What alternative treatments can be given to a geriatric patient with Pseudobulbar Affect (PBA) who cannot afford Nuedexta (dextromethorphan and quinidine)?

Alternative Treatments for Pseudobulbar Affect When Nuedexta is Unaffordable

Selective serotonin reuptake inhibitors (SSRIs) are the recommended first-line alternative to dextromethorphan/quinidine for treating pseudobulbar affect in geriatric patients who cannot afford Nuedexta. 1

Primary Alternative: SSRIs

• SSRIs represent the most practical alternative for PBA treatment when cost is prohibitive, as they have demonstrated efficacy in managing emotional lability and are significantly less expensive than branded dextromethorphan/quinidine 1
• While SSRIs lack the robust controlled trial data that dextromethorphan/quinidine possesses, they have been used successfully in clinical practice for PBA management 2, 3
• Common SSRI options include fluoxetine, sertraline, or citalopram, though specific dosing should be conservative in geriatric patients 1

Secondary Alternative: Tricyclic Antidepressants

• Tricyclic antidepressants (TCAs), particularly amitriptyline, have been used for PBA but require significant caution in elderly patients 2, 3
• TCAs carry substantial anticholinergic effects, orthostatic hypotension risk, sedation, and cardiac conduction abnormalities—all particularly problematic in geriatric populations 4
• If a TCA is necessary, use secondary amine TCAs (desipramine or nortriptyline) rather than tertiary amines like amitriptyline, as they have fewer anticholinergic side effects 4
• Start with the lowest available dose and escalate slowly, monitoring closely for falls, confusion, urinary retention, and cardiac effects 4

Third-Line Option: Divalproex Sodium

• Divalproex sodium (Depakote) may be considered for emotional lability, starting at 125 mg twice daily and titrating to therapeutic levels (40-90 mcg/mL) 1
• This option requires monitoring of drug levels and hepatic function, particularly in elderly patients
• Divalproex carries risks of sedation, tremor, and potential drug interactions that must be weighed carefully 1

Critical Considerations for Geriatric Patients

• Acknowledge and educate the patient and family about PBA to defuse potentially uncomfortable social situations, as understanding the neurological basis can reduce distress 4
• Cognitive and emotional therapy, psychotherapy, and support groups should be incorporated as non-pharmacological adjuncts regardless of medication choice 4
• Monitor for falls risk with any psychoactive medication in this population, as geriatric patients with neurological conditions have heightened vulnerability 4
• Avoid using dextromethorphan/quinidine in elderly patients with dementia if it can be obtained, as it has limited efficacy for behavioral symptoms without true PBA and increases fall risk 5, 6

Compounded Alternative (If Feasible)

• Compounded dextromethorphan-quinidine suspension has been used successfully in hospice settings and may be more cost-effective than branded Nuedexta, though availability depends on local compounding pharmacy access 7
• This option provides the same therapeutic benefit as the branded product at potentially lower cost 7
• Requires a compounding pharmacy willing to prepare the formulation and may still be cost-prohibitive depending on insurance coverage

Important Caveats

• Assess treatment efficacy within 1 month of starting any alternative therapy, as response should be evident relatively quickly 1
• If the patient has pre-existing cardiac conditions, avoid medications that prolong QT interval (including TCAs and theoretically high-dose SSRIs) 1
• Rule out depression as a contributing factor, as treating underlying mood disorders may improve emotional regulation independent of PBA-specific therapy 4
• The evidence base for alternatives to dextromethorphan/quinidine is substantially weaker, consisting primarily of case series and clinical experience rather than controlled trials 3