Treatment of pseudobulbar affect in ALS with dextromethorphan/quinidine: A randomized trial

Baylor College of Medicine, Houston, Texas, United States
Neurology (Impact Factor: 8.29). 11/2004; 63(8):1364-70. DOI: 10.1212/01.WNL.0000142042.50528.2F
Source: PubMed


Patients with ALS commonly exhibit pseudobulbar affect.
The authors conducted a multicenter, randomized, double-blind, controlled, parallel, three-arm study to test a defined combination of dextromethorphan hydrobromide (DM) and quinidine sulfate (Q) (AVP-923) for the treatment of pseudobulbar affect in ALS. Q inhibits the rapid first-pass metabolism of DM. The effects of AVP-923 (30 mg of DM plus 30 mg of Q) given twice daily for 28 days were compared with those of its components. Patients were evaluated on days 1, 15, and 29. The primary efficacy variable was the change from baseline in the Center for Neurologic Study Lability Scale (CNS-LS) score. Secondary efficacy variables were laughing/crying episode rates and changes in Visual Analog Scales for Quality of Life (QOL) and Relationships (QOR). Efficacy was evaluated in intention-to-treat subjects who were not poor metabolizers of DM (n = 65 for AVP-923, n = 30 for DM, and n = 34 for Q). Safety was assessed in all randomized subjects (n = 140).
AVP-923 patients experienced 3.3-point greater improvements in CNS-LS than DM patients (p = 0.001) and 3.7-point greater improvements than Q patients (p < 0.001). AVP-923 patients exhibited lower overall episode rates, improved QOL scores, and improved QOR scores (p < 0.01 for all endpoints). Adverse effects were mostly mild or moderate; treatment-related discontinuation was 24% for AVP-923, 6% for DM, and 8% for Q.
AVP-923 palliates pseudobulbar affect in ALS. Overall benefits of treatment are reflected in fewer episodes of crying and laughing and improvements in overall quality of life and quality of relationships.

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    • "Le syndrome pseudo-bulbaire, caractérisé par un rire et pleurer spasmodique, est fréquent et peut être amélioré par les tricycliques et les inhibiteurs de la recapture de la sérotonine. L'association de dextrométhorphan et de quinidine (Nuedex- ta W ), déjà utilisée aux États-Unis dans cette indication [9], a reçu en juin 2006 une autorisation de mise sur le marché de la part de l'Agence médicale européenne. "
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    • "Occasionally, the emotional outbursts are more troubling for the relatives and nursing staff than the patient, and treatment may not be necessary. A randomized controlled trial of a combination of dextrometorphan and quinidine showed this to be effective in improving emotional lability and quality of life (Brooks et al., 2004). Side-effects were experienced by 89% of patients and 24% discontinued treatment during the trial's 4-week duration. "

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