Pseudobulbar Affect (PBA) Management

 

Q: Which of the following is FDA approved treatment for Psedobulbar Affect?


 


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CLINICAL FEATURES:

 

  • Uncontrolled crying or laughing.

  • These episodes are unprovoked.

  • This is disproportionate or inappropriate to the social context- “disconnect” (*)

  • Duration of these episodes is generally brief.

  • Uncontrollable crying or laughter + lasting for long duration + patient inability to suppressed them. 

  • Crying common than Laughter.

 


PBA SEEN WITH FOLLOWING NEUROLOGICAL CONDITIONS:

 

  • Amyotrophic lateral sclerosis (ALS)

  • Extrapyramidal and cerebellar disorders: Parkinson’s disease, multiple system atrophy, progressive supranuclear palsy

  • Multiple sclerosis

  • Traumatic brain injury

  • Alzheimer’s disease and other dementias

  • Stroke

  • Brain tumors

 


 

NOTE ==> PATIENT WITH PBA HAVE HIGH INCIDENCE OF DEPRESSION AND ANXIETY DISORDERS.

 


SCALES

 

  1. Center for Neurologic Study – Lability Scale (CNS-LS)

  2. Pathological Laughter and Crying Scale (PLACS)

 


TREATMENT

 

FDA APPROVED TREATMENT:

 

(1) DEXTROMETHORPHAN-QUINIDINE (NUEDEXTA):

 

  • NUEDEXTA is a combination product containing= dextromethorphan hydrobromide (uncompetitive NMDA receptor antagonist and sigma-1 agonist) + quinidine sulfate (CYP450 2D6 inhibitor) 

  • Only FDA approved treatment of PBA.

  • Note that studies to support the effectiveness of NUEDEXTA were performed in patients with underlying amyotrophic lateral sclerosis or multiple sclerosis.

  • NUEDEXTA has NOT BEEN SHOWN TO BE SAFE OR EFFECTIVE in other types of emotional lability that can commonly occur, for example, in Alzheimer’s disease and other dementias.

  • DOSING: 1 capsule (Dextromethorphan 20 mg/Quinidine 10 mg) Daily X 7 days ==> then 1 capsule every 12 hours.

  • WARNINGS: (a)Thrombocytopenia, (b) Hepatitis, (c) QT Prolongation & Left ventricular hypertrophy.

  • Laboratory: CBC, Liver function test and EKG.

 


OFF LABEL TREATMENT:

 

(1) SSRIs:

  • Fluoxetine 20 mg daily.

  • Citalopram 20 mg daily.

  • Sertraline 50 mg daily.

 

(2) TCAs:

  • Nortriptyline 20–100 mg/day.

  • Amitriptyline 20–100 mg/day.

 


SOURCE:
  1. Ther Clin Risk Manag. 2013; 9: 483–489.
  2. NUEDEXTA package insert.
  3. Expert Rev Neurother. 2011 Jul; 11(7):1077-88.
  4. Brain Inj. 1999 Oct; 13(10):805-11.
  5. Drugs. 2011 Jun 18; 71(9):1193-207.
  6. Exp Neurol. 2007 Oct; 207(2):248-57.
  7. J Affect Disord. 2000 Apr; 58(1):19-36.

Please do post your questions or comments below. 


Dr. Harvinder Singh, M.D. (Admin)


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