Heart rate, respiratory rate, systolic and diastolic blood pressure, and oral 
and skin temperature changes following intravenous administration of TRH occur 
at lower infusion rates in patients with ALS and bulbar involvement than in 
patients with ALS without bulbar involvement. This autonomic sensitivity to TRH 
infusion is characteristic of a more advanced stage of ALS with difficulties in 
speaking and swallowing. Patients who will be receiving neuropeptides, such as 
TRH, must be carefully studied to determine whether subclinical bulbar 
involvement is present. Such patients may require a lower initial dose or dose 
rate adjustment as well as continual monitoring during neuropeptide 
administration.