Actor portrayals of an older male experiencing Pseudobulbar Affect (PBA) crying symptoms, next to a younger female holding playing cards Actor portrayals of an older male experiencing Pseudobulbar Affect (PBA) crying symptoms, next to a younger female holding playing cards

What is pba

PBA is often
misunderstood1

Pseudobulbar Affect (PBA) is a distinct neurologic condition caused by other neurologic conditions. It’s characterized by frequent and uncontrollable crying and/or laughing1-3

Actor portrayals.

Laughing and/or crying in PBA is:

“Uncontrollable” lock symbol with an “x” on it
Uncontrollable3

“It happens in public. I can’t control it.”

“Sudden” lightning bolt symbol
Sudden2

“I cry for no reason. It comes out of the blue.”

“Frequent” continuing arrow symbol
Frequent2

“I cry more than I used to. The littlest thing sets me off.”

“Disconnected” symbol
Disconnected from their actual mood2

“I don’t know why I’m laughing. It’s not funny.”

“Exaggerated” audio symbol
Exaggerated4

“I overreact to things now. My response is excessive.”

PBA symptoms can be mistaken for depression. Read more about the differences between the two conditions.1

Learn more

Patients don't always know how to explain their PBA episodes. Hear how they describe symptoms.5

An African American woman with long brown hair is seen in profile, facing to the right. The caption on screen says “Sequena, living with PBA.”

~2 million patients may have PBA

According to an online survey, PBA was estimated to affect approximately 2 million US patients with underlying neurologic conditions.1

Dan, male patient with PBA in his 60s Dan, male patient with PBA in his 60s
Dan, patient living with PBA

More patients than you think might be suffering from PBA

Presence of PBA crying and/or laughing symptoms in select neurologic conditions1*

Table that shows presence of PBA crying and/or laughing symptoms in select neurologic conditions Table that shows presence of PBA crying and/or laughing symptoms in select neurologic conditionsNeurologic condition (n, mean age of patients) Traumatic brain injury (n=590, 49 yrs) Multiple sclerosis (n=1215, 49 yrs) Amyotrophic lateral sclerosis (n=125, 60 yrs) Stroke (n=757, 68 yrs) Alzheimer disease (n=1799, 79 yrs) Parkinson's disease (n=804, 73 yrs) CNS-LS score of ≥13 52% 46% 45% 38% 29% 26% CNS-LS score of ≥21 16% 12% 12% 9% 7% 6% Mean years from primary condition diagnosis to study enrollment 10.3 (n=347) 9.9 (n=785) 2.3 (n=108) 4.6 (n=395) 3.7 (n=656) 5.3 (n=386)
Table that shows presence of PBA crying and/or laughing symptoms in select neurologic conditions Table that shows presence of PBA crying and/or laughing symptoms in select neurologic conditionsNeurologic 
condition (n, mean age 
of patients) CNS-LS 
score 
of 13 ≥ CNS-LS 
score 
of 21 ≥ Mean years 
from primary 
condition 
diagnosis to 
study enrollment Traumatic brain injury (n=590, 49 yrs) 52% 16% 10.3 
(n=347) Multiple 
sclerosis (n=1215, 49 yrs) 46% 12% 9.9 
(n=785) Amyotrophic 
lateral 
sclerosis (n=125, 60 yrs) 45% 12% 2.3 
(n=108) Stroke (n=757, 68 yrs) 38% 9% 4.6 
(n=395) Alzheimer 
disease (n=1799, 79 yrs) 29% 7% 3.7 
(n=656) Parkinson’s 
disease (n=804, 73 yrs) 26% 6% 5.3 
(n=386)

*Based on the PRISM Registry, including 5290 patients with stroke, amyotrophic lateral sclerosis, multiple sclerosis, traumatic brain injury, Alzheimer disease, and Parkinson’s disease.1 CNS-LS is a self-administered questionnaire, designed to be completed by the patient with a 7-item rating scale that measures perceived frequency and severity of PBA episodes. It was validated as a screening tool in amyotrophic lateral sclerosis and multiple sclerosis populations.4,6 A CNS-LS score of ≥13 may suggest PBA symptoms, and a score of ≥21 may suggest more severe and frequent PBA symptoms.1

CNS-LS=Center for Neurologic Study-Lability Scale; yrs=years.

Three circles with three steps: 1 - Ask 2 - Differentiate 3 - Document

The key to diagnosing PBA

Learn 3 steps to help you assess patients for PBA.

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Hear from Dr Nick Fisher

Dr Nick Fisher
Dr Nick Fisher

Dr Fisher is a paid consultant of Otsuka America Pharmaceutical, Inc.

Prevalence of PBA in your practice

Dr Nick Fisher describes the common ways patients with PBA describe their condition.

The importance of screening for PBA

Dr Nick Fisher shares why some doctors screen all their patients for PBA.

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  • References: 1.

    Brooks BR, Crumpacker D, Fellus J, Kantor D, Kaye RE. PRISM: a novel research tool to assess the prevalence of pseudobulbar affect symptoms across neurological conditions. PLoS One. 2013;8(8):e72232. doi:10.1371/journal.pone.0072232

  • 2.

    Nuedexta. Package insert. Otsuka America Pharmaceutical, Inc.; 2022.

  • 3.

    Miller A, Pratt H, Schiffer RB. Pseudobulbar affect: the spectrum of clinical presentations, etiologies and treatments. Expert Rev Neurother. 2011;11(7):1077-1088. doi:10.1586/ern.11.68

  • 4.

    Hammond FM, Alexander DN, Cutler AJ, et al. PRISM II: an open-label study to assess effectiveness of dextromethorphan/quinidine for pseudobulbar affect in patients with dementia, stroke or traumatic brain injury. BMC Neurol. 2016;16:89. doi:10.1186/s12883-016-0609-0

  • 5.

    Suavé WM. Recognizing and treating pseudobulbar affect. CNS Spectr. 2016;21(S1):34-44. doi:10.1017/ S1092852916000791

  • 6.

    Pioro EP, Brooks BR, Cummings J, et al. Dextromethorphan plus ultra low-dose quinidine reduces pseudobulbar affect. Ann Neurol. 2010;68(5):693-702. doi:10.1002/ana.22093

IMPORTANT SAFETY INFORMATION and INDICATION for NUEDEXTA® (dextromethorphan HBr and quinidine sulfate)

IMPORTANT SAFETY INFORMATION

CONTRAINDICATIONS:

  • Quinidine and Related Drugs: NUEDEXTA contains quinidine and should not be used concomitantly with other drugs containing quinidine, quinine, or mefloquine.
  • Hypersensitivity: NUEDEXTA is contraindicated in patients with a history of NUEDEXTA-, quinine-, mefloquine-, or quinidine-induced thrombocytopenia, hepatitis, bone-marrow depression, lupus-like syndrome, or known hypersensitivity to dextromethorphan (e.g., rash, hives).
  • MAOIs: NUEDEXTA is contraindicated in patients taking monoamine oxidase inhibitors (MAOIs), or in patients who have taken MAOIs within the preceding 14 days, due to the risk of serious and possibly fatal drug interactions, including serotonin syndrome. Allow at least 14 days after stopping NUEDEXTA before starting an MAOI.
  • Cardiovascular: NUEDEXTA is contraindicated in patients with a prolonged QT interval, congenital long QT syndrome, history suggestive of torsades de pointes, heart failure, patients receiving drugs that both prolong QT interval and are metabolized by CYP2D6 (e.g., thioridazine and pimozide), patients with complete atrioventricular (AV) block without implanted pacemaker, or at high risk of complete AV block.

Thrombocytopenia and Other Hypersensitivity Reactions: Quinidine can cause immune-mediated thrombocytopenia that can be severe or fatal. Non-specific symptoms, such as lightheadedness, chills, fever, nausea, and vomiting, can precede or occur with thrombocytopenia. NUEDEXTA should be discontinued immediately if thrombocytopenia occurs.

Hepatotoxicity: Hepatitis, including granulomatous hepatitis, has been reported in patients receiving quinidine, generally during the first few weeks of therapy. Discontinue immediately if this occurs.

Cardiac Effects: NUEDEXTA causes dose-dependent QTc prolongation. QT prolongation can cause torsades de pointes-type ventricular tachycardia, with the risk increasing as the degree of prolongation increases. When initiating NUEDEXTA in patients at risk for QT prolongation and torsades de pointes, electrocardiographic (ECG) evaluation of QT interval should be conducted at baseline and 3 to 4 hours after the first dose. Some risk factors include use with CYP3A4 inhibitors or drugs that prolong QT interval, electrolyte abnormalities, bradycardia, or left ventricular hypertrophy or dysfunction. If patients taking NUEDEXTA experience symptoms that could indicate the occurrence of cardiac arrhythmias (e.g., syncope or palpitations), NUEDEXTA should be discontinued, and the patient further evaluated.

Concomitant Use of CYP2D6 Substrates: NUEDEXTA inhibits CYP2D6 and may interact with other drugs metabolized by CYP2D6. Adjust dose of CYP2D6 substrates as needed.

Dizziness: NUEDEXTA may cause dizziness. Take precautions to reduce the risk of falls.

Serotonin Syndrome: Use of NUEDEXTA with selective serotonin reuptake inhibitors (SSRIs) or tricyclic antidepressants increases the risk of “serotonin syndrome.”

Anticholinergic Effects of Quinidine: Monitor for worsening in myasthenia gravis.

Adverse Reactions: The most common adverse reactions (incidence of ≥3% and two-fold greater than placebo) in patients taking NUEDEXTA are diarrhea, dizziness, cough, vomiting, asthenia, peripheral edema, urinary tract infection, influenza, increased gamma-glutamyltransferase, and flatulence.

These are not all the risks for use of NUEDEXTA.

To report SUSPECTED ADVERSE REACTIONS, contact Otsuka America Pharmaceutical, Inc. at 1-800-438-9927 or FDA at 1-800-FDA-1088 (www.fda.gov/‌medwatch).

INDICATION

NUEDEXTA is indicated for the treatment of pseudobulbar affect (PBA).

PBA occurs secondary to a variety of otherwise unrelated neurologic 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. PBA is a specific condition, distinct from other types of emotional lability that may occur in patients with neurologic disease or injury.

Please see FULL PRESCRIBING INFORMATION.