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Nuedexta to Relieve Outbursts of Laughter or Tears in Alzheimer’s

PseudoBulbar Affect (PBA) is a distressing neurologic condition characterized by sudden and uncontrolled outbursts of laughing and/or crying. Learn how Nuedexta, a new drug in final trials, will specifically help people with Alzheimer’s and dementia who are affected by PBA.

ALISO VIEJO, Calif. — Avanir Pharmaceuticals, Inc. announced interim data from the phase IV PRISM II study showing that treatment with NUEDEXTA® substantially reduced symptoms of pseudobulbar affect (PBA) in patients with Alzheimer’s disease/dementia. PBA is a distressing neurologic condition characterized by sudden and uncontrolled outbursts of laughing and/or crying in patients with neurologic disease and injury. A standard quality of life measure also showed clear improvement over the 3-month treatment period. The data were presented at the Alzheimer’s Association International Conference (AAIC).

“These initial data showing reduced symptoms of pseudobulbar affect (PBA) in patients with PBA secondary to Alzheimer’s and dementia are consistent with the benefits we saw in the pivotal phase III study, in PBA patients with ALS and MS, and provide further evidence that NUEDEXTA may offer relief from the debilitating episodes of PBA,” said Joao Siffert, MD, chief medical officer at Avanir. “PRISM II has now completed enrollment of patients with dementia and continues to enroll patients with stroke and traumatic brain injury, two additional important causes of PBA. We look forward to reporting data from these additional cohorts later this year.”

“PBA can have a devastating impact on the lives of patients that are already suffering with neurologic disorders such as Alzheimer’s disease and other dementias,” said Stephen D’Amico, MD, CMD, medical director at Cornerstone Medical Group, Tennessee. “The reduction in PBA symptoms and improvement in quality of life measures seen in this study are evidence of the clinically meaningful impact that treatment with NUEDEXTA may have.”

PRISM II assessed the safety and efficacy of NUEDEXTA in treating PBA in patients with Alzheimer’s disease/dementia, stroke and TBI. While the Alzheimer’s disease/dementia cohort is now fully enrolled at 134 patients, at the time of interim analysis 96 patients had evaluable safety data and 68 had effectiveness data (at least 30 treatment days). The study endpoints included a PBA symptom rating (Center for Neurologic Study-Lability Scale; CNS-LS; 7=no symptoms – 35=maximum symptoms), number of weekly PBA episodes, Mini-Mental State Examination (MMSE), quality of life (QOL; 0=no impairment-10=maximum impairment) improvements, and Clinician and Patient Global Impression of Change (CGI-C; PGI-C).

  • At baseline patients had a mean CNS-LS score of 20.2 and were suffering from a median of 29 PBA episodes per week.
  • At the end of the study period, mean CNS-LS improved to 12.8 (P<0.001 compared with baseline) and the median number of PBA episodes decreased to 5 per week.
  • At the end of the treatment period, consistent improvement was observed in other effectiveness measures
    • Mean QOL scores improved from 6.1 at baseline to 2.8 at endpoint (P<0.001)
    • 77.8% of patients or caregivers rated themselves/the patient as being much/very improved on the PGI-C
    • 79.3% of clinicians rated the patient to be much/very much improved on the CGI-C
  • MMSE mean score improved by 0.4 points at end of study from a baseline of 19.0
  • Adverse Events (AE) were reported by a total of 35 (36.5%) patients (6.3% treatment-related), most commonly headache (9.4%), urinary tract infection (5.2%), and diarrhea (4.2%). Eleven patients had serious AEs (only one deemed treatment-related).  Thirteen patients discontinued for AEs. This AE profile was generally consistent with that observed in other trials of NUEDEXTA. 


The objectives of the study are to evaluate the safety, tolerability, and effectiveness of NUEDEXTA capsules containing 20 mg dextromethorphan (DM) and 10 mg quinidine (Q) for treatment of PBA in patients with prevalent neurological conditions including Alzheimer’s disease/dementia, stroke and traumatic brain injury over a 12 week period.

PRISM II is a nationwide, open-label, multicenter, 12-week study enrolling up to approximately 450 patients at approximately 100 study centers. Eligible patients are aged >18 years with a clinical diagnosis of PBA and baseline score >13 on the Center for Neurologic Study-Lability Scale (CNS-LS). Patients with TBI due to a penetrating head injury are excluded. Patients are treated with NUEDEXTA mg twice daily. The primary endpoint is change from baseline in scores measured by the CNS-LS, a PBA rating instrument originally validated in patients with PBA secondary to ALS and MS. Determination of effectiveness is based on a comparison of CNS-LS change in PRISM II with results of previous phase III studies. Additional outcomes measures include: number of weekly PBA episodes (laughing and/or crying); Mini-Mental State Examination; quality of life; Clinician and Patient Global Impression of Change (CGIC; PGIC); patients’ satisfaction with treatment; Patient Health Questionnaire (PHQ-9) (to evaluate mood symptoms), and the Neurobehavioral Functioning Inventory for TBI patients. Safety measures include monitoring of adverse events, concomitant medication usage, and vital signs.

About PBA
PBA is a neurologic condition in patients with neurologic disease and injury characterized by uncontrollable, disruptive laughing and/or crying outbursts that are often contrary or exaggerated to the patient’s inner mood state. As a result, many of those afflicted with PBA show significant impairment on standard measures of health status, and impairments in occupational and social function, often leading to social isolation. PBA occurs secondary to a variety of neurologic conditions such as traumatic brain injury (TBI), multiple sclerosis (MS), amyotrophic lateral sclerosis (ALS), Parkinson’s disease, stroke and Alzheimer’s disease. When these disorders damage areas of the brain that regulate normal emotional expression, they can lead to uncontrollable, disruptive episodes of crying or laughing. For more information about PBA, please visit

The CNS-LS has been validated in ALS and MS patients.

NUEDEXTA is an innovative combination of two well-characterized components; dextromethorphan hydrobromide (20 mg), the ingredient active in the central nervous system, and quinidine sulfate (10 mg), a metabolic inhibitor enabling therapeutic dextromethorphan concentrations. NUEDEXTA acts on sigma-1 and NMDA receptors in the brain, although the mechanism by which NUEDEXTA exerts therapeutic effects in patients with PBA is unknown.

NUEDEXTA Important Safety Information
NUEDEXTA is indicated for the treatment of pseudobulbar affect (PBA). PBA occurs secondary to a variety of otherwise unrelated neurological conditions, and is characterized by involuntary, sudden, and frequent episodes of laughing and/or crying. PBA episodes typically occur out of proportion or incongruent to the underlying emotional state.

Studies to support the effectiveness of NUEDEXTA were performed in patients with amyotrophic lateral sclerosis (ALS) and multiple sclerosis (MS). NUEDEXTA has not been shown to be safe and effective in other types of emotional lability that can commonly occur, for example, in Alzheimer’s disease and other dementias.

NUEDEXTA and certain other medicines can interact, causing serious side effects. If you take certain drugs or have certain heart problems, NUEDEXTA may not be right for you.

NUEDEXTA causes dose-dependent QTc prolongation. When initiating NUEDEXTA in patients at risk for QT prolongation and torsades de pointes, electrocardiographic (ECG) evaluation should be conducted at baseline and 3-4 hours after the first dose.

The most common adverse reactions are diarrhea, dizziness, cough, vomiting, asthenia, peripheral edema, urinary tract infection, influenza, increased gamma-glutamyltransferase, and flatulence. NUEDEXTA may cause dizziness.

These are not all the risks from use of NUEDEXTA. Please refer to full Prescribing Information

About Avanir Pharmaceuticals, Inc.
Avanir Pharmaceuticals, Inc. is a biopharmaceutical company focused on bringing innovative medicines to patients with central nervous system disorders of high unmet medical need. As part of our commitment, we have extensively invested in our pipeline and are dedicated to advancing medicines that can substantially improve the lives of patients and their loved ones. For more information about Avanir, please visit

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May 7, 2015 1:44 pm

This is more a question than a comment. Is Nudexta appropriate for controlling behaviors (such as climbing out of wheelchair) of a demented patient?

May 19, 2016 9:02 pm

Good question, my mom tries to get up – out of her wheelchair – she can't walk without assistance any longer because of on-going balance issues – which have resulted in a lengthy fall history. Over the last week, she has exhibited crying spells and seems to have difficulty controlling them. Dr. prescribed Nuedexta today – to see if this medication will help. I have concerns about the side effects with the existing medications and the associated cost of the medication per month. Part D will cover most of it – but as she migrates into the higher TIERS, her copays will increase – and she can't afford this medication long term – along with her facility and personal bills.

B. Berger

B. Berger

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