A revised NICE Technology Appraisal restricted the use of acetylcholinesterase inhibitors (AchIs) in Alzheimer's to patients suffering moderately severe dementia based on Mini-Mental State Examination (MMSE) of 20 or below (National Institute for Health and Clinical Excellence, 2006). R(Eisai Ltd) v NICE [2007] upheld this guidance, albeit with caveats advising against undue reliance on MMSE scores for those who have learning disability or for whom English is not a first language. In Derby, the new guidance was in place from 1 January 2007 onwards and policed by our pharmacy department where all applications for AchIs must be submitted.

We undertook a mirror image study of my prescribing, comparing data for two 6 month periods before and after implementation (1 Feb 2006 to 31 July 2006 and 1 Feb 2007 to 31 July 2007 respectively).

Eleven patients began AchI therapy in the first period and 22 in the second. In both periods, three of the initiates had dementia with Lewy bodies while the remainder of the patients had Alzheimer's or mixed Alzheimer's vascular dementia. Mean MMSE of the Alzheimer's mixed group was 23.9 (range 14-28) in the first period and 17.7 (range 8-28) in the second (t=2.79, P=0.0098). In the latter group, six patients were judged to have moderately severe impairment despite MMSE above or below the NICE threshold.

These results suggest that the new guidance has significantly restricted the use of AchIs to those with more severe cognitive impairment but there is little evidence that rate of usage has been curbed. In fact, the publicity surrounding the controversial guidance may have fuelled demand for these agents.