28 April 2011
A NICE review and re-appraisal of donepezil, galantamine, rivastigmine and memantine for the treatment of Alzheimer’s disease has resulted in a change in the guidance.
- the three acetylcholinesterase (AChE) inhibitors*(donepezil, galantamine and rivastigmine) are now recommended as options for managing mild as well as moderate Alzheimer’s disease, and
- memantine is now recommended as an option for managing moderate Alzheimer’s disease for people who are intolerant to or have a contraindication to AChE inhibitors, and as an option for managing severe Alzheimer’s disease.
* If prescribing an AChE inhibitor, treatment should normally be started with the drug with the lowest acquisition cost (taking into account required daily dose and the price per dose once shared care has started). However, an alternative AChE inhibitor could be prescribed if it is considered appropriate when taking into account adverse event profiles, expectations about adherence, medical comorbidity, possibility of drug interactions and dosing profiles.
What are the implications of this guidance?
The NICE/SCIE dementia guidance CG42 (March 2011) has been amended to incorporate the updated NICE technology appraisal TA217. All other aspects of the management of dementia are unchanged.
Mild to moderate Alzheimer’s disease:
Donepezil, galantamine, or rivastigmine should be considered as first choice options. Memantine should be considered for moderate Alzheimer’s only in patients who are intolerant of or have a contraindication to AChE inhibitors. For all these options the following criteria should apply:
- Only specialists in the care of patients with dementia should initiate treatment.
- Carers’ views on the patient’s condition should be sought at baseline and at follow-up.
- Treatment should be continued only when it is considered to be having a worthwhile effect on cognitive, global, functional or behavioural symptoms.
- Patients who continue on treatment should be reviewed regularly using cognitive, global, functional and behavioural assessment.
- Treatment should be reviewed by an appropriate specialist team, unless there are locally agreed shared care protocols.
- When considering donepezil, galantamine, or rivastigmine treatment should normally be started with the drug with the lowest acquisition cost (taking into account required daily dose and the price per dose once shared care has started). However, the exceptions outlined above apply.
People with mild to moderate dementia should be offered the opportunity to participate in a structured group cognitive stimulation programme irrespective of drug treatment for cognitive symptoms.
Severe Alzheimer’s disease:
Only memantine is recommended as an option for severe Alzheimer’s disease. The criteria for its use in moderate Alzheimer’s described above also apply to its use in severe disease.
Assessment of the severity of Alzheimer’s disease and the need for treatment:
When using assessment scales to determine the severity of Alzheimer’s disease, healthcare professionals should take into account any physical, sensory or learning disabilities, or communication difficulties that could affect the results and make any adjustments they consider appropriate. Healthcare professionals should also be mindful of the need to secure equality of access to treatment for patients from different ethnic groups, in particular those from different cultural backgrounds.
The NICE technology appraisal also recommends that, when assessing the severity of Alzheimer’s disease and the need for treatment, healthcare professionals should not rely solely on cognition scores in circumstances in which it would be inappropriate to do so. Further details can be found in the TA217 quick reference guidance.
More information on Alzheimer’s disease can be found in the NPC e-learning materials on dementia.
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