This guidance applies to donepezil, galantamine, rivastigmine and memantine within the marketing authorisations held for each drug at the time of this appraisal; that is: - donepezil, galantamine, rivastigmine for mild to moderately severe Alzheimer's disease - memantine for moderately severe to severe Alzheimer's disease.
The benefits of these drugs for patients with other forms of dementia (for example, vascular dementia or dementia with Lewy bodies) have not been assessed in this guidance.
1.1 The three acetylcholinesterase inhibitors donepezil, galantamine and rivastigmine are recommended as options in the management of people with Alzheimer's disease of moderate severity only (that is, those with a Mini Mental State Examination [MMSE] score of between 10 and 20 points), and under the following conditions.
- Only specialists in the care of people with dementia (that is, psychiatrists including those specialising in learning disability, neurologists, and physicians specialising in the care of the elderly) should initiate treatment. Carers' views on the patient's condition at baseline should be sought.
- Patients who continue on the drug should be reviewed every 6 months by MMSE score and global, functional and behavioural assessment. Carers' views on the patient's condition at follow-up should be sought. The drug should only be continued while the patient's MMSE score remains at or above 10 points and their global, functional and behavioural condition remains at a level where the drug is considered to be having a worthwhile effect. Any review involving MMSE assessment should be undertaken by an appropriate specialist team, unless there are locally agreed protocols for shared care.
1.2 When the decision has been made to prescribe an acetylcholinesterase inhibitor, it is recommended that therapy should be initiated with a 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 acetylcholinesterase inhibitor could be prescribed where it is considered appropriate having regard to adverse event profile, expectations around concordance, medical comorbidity, possibility of drug interactions and dosing profiles.
1.3 Memantine is not recommended as a treatment option for people with moderately severe to severe Alzheimer's disease except as part of well designed clinical studies.
1.4 People with mild Alzheimer's disease who are currently receiving donepezil, galantamine or rivastigmine, and people with moderately severe to severe Alzheimer's disease currently receiving memantine, whether as routine therapy or as part of a clinical trial, may be continued on therapy (including after the conclusion of a clinical trial) until they, their carers and/or specialist consider it appropriate to stop.