firedoor

let it bleed
Jun 16, 2010
181
2
Status
Attending Physician
Honestly, I often feel as though I'm flipping a coin on this one.

Aside from contraindications (COPD, GI ulcer or cardiac conduction problems w/ aricept and renal considerations with Namenda), I'm usually ambivalent about choosing one over the other.

Neglecting cost (surprisingly Namenda is cheaper according to epocrates), what considerations do you take into account when selecting on one of these agents?

I have recently wondered if cholinesterase inhibitors might not be the best choice with respect to mood:

http://www.psycom.net/depression.central.cholinergic.html

And if it's more appropriate to prescribe cholinesterase inhibitors in the morning vs. evening with respect to memory consolidation (the two links below appear to conflict on this question):

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC357065/

http://www.ncbi.nlm.nih.gov/pubmed/17141741

Also, might namenda be preferred for those with alcohol, other SUD's or other psychopathologies related to the NMDA receptor (i.e. anxiety?)

http://ajp.psychiatryonline.org/cgi/content/full/164/3/519

Might the combination of namenda and aricept be neurotoxic in humans?

http://www.ncbi.nlm.nih.gov/pubmed/17112636


Lastly, I'm completely scratching my head with this new 23 mg indication for Aricept. When is this dose preferrable to 10 mg/day and how much more significant are side effects at 23 mg vs 10 mg?

And the Exelon patch??

Please, share your knowledge on this topic. Any related information on these medications' effects on sleep, medical or psychiatric comorbidities (especially dementia-related psychosis and behavioral disturbances), relvevant polypharmacy or off-label use (including substance-induced dementias) would be appreciated.
 
Last edited:

RedPakotaSea

5+ Year Member
Feb 8, 2010
57
0
Status
Are there any studies that demonstrate that either are effective, beyond marginal improvements in cognitive function?

I just did a quick search, and this is what I came up with:

The most recent Cochrane review for high-dose rivastigmine in Alzheimer's disease demonstrated a 2 pt increase in the ADAS-Cog (70 pt scale), a 2 pt increase in the Progressive Deterioration Scale (100 pt scale assessing ADLs), and a 0.8 pt increase on the MMSE compared with placebo at 26 weeks. Similar results were obtained for donepezil and memantine. It seems clear that acetylcholinesterase-inhibitors have efficacy in improving cognitive function in Alzheimer's disease, but the effect sizes are tiny and the costs are significant. More importantly, there is no improvement in quality of life scales. The skeptic in me thinks that prescribing these drugs is a giant waste of health care dollars.

I think it would at least be worth having an honest discussion with patients and/or their families regarding expected benefits, potential side effects, and the lack of data demonstrating improvement in quality of life.

I apologize...I realize that this post isn't what you were looking for, but it seems to be a relevant side discussion.
 

WhoisJohnGalt

NYC Psychiatrist
10+ Year Member
7+ Year Member
May 27, 2005
984
10
Status
Attending Physician
Are there any studies that demonstrate that either are effective, beyond marginal improvements in cognitive function?

I just did a quick search, and this is what I came up with:

The most recent Cochrane review for high-dose rivastigmine in Alzheimer's disease demonstrated a 2 pt increase in the ADAS-Cog (70 pt scale), a 2 pt increase in the Progressive Deterioration Scale (100 pt scale assessing ADLs), and a 0.8 pt increase on the MMSE compared with placebo at 26 weeks. Similar results were obtained for donepezil and memantine. It seems clear that acetylcholinesterase-inhibitors have efficacy in improving cognitive function in Alzheimer's disease, but the effect sizes are tiny and the costs are significant. More importantly, there is no improvement in quality of life scales. The skeptic in me thinks that prescribing these drugs is a giant waste of health care dollars.

I think it would at least be worth having an honest discussion with patients and/or their families regarding expected benefits, potential side effects, and the lack of data demonstrating improvement in quality of life.

I apologize...I realize that this post isn't what you were looking for, but it seems to be a relevant side discussion.
:thumbup: Unless the family is really jonesing for something and can't be talked out of it (in which case I'm going to do whatever's cheapest), my inclination is to do neither and just treat behavioral symptoms as needed.
 

meehawl

Forensic Psychiatrist
10+ Year Member
15+ Year Member
Apr 15, 2004
73
0
Status
Attending Physician
More importantly, there is no improvement in quality of life scales. The skeptic in me thinks that prescribing these drugs is a giant waste of health care dollars.
It may be worse than that:
Effect of rivastigmine as an adjunct to usual care with haloperidol on duration of delirium and mortality in critically ill patients: a multicentre, double-blind, placebo-controlled randomised trial
Although a sample size of 440 patients was planned, after inclusion of 104 patients with delirium who were eligible for the intention-to-treat analysis (n=54 on rivastigmine, n=50 on placebo), the DSMB recommended that the trial be halted because mortality in the rivastigmine group (n=12, 22%) was higher than in the placebo group (n=4, 8%; p=0·07). Median duration of delirium was longer in the rivastigmine group (5·0 days, IQR 2·7—14·2) than in the placebo group (3·0 days, IQR 1·0—9·3; p=0·06).