progression, it will not improve the patient's weakness and it does not have any meaningful impact on daily function or quality of life. A recent study (Fang et al., PMID 29525492) showed that r...

I do. My personal experience has been that it is well-tolerated and generally not a financial burden. It is often difficult to explain the expected benefit other than that it may slow their course, but given that all courses are different, I'm generally hesitant to give specific expectations (e.g. it will add x months, etc.). The risk is low if LFTs are monitored regularly as per the package insert.