Nuedexta

Background

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Originally introduced and approved by the FDA as Zenvia in 2010, Avanir Pharmaceuticals renamed the drug to Nuedexta.

A report by CNN claims that sales of Nuedexta increased five-fold to $300m in 2018 as a result of the mis-prescribing, with around half those revenues coming from use of the drug in elderly care facilities.

According to MedPage Today, Dextromethorphan-quinidine (Nuedexta), approved by the FDA for pseudobulbar affect based on studies in patients with amyotrophic lateral sclerosis (ALS) or multiple sclerosis (MS), appeared to be prescribed primarily for patients with other underlying disorders, an analysis of insurance records found.

Few patients who received the drug had a diagnosis of MS (8.4%) or ALS (6.8%); most (57%) had a diagnosis of dementia or Parkinson's disease, reported Aaron Kesselheim, MD, JD, MPH, of Brigham and Women's Hospital in Boston, and co-authors in JAMA Internal Medicine.

Otsuka paid $3.5bn to acquire Avanir in 2014 as part of a strategy to expand its presence in the central nervous system (CNS) disease category in the US. At the time, it said AVP-786 (second-generation version of Nuedexta) was one of the main attractions of the business.

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Shares in the Japanese company plunged 14% in the wake of the new trial announcement, while Concert Pharmaceuticals – which out-licensed the drug to Avanir – was also hit hard.

Based upon reports, a more than 15-fold increase in the number of patients prescribed Nuedexta from 2011 to 2016 — 3,296 to 50,402, respectively – was also found. Likewise, the reported spending by Centers for Medicare & Medicaid Services on Nuedexta increased from $3.9 million in 2011 to $200.4 million in 2016, the study found.

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Treatment / Use

According to Drugs.com, Nuedexta is the first and only FDA-approved treatment for pseudobulbar affect (PBA). 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 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 patient's 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. The primary outcome measure, laughing and crying episodes, was significantly lower in the Nuedexta arm compared to placebo. The secondary outcome measure, the Center for Neurologic Studies Lability Scale (CNS-LS), demonstrated a significantly greater mean decrease in CNS-LS score from baseline for the Nuedexta arm compared to placebo.

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Injuries / Complications / Concerns

Between October 2011 and April 2016, Dr. Raheja wrote 10,088 prescriptions for Nuedexta, the most of any doctor in the country, according to prosecutors.

There have been reports of adverse events including falls and deaths associated with Nuedexta.