4.11 Dementia

NICE TA217: Alzheimer's disease - donepezil, galantamine, rivastigmine and memantine (March 2011)

NICE CG42: Dementia (November 2006)

Donepezil
  • Tablets 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)
  • Oral solution 4mg/ml (£437.00 = 100ml)

Indications

Dose

  • 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
  • Tablets 10mg, 20mg (£2.56 = 20mg daily)
  • Oral solution 10mg/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
  • Capsules 1.5mg, 3mg, 4.5mg, 6mg (£5.22 = 2 x 3mg daily)
  • Oral solution 2mg/ml (£96.82 = 120ml)

Indications

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
  • 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.

 

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