When do you consider ultrahigh-dose methylcobalamin injections for ALS?

I have noted that several ALS experts are offering this option nowadays to patients. I will analyze herein why I am NOT in favor of this approach, and, if I would offer methylcobalamin to any of my ALS patients, I would prefer to offer the oral form:

1) The reason it is offered is a positive randomiz...

I believe the evidence is rather good that high-dose IM B12 may help slow down the progression of ALS. Certainly, I have patients who are interested in using it, and I prescribe it to them. It is certainly not all that effective in my own experience. The mechanism by which it works is also not clear...

Agree with the skepticism expressed by @Dr. First Last. The arguments are that Methylcobalamin may be more protective than cyanocobalamin, as cyanocobalamin needs to be converted to be active. Also, methyl is thought to be retained longer.

All of this is hypothetical and has no clear evidence to sup...

I discuss this treatment option if patients are within 12 months from their disease onset. Unless there is another trial in the future on ultra-high dose methylcobalamin demonstrating the lack of efficacy in early stage ALS, I think it is very reasonable to offer this treatment to this subset of pat...