Off-Label Dextromethorphan/Bupropion for Emotional Lability Following Resection of an IDH-Mutant Astrocytoma: A Case Report
Olivia Hill, Riley K Imlay, Ankit Chalia, Sowjanya Kalluri, Venkata Sugnanam, Michael Ang-Rabanes, Raja Mogallapu
Healthcare October 20, 2026 DOI: 10.3390/healthcare14203530 (opens in new tab)
Study at a glance
AI-extracted from the abstract| Characteristics | Case study Case report Peer reviewed |
|---|---|
| Sample size | 1 |
| Population | A 42-year-old woman with a history of resected right frontal IDH-mutant grade 2 astrocytoma and symptoms of pseudobulbar affect |
| Interventions | Dextromethorphan/quinidine Dextromethorphan/bupropion |
| Duration | Six weeks after initiation of dextromethorphan/bupropion |
| Measures | Center for Neurologic Study–Lability Scale (CNS-LS), Patient Health Questionnaire-9 (PHQ-9) |
| Key findings | In this single patient, off-label dextromethorphan/bupropion was associated with a reduction in CNS-LS score from 21 to 10 and PHQ-9 from 9 to 4 at six weeks, along with fewer crying episodes and improved subjective executive difficulties; symptoms recurred when treatment was interrupted and improved after resumption. The authors state the findings are hypothesis-generating and cannot establish efficacy or causality. |
Abstract
Pseudobulbar affect (PBA) is characterized by recurrent, involuntary episodes of crying or laughing that may be disproportionate or incongruent with an individual’s underlying mood. Although dextromethorphan/quinidine is FDA-approved for PBA, clinical experience with dextromethorphan/bupropion for this indication remains limited. We describe a 42-year-old woman with a history of resected right frontal IDH-mutant grade 2 astrocytoma who developed recurrent episodes of involuntary crying associated with emotional lability and subjective executive difficulties. At initial behavioral-health evaluation, the Center for Neurologic Study–Lability Scale (CNS-LS) score was 21/35 and the Patient Health Questionnaire-9 (PHQ-9) score was 9. The phenomenology of the crying episodes, clinical examination, neurological history, imaging surveillance, and consideration of alternative explanations supported a working clinical diagnosis of PBA, although the CNS-LS was used as a symptom measure rather than a stand-alone diagnostic test. Treatment with dextromethorphan/quinidine was associated with an initial reduction in crying episodes and CNS-LS score, followed by recurrence of symptoms. Because further treatment modification was limited by insurance coverage, an off-label trial of dextromethorphan/bupropion was subsequently initiated. Six weeks later, the CNS-LS score had decreased to 10 and the PHQ-9 score to 4. Subjective executive difficulties also improved. A temporary interruption in dextromethorphan/bupropion was followed by recurrence of crying episodes, with improvement after treatment was resumed. This case describes an association between off-label dextromethorphan/bupropion exposure and improvement in emotional-lability symptoms in a patient with a complex neurological and psychiatric presentation. The findings are hypothesis-generating and cannot establish efficacy or causality because of the single-patient design, absence of repeated CNS-LS assessments at all visits, and concomitant medication changes. Controlled studies are needed to determine whether dextromethorphan/bupropion has a therapeutic role in PBA.