4.11 Drugs for dementia

NICE TA217: Alzheimer's disease - donepezil, galantamine, rivastigmine and memantine (updated June 2018)

NICE CG42: Dementia (November 2006)

Prescribing information:

Other resources:

Behavioural and psychological symptoms can be part of the dementing process, but it is important to exclude any intercurrent illness. Behavioural and psychological approaches are important and the use of medication has a lower profile. If medication is used, the rule of start low, go slow, monitor effects frequently applies. It is important to review any drug at regular intervals and assess whether it can be stopped as the treatment symptoms may have remitted.

Only specialists in the care of patients with dementia (that is, psychiatrists including those specialising in learning disability, neurologists, and physicians specialising in the care of older people) should make a diagnosis of Alzheimer's Dementia, assess whether the individual is suitable for treatment and initiate treatment where appropriate.

Oral solutions, orodispersible and patch preparations of dementia drugs should not be used routinely but may occasionally be initiated by specialists for patients in whom tablets are not suitable.

Donepezil hydrochloride
  • Tablet 5mg, 10mg (£1.11 = 10mg daily)
  • Orodispersible tablets 5mg, 10mg (£8.12 = 10mg daily)

Indications

Dose

  • Initially 5mg once daily at bedtime, increased if necessary after one month to maximum 10mg daily
  • Hepatic impairment: mild to moderate hepatic impairment: dose escalation according to individual tolerability. No data is available for patients with severe hepatic impairment.

Notes

  1. Donepezil has a long half-life so short accidental omission unlikely to have serious consequences
Galantamine
  • Luventa® XL capsules MR 8mg, 16mg, 24mg (£39.10 = 24mg daily)
  • Tablet 8mg, 12mg (£74.10 = 12mg twice daily)
  • Oral solution 4mg/ml (£437.00 = 100ml)

Indications

Dose

  • Standard release: initially 4mg twice daily for 4 weeks increased to 8mg twice daily for 4 weeks; maintenance 8–12mg twice daily
  • Modified release: initially 8mg once daily for 4 weeks increased to 16mg once daily for 4 weeks; maintenance 16–24mg daily
  • Hepatic impairment: moderately impaired hepatic function - begin dosing at 4mg once daily (taken in morning) for at least one week. Thereafter, proceed with 4mg twice daily for at least four weeks. In these patients, daily doses should not exceed 8mg twice daily. No dosage adjustment required for patients with mild hepatic impairment.

Notes

  1. It is sensible to re-titrate galantamine from initial dose in the event of a treatment break (this is not mentioned in the product SPC)
Memantine
  • Tablet 10mg, 20mg (£2.56 = 20mg daily)
  • Oral solution 10mg per ml (£55.86 = 50ml)

Indications

Dose

  • Initially 5mg once daily, at the same time of day, increased in steps of 5mg at weekly intervals to maximum 20mg daily
  • Dose in renal impairment: Mild renal impairment (creatinine clearance 50-80ml/min), no dose adjustment required. Moderate renal impairment (creatinine clearance 30-49ml/min) the daily dose should be 10mg. If tolerated well after at least 7 days, the dose could be increased to 20mg/day.
  • Severe renal impairment (creatinine clearance 5-29ml/min) the daily dose should be 10mg.
  • Dose titration:
    • Week one: 0.5ml solution (5mg) per day for 7 days
    • Week two: 1ml solution (10mg) per day for 7 days
    • Week three: 1.5ml solution (15mg) per day for 7 days
    • Week four: 2ml solution (20mg) per day (maintenance / maximum dose)

Notes

  1. Ensure the person administering the oral solution pump is familiar with it's safe usage
Rivastigmine
  • Capsule 1.5mg, 3mg, 4.5mg, 6mg (£5.22 = 2 x 3mg twice daily)
  • Oral solution 2mg/ml (£96.82 = 120ml)
  • Alzest® patches 4.6mg/24 hours, 9.5mg/24 hours (£19.97 = 9.5mg x 30 patches)
  • Patches 13.3mg/24 hours (£77.97 = 30 patches)

Indications

  • Mild to moderate dementia in Alzheimer's disease (oral or transdermal)
  • Mild to moderate dementia in Parkinson's disease (oral)

Dose

  • Oral, initially 1.5mg twice daily, increased in steps of 1.5mg twice daily at intervals of at least 2 weeks according to response and tolerance; usual range 3–6mg twice daily; maximum 6mg twice daily; if treatment interrupted for more than several days, treatment should be retitrated from 1.5mg twice daily
  • Transdermal application, initially apply 4.6mg/24 hours patch, removing after 24 hours and siting a replacement patch on a different area; after at least 4 weeks, and if well tolerated, increase to usual maintenance dose of 9.5mg/24 hours patch daily; after a further 6 months if well tolerated and cognitive deterioration or functional decline are demonstrated, the dose can be increased to 13.3mg/24 hours patch daily (caution in patients with body-weight less than 50 kg); if treatment interrupted for more than three days, treatment should be retitrated from 4.6mg/24 hours patch
  • Renal or hepatic impairment: oral formulations, moderate renal impairment and mild to moderate hepatic impairment - titrate according to individual tolerability.

Notes

  1. Rivastigmine is the only cholinesterase inhibitor currently licensed for use in Parkinson's Disease.
  2. When prescribing rivastigmine patches 4.6mg/ 24 hours and 9.5mg/24hours, prescribing as branded Alzest® is recommended as it is significantly lower cost.
  3. Rivastigmine patches MHRA Drug Safety Update (June 2010)Symptoms of rivastigmine overdose include nausea, vomiting, diarrhoea, hypertension, and hallucinations; bradycardia and/or syncope, associated with malaise or falls, may also occur. In case of suspected overdose, all rivastigmine patches should be removed immediately and no further patch should be applied for the next24 hours
  4. It is important to instruct patients and caregivers on the proper use of thetransdermal patch, particularly that:
    1. Only one patch should be applied per day to healthy skin on the upper or lower back, upper arm, or chest
    2. The patch should be replaced by a new one after 24 hours, and the previous day's patch must be removed before application of a new patch to a different skin location
    3. Application to the same skin location within 14 days should be avoided to minimise skin irritation
    4. The patch should not be cut into pieces

 

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