-
-
rivastigmine
- Exelon
- Short ½ life (BID and re-titration after several missed doses)
-
galantamine
- Razadyne
- Short ½ life (BID and re-titration after several missed doses)
-
tacrine
- Cognex
- Removed- hepatotoxicity
-
Cholinesterase inhibitors
- donepexil (Aricept)
- rivastigmine (Exelon)
- galantamine (Razadyne)
- tacrine (Cognex)
- Urinary incontinence, bradycardia, headache, sweating, weakness
- - Slowly titrate up over several months
- Do not abruptly D/C
- Allow 1 week washout b/w agents
- - Allow 6 months before Tx failure
- Do not use with anticholinergics
-
memantine
- Namenda
- NMDA Antagonist (Antiglutamtergic)
- - Neuroprotective to excitotoxicity
- Indicated for moderate-severe Alzheimer’s disease
- Monotherapy or combination (w/donepezil- Namzaric)
- - Helps with Cognition and Function
- Severe renal impairment dose adjustment
- ADR- constipation, dizziness, headache, confusion
- - Decreases GI effects of cholinesterase inhibitors
-
Namzaric (memantine ER + donepezil)
- Indicated for pts maxed out on each agent
- 1-1 Dosing switch (at bedtime)
-
Vascular Disease and Alzheimer’s
- Monitor BP, glucose, cholesterol, and homocysteine
- Aspirin 81 mg Daily Recommended
- - Management of brain vascular disease may decrease the risk of Alzheimer's disease
-
Estrogen
- A loss of estrogen may contribute to AD
- Estrogen replacement is not recommended
- Lack of evidence
-
Anti-inflammatory Agents (i.e. NSAIDs, Steroids)
- Use is not recommended, solely for AD, secondary to risk of use
- More risk of GI bleeding
-
Lipid Lowering Agents (i.e. statins)
- Not recommended unless patient has compelling indication
- Rare ADR (statins) – May cause cognitive impairment
-
Dietary/Food Supplements
- Overall not recommended- lack of evidence
- Vitamin E
- Ginkgo Biloba
- Huperzine A
- Polyphenols
- AC1202 (Axona®) – Medical food
-
Non-cognitive Sx
- Psychotic, Inappropriate or disruptive, Depression
- Non-Pharmacologic Treatment recommended first
- Pharmacologic Treatment
- - Avoid medications with anticholinergic properties
-
Depression
- Antidepressants
- - SSRIs, may be effective for behavior regardless of depression
- - Avoid TCAs- cardiotoxic and anticholinergic properties
-
Hallucinations/Delusions
- - Atypical Antipsychotics
- BBW: Small risk of death
- anticholinergic properties (Seroquel, Zyprexa)
-
Agitation, anxiety, aggression
- Benzodiazepines – PRN
- - May increase cognitive decline
- - Liver impairment- lorazepam, oxazepam, temazepam
-
Mood Stabilizers
- Lacking evidence for use
- CBZ, gabapentin, valproic acid
-
Monitoring
- MMSE
- Neuropsychiatric Inventory Questionnaire
- Baseline, 8 weeks, Q6 months
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