THERAPEUTICS

Brands

• Aricept, Aricept Evess, Aricept ODT, Memorit

Generic?

• Yes

Class

• Cholinesterase inhibitor

Commonly Prescribed for

(FDA approved in bold)

• Alzheimer's dementia (AD) (mild, moderate, or severe)

• Vascular dementia

• Mild cognitive impairment

• Dementia with Lewy bodies (DLB)

• HIV dementia

• Autism

• Attention deficit hyperactivity disorder

How the Drug Works

• Increases the concentration of acetylcholine through reversible, non-competitive inhibition of acetylcholinesterase, which increases availability of acetylcholine. A deficiency of cholinergic function is felt to be important in producing the signs and symptoms of AD. May interfere with amyloid deposition

• Although symptoms of AD can improve, donepezil does not prevent disease progression

How Long Until It Works

• Typically 2–6 weeks at a given dose, but effect is best observed over a period of months

If It Works

• Continue to use but symptoms of dementia usually continue to worsen

If It Doesn't Work

• Consider adjusting dose

• Change to another cholinesterase inhibitor or NMDA antagonist (memantine)

• Non-pharmacological measures are the basis of dementia treatment. Maintain regular schedules and routines. Avoid prolonged travel, unnecessary medical procedures or emergency room visits, crowds, and large social gatherings

• Limit drugs with sedative properties such as opioids, hypnotics, AEDs, and TCAs

• Treat other disorders that can worsen symptoms, such as hyperglycemia or urinary difficulties

Best Augmenting Combos for Partial Response or Treatment-Resistance

• Addition of the NMDA receptor antagonist memantine may be beneficial. In one study donepezil plus memantine reduced the rate of progression compared to that in those taking donepezil alone

• Treat depression or apathy with SSRIs but be cautious for increased risk of AEs (e.g., QTc prolongation, injurious falls). Avoid TCAs in demented patients due to risk of confusion. In dementia patients with severe depression, electroconvulsive therapy can be an option

• For significant confusion and agitation avoid neuroleptics (especially in DLB) because of the risk of neuroleptic malignant syndrome. Atypical antipsychotics (e.g., risperidone, clozapine, aripiprazole) or SSRIs can be used instead