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Akbar D, Rhee TG, Ceban F, Ho R, Teopiz KM, Cao B, Subramaniapillai M, Kwan ATH, Rosenblat JD, McIntyre RS. Dextromethorphan-Bupropion for the Treatment of Depression: A Systematic Review of Efficacy and Safety in Clinical Trials. CNS Drugs 2023; 37:867-881. [PMID: 37792265 DOI: 10.1007/s40263-023-01032-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/24/2023] [Indexed: 10/05/2023]
Abstract
BACKGROUND A significant proportion of adults with major depressive disorder (MDD) do not respond to treatments which are currently used in clinical practice such as first-generation monoamine-based antidepressants. OBJECTIVES The objective of this systematic review was to assess the efficacy, safety, and mechanisms of action of AXS-05, a combination of the NMDA-receptor antagonist dextromethorphan with bupropion, in adults with MDD. METHODS We searched PubMed, Embase, Google Scholar, and ClinicalTrials.gov for current studies reporting on efficacy and/or safety of AXS-05 in patients with MDD. The search terms included: "AXS-05" OR "dextromethorphan and bupropion" AND "depression". Studies from database inception to January 2023 were evaluated. Risk of bias was assessed using the Cochrane Risk of Bias tool. RESULTS The search yielded 54 studies of which 5 were included. All studies had low risk of bias. Depression severity, measured with the Montgomery-Åsberg Depression Rating Scale (MADRS) significantly decreased as early as 1-week post-treatment from baseline when compared to a placebo-controlled group (LS mean difference 2.2; 95% CI 0.6-3.9; p = 0.007) and at 2 weeks compared to an active control group (LS mean difference 4.7; 95% CI 0.6-8.8; p = 0.024). Treatment efficacy could be maintained for up to 12 months with mean MADRS score reduction of 23 points from baseline. Clinical remission and response rates also improved at week 1 and were maintained for 12 months. The treatment was well-tolerated, with some transient adverse events reported. CONCLUSION Current evidence suggests that the combination of dextromethorphan and bupropion is a well-tolerated, rapid-acting treatment option for adults with MDD. Initial success with AXS-05 supports the mechanistic role of glutamatergeric and sigma 1 signaling in the pathophysiology of MDD.
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Affiliation(s)
- Dania Akbar
- Mood Disorder Psychopharmacology Unit, University Health Network, Toronto, ON, Canada
| | - Taeho Greg Rhee
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
- VA New England Mental Illness, Research, Education and Clinical Center (MIRECC), VA Connecticut Healthcare System, West Haven, CT, USA
- Department of Public Health Sciences, University of Connecticut School of Medicine, Farmington, CT, USA
| | - Felicia Ceban
- Mood Disorder Psychopharmacology Unit, University Health Network, Toronto, ON, Canada
- Brain and Cognition Discovery Foundation (BCDF), 77 Bloor St W Suite 617, Toronto, ON, M5S 1M2, Canada
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Roger Ho
- Department of Psychological Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Institute for Health Innovation and Technology (iHealthtech), National University of Singapore, Singapore, Singapore
| | - Kayla M Teopiz
- Brain and Cognition Discovery Foundation (BCDF), 77 Bloor St W Suite 617, Toronto, ON, M5S 1M2, Canada
| | - Bing Cao
- Key Laboratory of Cognition and Personality, Faculty of Psychology, Ministry of Education, Southwest University, Chongqing, 400715, People's Republic of China
| | - Mehala Subramaniapillai
- Brain and Cognition Discovery Foundation (BCDF), 77 Bloor St W Suite 617, Toronto, ON, M5S 1M2, Canada
| | - Angela T H Kwan
- Mood Disorder Psychopharmacology Unit, University Health Network, Toronto, ON, Canada
- Brain and Cognition Discovery Foundation (BCDF), 77 Bloor St W Suite 617, Toronto, ON, M5S 1M2, Canada
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Joshua D Rosenblat
- Mood Disorder Psychopharmacology Unit, University Health Network, Toronto, ON, Canada
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Roger S McIntyre
- Brain and Cognition Discovery Foundation (BCDF), 77 Bloor St W Suite 617, Toronto, ON, M5S 1M2, Canada.
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada.
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, ON, Canada.
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2
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Boostani R, Olfati N, Shamshiri H, Salimi Z, Fatehi F, Hedjazi SA, Fakharian A, Ghasemi M, Okhovat AA, Basiri K, Haghi Ashtiani B, Ansari B, Raissi GR, Khatoonabadi SA, Sarraf P, Movahed S, Panahi A, Ziaadini B, Yazdchi M, Bakhtiyari J, Nafissi S. Iranian clinical practice guideline for amyotrophic lateral sclerosis. Front Neurol 2023; 14:1154579. [PMID: 37333000 PMCID: PMC10272856 DOI: 10.3389/fneur.2023.1154579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 05/09/2023] [Indexed: 06/20/2023] Open
Abstract
Amyotrophic lateral sclerosis (ALS) is a rapidly progressive neurodegeneration involving motor neurons. The 3-5 years that patients have to live is marked by day-to-day loss of motor and sometimes cognitive abilities. Enormous amounts of healthcare services and resources are necessary to support patients and their caregivers during this relatively short but burdensome journey. Organization and management of these resources need to best meet patients' expectations and health system efficiency mandates. This can only occur in the setting of multidisciplinary ALS clinics which are known as the gold standard of ALS care worldwide. To introduce this standard to the care of Iranian ALS patients, which is an inevitable quality milestone, a national ALS clinical practice guideline is the necessary first step. The National ALS guideline will serve as the knowledge base for the development of local clinical pathways to guide patient journeys in multidisciplinary ALS clinics. To this end, we gathered a team of national neuromuscular experts as well as experts in related specialties necessary for delivering multidisciplinary care to ALS patients to develop the Iranian ALS clinical practice guideline. Clinical questions were prepared in the Patient, Intervention, Comparison, and Outcome (PICO) format to serve as a guide for the literature search. Considering the lack of adequate national/local studies at this time, a consensus-based approach was taken to evaluate the quality of the retrieved evidence and summarize recommendations.
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Affiliation(s)
- Reza Boostani
- Department of Neurology, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Nahid Olfati
- Department of Neurology, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Hosein Shamshiri
- Department of Neurology, Faculty of Medicine, Tehran University of Medical Sciences, Tehran, Iran
- Neuromuscular Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Zanireh Salimi
- Psychiatry and Behavioral Sciences Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
- Department of Psychiatry, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Farzad Fatehi
- Department of Neurology, Faculty of Medicine, Tehran University of Medical Sciences, Tehran, Iran
- Neuromuscular Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Seyed Arya Hedjazi
- Legal Medicine Research Center, Legal Medicine Organization, Tehran, Iran
| | - Atefeh Fakharian
- Pulmonary Rehabilitation Research Center (PRRC), Shahid Beheshti University of Medical Sciences, Tehran, Iran
- National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Department of Internal Medicine, Faculty of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Majid Ghasemi
- Department of Neurology, Faculty of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Ali Asghar Okhovat
- Department of Neurology, Faculty of Medicine, Tehran University of Medical Sciences, Tehran, Iran
- Neuromuscular Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Keivan Basiri
- Department of Neurology, Faculty of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
- Isfahan Neuroscience Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Bahram Haghi Ashtiani
- Department of Neurology, Faculty of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Behnaz Ansari
- Department of Neurology, Faculty of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
- Isfahan Neuroscience Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
- AL Zahra Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Gholam Reza Raissi
- Department of Physical Medicine and Rehabilitation, Faculty of Medicine, Iran University of Medical Sciences, Tehran, Iran
- Neuromusculoskeletal Research Center, Iran University of Medical Sciences, Tehran, Iran
| | | | - Payam Sarraf
- Iranian Center of Neurological Research, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
- Department of Neurology, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Sara Movahed
- Department of Nutrition, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
- Metabolic Syndrome Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Akram Panahi
- Department of Neurology, Faculty of Medicine, Tehran University of Medical Sciences, Tehran, Iran
- Neuromuscular Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Bentolhoda Ziaadini
- Department of Neurology, Faculty of Medicine, Kerman University of Medical Sciences, Kerman, Iran
- Neurology Research Center, Kerman University of Medical Sciences, Kerman, Iran
| | - Mohammad Yazdchi
- Department of Neurology, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
- Neurosciences Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Jalal Bakhtiyari
- Department of Speech Therapy, School of Rehabilitation, Tehran University of Medical Sciences, Tehran, Iran
| | - Shahriar Nafissi
- Department of Neurology, Faculty of Medicine, Tehran University of Medical Sciences, Tehran, Iran
- Neuromuscular Research Center, Tehran University of Medical Sciences, Tehran, Iran
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3
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Majhi PK, Sayyad S, Mishra P, Kamte S, Sahu R, Ghosh G, Subudhi BB. Low-volume plasma sampling for determination of dextromethorphan and dextrorphan in rat plasma: LC-MS/MS method and its application in pharmacokinetic study. Biomed Chromatogr 2023; 37:e5588. [PMID: 36698254 DOI: 10.1002/bmc.5588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 01/12/2023] [Accepted: 01/20/2023] [Indexed: 01/27/2023]
Abstract
Dextromethorphan (DM) and its metabolite dextrorphan (DX) continue to draw the attention of researchers owing to their diverse pharmacodynamics. Thus, there are possibilities for repurposing DM. Most of the pharmacodynamics of DM needs further validation in different preclinical models. Also, it is necessary to correlate the pharmacodynamics with relevant pharmacokinetics data. Multiple bioanalytical techniques developed for this purpose primarily use a high sample processing volume. Since sample volume is a limiting factor for many preclinical models, an effort was taken to develop an alternative method suitable for handling low sample processing volumes. An efficient solid-phase extraction technique, robust liquid chromatographic (LC) separation and highly sensitive tandem mass spectrometric detection (MS/MS) showed suitability for use of a 30 μl sample processing volume. This led to the development of a highly specific, selective, accurate and precise-bio-analytical method for simultaneous quantification of DM and DX in rat plasma. The validated method was linear in the range of 0.196-403.356 ng/ml for DM and 0.102-209.017 ng/ml for DX. The application of the method was demonstrated through the estimation of pharmacokinetic parameters that showed good congruence with earlier studies.
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Affiliation(s)
- Praful Kumar Majhi
- School of Pharmaceutical Sciences, Siksha O Anusandhan Deemed to be University, Bhubaneswar, India.,Synapse Labs Pvt. Ltd, Pune, India
| | | | | | | | - Rajanikant Sahu
- School of Pharmaceutical Sciences, Siksha O Anusandhan Deemed to be University, Bhubaneswar, India
| | - Goutam Ghosh
- School of Pharmaceutical Sciences, Siksha O Anusandhan Deemed to be University, Bhubaneswar, India
| | - Bharat Bhusan Subudhi
- School of Pharmaceutical Sciences, Siksha O Anusandhan Deemed to be University, Bhubaneswar, India
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Abstract
BACKGROUND Antidepressants may be useful in the treatment of abnormal crying associated with stroke. This is an update of a Cochrane Review first published in 2004 and last updated in 2019. OBJECTIVES To evaluate the benefits and harms of pharmaceutical treatment in people with emotionalism after stroke. SEARCH METHODS We searched the Cochrane Stroke Group Register, CENTRAL, MEDLINE, Embase, four other databases, and three trials registers (May 2022). SELECTION CRITERIA We included randomised controlled trials (RCTs) and quasi-RCTs comparing psychotropic medication to placebo in people with stroke and emotionalism (also known as emotional lability, pathological crying or laughing, emotional incontinence, involuntary emotional expression disorder, and pseudobulbar affect). DATA COLLECTION AND ANALYSIS Two review authors independently selected trials, assessed risk of bias, extracted data from all included trials, and used GRADE to assess the certainty of the body of evidence. We calculated the mean difference (MD) or standardised mean difference (SMD) for continuous data and the risk ratio (RR) for dichotomous data, with 95% confidence intervals (CIs). We assessed heterogeneity using the I2 statistic. The primary emotionalism measures were the proportion of participants achieving at least a 50% reduction in abnormal emotional behaviour at the end of treatment, improved score on the Center for Neurologic Study - Lability Scale (CNS-LS) or Clinician Interview-Based Impression of Change (CIBIC), or diminished tearfulness. MAIN RESULTS We did not identify any new trials for this update. We included seven trials with a total of 239 participants. Two trials had a cross-over design, but outcome data were not available from the first phase (precross-over) in an appropriate format for inclusion as a parallel randomised controlled trial (RCT). Thus, the results of the review are based on five trials with a total of 213 participants. It is uncertain whether fluoxetine increases the number of people who have a 50% reduction in emotionalism when compared to placebo (risk ratio (RR) 0.26, 95% CI 0.09 to 0.77; P = 0.02; 1 trial, 19 participants) because the certainty of evidence is very low. Sertraline may lead to little to no difference in Center for Neurologic Study - Lability Scale (CNS-LS) scores and Clinician Interview-Based Impression of Change (CIBIC) scores when compared to placebo (RR 0.20, 95% CI 0.03 to 1.50; P = 0.12; 1 trial, 28 participants; low-certainty evidence). Antidepressants probably increase the number of people who experience a reduction in tearfulness (RR 0.32, 95% CI 0.12 to 0.86; P = 0.02; 3 trials, 164 participants; moderate-certainty evidence). No trials were found that evaluated the impact of other pharmaceutical interventions. Only two trial authors systematically recorded and reported adverse events, resulting in limited data on the potential harms of treatment. Six trials reported death as an adverse event and found no difference between the groups (antidepressants versus placebo) in the number of deaths reported (RR 0.59, 95% CI 0.08 to 4.50; P = 0.61; 172 participants; moderate-certainty evidence). This review provides very low- to moderate-certainty evidence that antidepressants may reduce the frequency and severity of emotionalism. The included trials were small and had some degree of bias. AUTHORS' CONCLUSIONS Antidepressants may reduce the frequency and severity of crying or laughing episodes when compared to placebo, based on very low-certainty evidence. Our conclusions must be qualified by several methodological deficiencies in the trials and interpreted with caution despite the effect being very large. The effect does not seem specific to one drug or class of drugs. More reliable data are required before appropriate conclusions can be made about the treatment of post-stroke emotionalism. Future trialists investigating the effect of antidepressants in people with emotionalism after stroke should consider developing and using a standardised method to diagnose emotionalism, determine severity, and assess change over time; provide treatment for a sufficient duration and follow-up to better assess rates of relapse or maintenance; and include careful assessment and complete reporting of adverse events.
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Affiliation(s)
- Sabine Allida
- Mental Health Program, The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Allan House
- Division of Psychological and Social Medicine, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Maree L Hackett
- Mental Health Program, The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia
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Herrmann N, Wang HJ, Song BX, Bawa KK, Lanctôt KL. Risks and benefits of current and novel drugs to treat agitation in Alzheimer's disease. Expert Opin Drug Saf 2022; 21:1289-1301. [PMID: 36252087 DOI: 10.1080/14740338.2022.2136162] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION At present, no pharmacological interventions have been approved for the treatment of agitation in Alzheimer's disease (AD), an important neuropsychiatric symptom that has been linked to increased mortality and greater caregiver burden. Antipsychotics offer some benefit, but increase the risk of adverse events such as falls, extrapyramidal symptoms, stroke, and mortality. Over the past 10 years, several new and repurposed medications have shown promise for treating AD-associated agitation. AREAS COVERED We review the risks and benefits of emerging therapies for agitation in AD, which include newer atypical antipsychotics, selective serotonin reuptake inhibitors, cannabinoids, and dextromethorphan combination products. Other drugs such as mirtazapine, prazosin, and lithium are also discussed. Clinicaltrials.gov, PubMed/MEDLINE, EMBASE and Cochrane Central databases were searched for relevant studies from 1 January 2012 to 1 May 2022. EXPERT OPINION At the present time, there are no pharmacological interventions for the treatment of agitation in AD whose benefits clearly outweigh their potential safety concerns. Therefore, management of agitation in AD should primarily be based on non-pharmacological approaches. When medications are considered necessary, they should only be initiated with the caregiver's appreciation of their risks and benefits and with careful and ongoing assessment of their safety.
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Affiliation(s)
- Nathan Herrmann
- Department of Psychiatry, Neuropsychopharmacology Research Group, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Hui Jue Wang
- Department of Psychiatry, Neuropsychopharmacology Research Group, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Department of Pharmacology and Toxicology, University of Toronto, Toronto, Ontario, Canada
| | - Bing Xin Song
- Department of Psychiatry, Neuropsychopharmacology Research Group, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Department of Pharmacology and Toxicology, University of Toronto, Toronto, Ontario, Canada
| | - Kritleen K Bawa
- Department of Psychiatry, Neuropsychopharmacology Research Group, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Krista L Lanctôt
- Department of Psychiatry, Neuropsychopharmacology Research Group, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada.,Department of Pharmacology and Toxicology, University of Toronto, Toronto, Ontario, Canada
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6
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Effect of dextromethorphan in the mouse forced swim and tail suspension tests: Evidence for involvement of the alpha receptors. LEARNING AND MOTIVATION 2021. [DOI: 10.1016/j.lmot.2021.101722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Khoury R, Marx C, Mirgati S, Velury D, Chakkamparambil B, Grossberg GT. AVP-786 as a promising treatment option for Alzheimer's Disease including agitation. Expert Opin Pharmacother 2021; 22:783-795. [PMID: 33615952 DOI: 10.1080/14656566.2021.1882995] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
INTRODUCTION To date, there is no FDA-approved treatment for agitation in Alzheimer's disease (AD). Medications currently used off-label have modest clinical efficacy and serious side effects. AREAS COVERED The authors review the pharmacology, mechanism of action, pharmacokinetics, efficacy, safety and tolerability data of AVP-786, for the treatment of agitation in AD. EXPERT OPINION AVP-786, the deuterated form of dextromethorphan/quinidine (AVP-923) which is an approved treatment for Pseudo-Bulbar Affect, emerges as a promising and safe treatment for agitation in AD. Deuteration is an innovative technology that accelerates drug development by conducting faster and less costly clinical trials. No phase II trial was conducted with AVP-786 for the treatment of agitation in AD; the decision to expedite the development of this drug was based on a successful phase II study with AVP-923. Phase III trials with AVP-786 (TRIAD-1 and TRIAD-2) showed mixed findings probably due to the difference in study design. Future phase III studies should use innovative study designs such as the Sequential Parallel Comparison Design to mitigate high placebo response, and the Cohen-Mansfield Agitation Inventory for agitation assessment. They should also include positron emission tomography studies to assess occupancy of various receptors in the brain after AVP-786 is administered.
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Affiliation(s)
- Rita Khoury
- Department of Psychiatry and Clinical Psychology, Saint Georges Hospital University Medical Center University of Balamand, Beirut, Lebanon
| | - Charlotte Marx
- Department of Psychiatry and Behavioral Neuroscience, Saint Louis University School of Medicine, Missouri, USA
| | - Sidney Mirgati
- Department of Psychiatry and Behavioral Neuroscience, Saint Louis University School of Medicine, Missouri, USA
| | - Divya Velury
- Department of Psychiatry and Behavioral Neuroscience, Saint Louis University School of Medicine, Missouri, USA
| | - Binu Chakkamparambil
- Department of Psychiatry and Behavioral Neuroscience, Saint Louis University School of Medicine, Missouri, USA
| | - George T Grossberg
- Department of Psychiatry and Behavioral Neuroscience, Saint Louis University School of Medicine, Missouri, USA
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Villeneuve Y, Cruz-Santiago D, Masson H, Clerc D. Treatment of pseudobulbar affect in a mixed neurodegenerative disorder with compounded quinidine capsules and dextromethorphan cough syrup. SAGE Open Med Case Rep 2020; 8:2050313X20921076. [PMID: 32547756 PMCID: PMC7273619 DOI: 10.1177/2050313x20921076] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2019] [Accepted: 03/27/2020] [Indexed: 11/29/2022] Open
Abstract
An elderly woman admitted in our geriatric inpatient unit suffered from disturbing outbursts of crying and, less frequently, episodes of laughing. The patient was diagnosed with pseudobulbar affect related to a mixed neurodegenerative disorder. This condition is often underdiagnosed and undertreated, despite being relatively frequent in patients with neurodegenerative disorders. This case report describes the treatment of pseudobulbar affect in this patient. The only available treatment in Canada for this condition, antidepressants, was not effective for our patient. Dextromethorphan/quinidine is a good accepted alternative, but the combination is not marketed in Canada. To manage this problem, we used compounded quinidine capsules and dextromethorphan cough syrup. The crying of our patient improved significantly and rapidly after the initiation of this treatment. This case will help professionals to review their central role in treating this complex and disabling condition.
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Affiliation(s)
- Yannick Villeneuve
- Department of Pharmacy, Institut Universitaire de Gériatrie de Montréal, Montreal, Quebec, Canada
- Yannick Villeneuve, Department of Pharmacy, Institut Universitaire de Gériatrie de Montréal, Montreal, Quebec, H3W 1W5, Canada.
| | - Diana Cruz-Santiago
- Department of Geriatric Medicine, Institut Universitaire de Gériatrie de Montréal, Montreal, Quebec, Canada
- Department of Family and Emergency Medicine, Université de Montréal, Montreal, Quebec, Canada
| | - Helene Masson
- Department of Neurosciences, Centre Hospitalier de l’Université de Montréal, Montreal, Quebec, Canada
| | - Doris Clerc
- Department of Geriatric Medicine, Institut Universitaire de Gériatrie de Montréal, Montreal, Quebec, Canada
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Hicks AJ, Clay FJ, Ponsford JL, Perry LA, Jayaram M, Batty R, Hopwood M. Pharmacotherapy for the Pseudobulbar Affect in Individuals Who Have Sustained a Traumatic Brain Injury: a Systematic Review. Neuropsychol Rev 2020; 30:28-50. [PMID: 31942705 DOI: 10.1007/s11065-020-09427-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2018] [Accepted: 01/03/2020] [Indexed: 12/11/2022]
Abstract
Pseudobulbar affect is a debilitating condition that significantly reduces quality of life for many individuals following traumatic brain injury (TBI). It is characterized by embarrassing and often uncontrollable episodes of crying or laughter. The aim of this systematic review was to evaluate the effectiveness of pharmacotherapy as compared to all other comparators for the management of pseudobulbar affect in adults who have sustained TBI. Six databases were searched, with additional hand searching of journals, clinical trials registries and international drug regulators to identify published and unpublished studies in English up to June 2018. Studies were eligible for this review if they included adults who had sustained a medically confirmed TBI and presented with pseudobulbar affect. All pharmacotherapy and comparator interventions were considered for inclusion, and study design was not limited to randomised controlled trials. Evidence quality was assessed using Joanna Briggs Institute Critical Appraisal Instruments. Two quasi-experimental studies examining the effectiveness of dextrometamorphan/quinidine (DM/Q) were identified. These studies reported that DM/Q was effective in reducing symptoms of pseudobulbar affect and had a positive safety profile, over follow-up periods of 3 months (n = 87) and 12 months (n = 23). However, both studies were limited by lack of a control group and a high dropout rate. The findings of twelve case reports examining the effectiveness of DM/Q (n = 6) and anti-depressants (n = 6) are also discussed. Further research is required to determine which pharmacological interventions provide the best outcomes for individuals with pseudobulbar affect following TBI, with consideration given to side effect profiles and financial costs.
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Affiliation(s)
- Amelia J Hicks
- Monash-Epworth Rehabilitation Research Centre, Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Melbourne, Australia.
| | - Fiona J Clay
- Department of Psychiatry, University of Melbourne, Melbourne, Australia.,Department of Forensic Medicine, Monash University, Southbank, Australia.,Albert Road Clinic, Department of Psychiatry, University of Melbourne, Melbourne, Australia
| | - Jennie L Ponsford
- Monash-Epworth Rehabilitation Research Centre, Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Melbourne, Australia
| | - Luke A Perry
- Department of Psychiatry, University of Melbourne, Melbourne, Australia
| | - Mahesh Jayaram
- Department of Psychiatry, University of Melbourne, Melbourne, Australia
| | - Rachel Batty
- Department of Psychiatry, University of Melbourne, Melbourne, Australia
| | - Malcolm Hopwood
- Department of Psychiatry, University of Melbourne, Melbourne, Australia.,Albert Road Clinic, Department of Psychiatry, University of Melbourne, Melbourne, Australia
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10
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Finegan E, Chipika RH, Li Hi Shing S, Hardiman O, Bede P. Pathological Crying and Laughing in Motor Neuron Disease: Pathobiology, Screening, Intervention. Front Neurol 2019; 10:260. [PMID: 30949121 PMCID: PMC6438102 DOI: 10.3389/fneur.2019.00260] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Accepted: 02/26/2019] [Indexed: 12/11/2022] Open
Abstract
Pathological crying and laughing (PCL) has significant quality-of-life implications in amyotrophic lateral sclerosis (ALS); it can provoke restrictive life-style modifications and lead to social isolation. Despite its high prevalence and quality of life implications, it remains surprisingly understudied. Divergent pathophysiological models have been proposed, centered on corticobulbar tract degeneration, prefrontal cortex pathology, sensory deafferentation, and impaired cerebellar gate-control mechanisms. Quantitative MRI techniques and symptom-specific clinical instruments offer unprecedented opportunities to elucidate the anatomical underpinnings of PCL pathogenesis. Emerging neuroimaging studies of ALS support the role of cortico-pontine-cerebellar network dysfunction in context-inappropriate emotional responses. The characterization of PCL-associated pathophysiological processes is indispensable for the development of effective pharmacological therapies.
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Affiliation(s)
| | | | | | | | - Peter Bede
- Computational Neuroimaging Group, Biomedical Sciences Institute, Trinity College Dublin, Dublin, Ireland
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11
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Hakimi M, Maurer CW. Pseudobulbar Affect in Parkinsonian Disorders: A Review. J Mov Disord 2019; 12:14-21. [PMID: 30732430 PMCID: PMC6369372 DOI: 10.14802/jmd.18051] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Accepted: 12/14/2018] [Indexed: 12/11/2022] Open
Abstract
Pseudobulbar affect (PBA) is a neurological symptom of inappropriate and uncontrollable laughter or crying that occurs secondary to a variety of neurological conditions, including parkinsonian disorders. PBA is a socially and emotionally debilitating symptom that has been estimated to affect 3.6% to 42.5% of the population with Parkinson's disease. While indexing measures and treatment options for PBA have been extensively studied in neurological conditions such as amyotrophic lateral sclerosis and multiple sclerosis, there has been considerably less attention given in the literature to PBA in parkinsonian disorders. The purpose of this review is to discuss the pathophysiology of PBA, its prevalence and impact on quality of life in parkinsonian disorders, and the treatment options currently available. Areas requiring further study, including the development of standardized, cross-culturally validated methods of symptom assessment, and evidence-based studies exploring the efficacy of current treatment options in parkinsonian disorders, are also highlighted.
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Affiliation(s)
- Mathew Hakimi
- Stony Brook University School of Medicine, Stony Brook, NY, USA
| | - Carine W Maurer
- Department of Neurology, Stony Brook University School of Medicine, Stony Brook, NY, USA
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12
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The psychopharmacology of pseudobulbar affect. ACTA ACUST UNITED AC 2019; 165:243-251. [DOI: 10.1016/b978-0-444-64012-3.00014-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2023]
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13
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Clay FJ, Hicks AJ, Perry LA, Ponsford JL, Jayaram M, Hopwood M. Pharmacotherapy for the pseudobulbar affect in individuals who have sustained a traumatic brain injury: a systematic review protocol. JBI DATABASE OF SYSTEMATIC REVIEWS AND IMPLEMENTATION REPORTS 2018; 16:1739-1757. [PMID: 30204664 DOI: 10.11124/jbisrir-2017-003648] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Abstract
REVIEW OBJECTIVE/QUESTION The objective of this systematic review is to synthesize current evidence on the effectiveness of pharmacotherapy as compared to all comparators for the management of pseudobulbar affect in adults 16 years and over who have sustained a traumatic brain injury. The specific review question is: What is the effectiveness of pharmacotherapy for the management of pseudobulbar affect in adults 16 years and over who have sustained a traumatic brain injury?
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Affiliation(s)
- Fiona J Clay
- Department of Psychiatry, University of Melbourne, Melbourne, Australia
- Department of Forensic Medicine, Monash University, Melbourne, Australia
- Joanna Briggs Institute, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, Australia
| | - Amelia J Hicks
- Monash-Epworth Rehabilitation Research Centre, Monash Institute of Cognitive and Clinical Neurosciences, School of Psychological Sciences, Monash University, Melbourne, Australia
| | - Luke A Perry
- Department of Psychiatry, University of Melbourne, Melbourne, Australia
| | - Jennie L Ponsford
- Monash-Epworth Rehabilitation Research Centre, Monash Institute of Cognitive and Clinical Neurosciences, School of Psychological Sciences, Monash University, Melbourne, Australia
| | - Mahesh Jayaram
- Department of Psychiatry, University of Melbourne, Melbourne, Australia
| | - Malcolm Hopwood
- Department of Psychiatry, University of Melbourne, Melbourne, Australia
- Professorial Psychiatry Unit Albert Road Clinic, Department of Psychiatry, University of Melbourne, Melbourne, Australia
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Nguyen L, Scandinaro AL, Matsumoto RR. Deuterated (d6)-dextromethorphan elicits antidepressant-like effects in mice. Pharmacol Biochem Behav 2017; 161:30-37. [DOI: 10.1016/j.pbb.2017.09.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2017] [Revised: 08/23/2017] [Accepted: 09/08/2017] [Indexed: 12/11/2022]
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Liu T, Li J, Huang S, Li C, Zhao Z, Wen G, Chen F. Altered resting-state functional activity in isolated pontine infarction patients with pathological laughing and crying. Oncotarget 2017; 8:84529-84539. [PMID: 29137445 PMCID: PMC5663617 DOI: 10.18632/oncotarget.19307] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Accepted: 06/24/2017] [Indexed: 12/11/2022] Open
Abstract
We used resting-state functional magnetic resonance imaging to investigate the global spontaneous neural activity involved in pathological laughing and crying after stroke. Twelve pathological laughing and crying patients with isolated pontine infarction were included, along with 12 age- and gender-matched acute isolated pontine infarction patients without pathological laughing and crying, and 12 age- and gender-matched healthy controls. We examined both the amplitude of low-frequency fluctuation and the regional homogeneity in order to comprehensively evaluate the intrinsic activity in patients with post-stroke pathological laughing and crying. In the post-stroke pathological laughing and crying group, changes in these measures were observed mainly in components of the default mode network (medial prefrontal cortex/anterior cingulate cortex, middle temporal gyrus, inferior temporal gyrus, superior frontal gyrus, middle frontal gyrus and inferior parietal lobule), sensorimotor network (supplementary motor area, precentral gyrus and paracentral lobule), affective network (medial prefrontal cortex/anterior cingulate cortex, parahippocampal gyrus, middle temporal gyrus and inferior temporal gyrus) and cerebellar lobes (cerebellum posterior lobe). We therefore speculate that when disinhibition of the volitional system is lost, increased activation of the emotional system causes pathological laughing and crying.
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Affiliation(s)
- Tao Liu
- Department of Neurology, Hainan General Hospital, Haikou 570311, China
| | - Jianjun Li
- Department of Radiology, Hainan General Hospital, Haikou 570311, China
| | - Shixiong Huang
- Department of Neurology, Hainan General Hospital, Haikou 570311, China
| | - Changqinq Li
- Department of Radiology, Hainan General Hospital, Haikou 570311, China
| | - Zhongyan Zhao
- Department of Neurology, Hainan General Hospital, Haikou 570311, China
| | - Guoqiang Wen
- Department of Neurology, Hainan General Hospital, Haikou 570311, China
| | - Feng Chen
- Department of Radiology, Hainan General Hospital, Haikou 570311, China
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Garay RP, Grossberg GT. AVP-786 for the treatment of agitation in dementia of the Alzheimer's type. Expert Opin Investig Drugs 2016; 26:121-132. [PMID: 27936965 DOI: 10.1080/13543784.2017.1267726] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Agitation is common and distressing in patients with Alzheimer-type dementia, but safe, effective treatments remain elusive. Psychological treatments are first-line options, but they have limited efficacy. Off-label psychotropic medications are frequently used, but they also have limited effectiveness, and their use may have harmful side effects, including death. Areas covered: This review discusses the history leading to the conception of AVP-786 (deuterated (d6)-dextromethorphan/quinidine), its pharmacokinetic and pharmacodynamic profiles and safety issues, together with an overview of recent clinical trials. Data were found in the medical literature, in US and EU clinical trial registries and in information provided by the manufacturer. Expert opinion: AVP-786 is one of six investigational compounds in recent phase III clinical development for agitation in Alzheimer disease (AD). Quinidine and deuteration appear to prolong dextromethorphan's plasma half-life and facilitate brain penetration. The FDA granted fast-track designation to AVP-786 and allowed use of data generated on dextromethorphan-quinidine (AVP-923, Nuedexta®) for regulatory filings. AVP-923 reduced agitation in AD and was well tolerated in a phase II RCT that included more than 200 patients. A phase III clinical development program of AVP-786 for AD agitation was recently initiated. This program is expected to start generating results in July 2018.
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Affiliation(s)
- Ricardo P Garay
- a Geriatric Psychiatry, Department of Psychiatry and Behavioural Neuroscience , Pharmacology and Therapeutics, Craven , Villemoisson-sur-Orge , France
| | - George T Grossberg
- b Department of Psychiatry and Behavioural Neuroscience , St Louis University School of Medicine , St Louis , MO , USA
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Chang YD, Davis MP, Smith J, Gutgsell T. Pseudobulbar Affect or Depression in Dementia? J Pain Symptom Manage 2016; 51:954-8. [PMID: 26899823 DOI: 10.1016/j.jpainsymman.2015.12.321] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Revised: 12/21/2015] [Accepted: 12/24/2015] [Indexed: 12/11/2022]
Affiliation(s)
- Young D Chang
- Department of Supportive Care, Moffitt Cancer Center, Tampa, Florida, USA
| | - Mellar P Davis
- Harry R. Horvitz Center for Palliative Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA.
| | - Joshua Smith
- Department of Supportive Care, Moffitt Cancer Center, Tampa, Florida, USA
| | - Terrence Gutgsell
- Harry R. Horvitz Center for Palliative Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA
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Abstract
Life-threatening and benign drug reactions occur frequently in the skin, affecting 8 % of the general population and 2-3 % of all hospitalized patients, emphasizing the need for physicians to effectively recognize and manage patients with drug-induced eruptions. Neurologic medications represent a vast array of drug classes with cutaneous side effects. Approximately 7 % of the United States (US) adult population is affected by adult-onset neurological disorders, reflecting a large number of patients on neurologic drug therapies. This review elucidates the cutaneous reactions associated with medications approved by the US Food and Drug Administration (FDA) to treat the following neurologic pathologies: Alzheimer disease, amyotrophic lateral sclerosis, epilepsy, Huntington disease, migraine, multiple sclerosis, Parkinson disease, and pseudobulbar affect. A search of the literature was performed using the specific FDA-approved drug or drug classes in combination with the terms 'dermatologic,' 'cutaneous,' 'skin,' or 'rash.' Both PubMed and the Cochrane Database of Systematic Reviews were utilized, with side effects ranging from those cited in randomized controlled trials to case reports. It behooves neurologists, dermatologists, and primary care physicians to be aware of the recorded cutaneous adverse reactions and their severity for proper management and potential need to withdraw the offending medication.
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Affiliation(s)
| | | | - Sylvia Hsu
- Department of Dermatology, Baylor College of Medicine, Houston, TX, USA
| | - Joseph S Kass
- Department of Neurology, Baylor College of Medicine, 7200 Cambridge St., 9th Floor, Houston, TX, 77030, USA.
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Nguyen L, Thomas KL, Lucke-Wold BP, Cavendish JZ, Crowe MS, Matsumoto RR. Dextromethorphan: An update on its utility for neurological and neuropsychiatric disorders. Pharmacol Ther 2016; 159:1-22. [PMID: 26826604 DOI: 10.1016/j.pharmthera.2016.01.016] [Citation(s) in RCA: 74] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Dextromethorphan (DM) is a commonly used antitussive and is currently the only FDA-approved pharmaceutical treatment for pseudobulbar affect. Its safety profile and diverse pharmacologic actions in the central nervous system have stimulated new interest for repurposing it. Numerous preclinical investigations and many open-label or blinded clinical studies have demonstrated its beneficial effects across a variety of neurological and psychiatric disorders. However, the optimal dose and safety of chronic dosing are not fully known. This review summarizes the preclinical and clinical effects of DM and its putative mechanisms of action, focusing on depression, stroke, traumatic brain injury, seizure, pain, methotrexate neurotoxicity, Parkinson's disease and autism. Moreover, we offer suggestions for future research with DM to advance the treatment for these and other neurological and psychiatric disorders.
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Affiliation(s)
- Linda Nguyen
- Department of Behavioral Medicine and Psychiatry, School of Medicine, West Virginia University, Morgantown, WV 26506, USA; Department of Pharmaceutical Sciences, School of Pharmacy, West Virginia University, Morgantown, WV 26506, USA
| | - Kelan L Thomas
- College of Pharmacy, Touro University California, Vallejo, CA 94592, USA
| | - Brandon P Lucke-Wold
- Graduate Program in Neuroscience, School of Medicine, West Virginia University, Morgantown, WV 26506, USA
| | - John Z Cavendish
- Graduate Program in Neuroscience, School of Medicine, West Virginia University, Morgantown, WV 26506, USA
| | - Molly S Crowe
- Department of Psychology, West Virginia University, Morgantown, WV 26506, USA
| | - Rae R Matsumoto
- Department of Behavioral Medicine and Psychiatry, School of Medicine, West Virginia University, Morgantown, WV 26506, USA; College of Pharmacy, Touro University California, Vallejo, CA 94592, USA.
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Wang G, Teng F, Chen Y, Liu Y, Li Y, Cai L, Zhang X, Nie Z, Jin L. Clinical Features and Related Factors of Poststroke Pathological Laughing and Crying: A Case–Control Study. J Stroke Cerebrovasc Dis 2016; 25:556-64. [DOI: 10.1016/j.jstrokecerebrovasdis.2015.11.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Revised: 10/26/2015] [Accepted: 11/03/2015] [Indexed: 12/14/2022] Open
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Lapchak PA. Neuronal Dysregulation in Stroke-Associated Pseudobulbar Affect (PBA): Diagnostic Scales and Current Treatment Options. ACTA ACUST UNITED AC 2015; 6. [PMID: 26693049 PMCID: PMC4675467 DOI: 10.4172/2155-9562.1000323] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Until recently there was little understanding of the exact pathophysiology and treatment choices for stroke patients with Pseudobulbar affect (PBA). PBA is typically characterized by outbursts or uncontrollable laughing or crying and in the majority of patients, the outbursts being involuntary and incompatible with the patients' emotional state. PBA is a behavioral syndrome reported to be displayed in 28-52% of stroke patients with first or multiple strokes, and incidence may be higher in patients who have had prior stroke events, and higher in females. There is typically involvement of glutaminergic, serotoninergic and dopaminergic neuronal circuits of the corticolimbic-subcorticothalamic-pontocerebellar network. PBA is now understood to be a disinhibition syndrome in which specific pathways involving serotonin and glutamate are disrupted or modulated causing reduced cortical inhibition of a cerebellar/brainstem-situated "emotional" laughing or crying focal center. Stroke-induced disruption of one or more neuronal pathway circuits may "disinhibit" voluntary laughing and crying making the process involuntary. With a "new" treatment currently being marketed to treat PBA patients, this article will delve into the neurological and physiological basis for PBA in stroke, and review progress with the diagnosis and treatment of PBA.
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Affiliation(s)
- Paul A Lapchak
- Department of Neurology & Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, USA
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Affiliation(s)
- Marian W Roman
- a University of Tennessee , College of Nursing , Knoxville , Tennessee , USA
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