Hostname: page-component-7c8c6479df-24hb2 Total loading time: 0 Render date: 2024-03-29T07:21:11.778Z Has data issue: false hasContentIssue false

Cholinesterase Inhibitors and Memantine: Best Practices

Published online by Cambridge University Press:  07 November 2014

Rachelle S. Doody*
Affiliation:
Dr. Doody is Effie Marie Cain chair of Alzheimer’s disease research, director of the Alzheimer’s Disease and Memory Disorders Center, and professor of neurology at, Baylor College of Medicine, in Houston, Texas

Extract

Today’s therapies must be put in the context of both currently available treatments as well as treatment trials with exciting potential for use in the near future. Current clinical trial methodologies do not allow for clear separation of symptomatic treatments from disease-modifying therapies; it may be unproductive to maintain this distinction given the current range of treatments available. A more currently relevant focus is added value. Therapies should aim to provide added value through incremental benefits above and beyond existing treatments, as well as enduring benefits.

Alzheimer’s disease (AD) treatment guidelines are not used by physicians only. Healthcare payers often make use of these guidelines to delimit coverage. Cost concerns will also impact AD treatments after generic cholinesterase inhibitors are made available; it is widely believed that a great number of patients will switch to generics. Therefore, treatment guidelines must account for the possible adverse effects of switching therapies as well as the desirability of persistent treatment. There are many AD treatment guidelines, among them the American Academy of Neurology (AAN) Management of Dementia Guidelines, which are currently being revised. The Institute for the Study on Aging (ISOA) Management of Alzheimer’s Disease in Managed Care Guideline also presents a different approach for a different audience.

The first step to creating evidence-based best practices guidelines is to determine what is meant by “evidence.” A system of classification exists for examining forms of evidence: Class I evidence is provided by one or more well-designed, randomized, controlled clinical trials, including overviews or meta-analyses of such trials. Class II evidence is provided by well-designed observational studies with concurrent controls; for example, case-control studies that generate hypotheses about epidemiologic associations. Class III evidence is provided by expert opinion, case series, case reports, and studies with historical controls.

Type
Research Article
Copyright
Copyright © Cambridge University Press 2008

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

1.Doody, RS, Stevens, JC, Beck, C, et al.Practice parameter: management of dementia (an evidence-based review). Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2001;56(9):11541166.Google Scholar
2.Fillet, HM, Doody, R, Binaso, K, et al.Recommendations for Best Practice in the Treatment of Alzheimer’s Disease in Managed Care. Am J Geriatric Psychopharm. 2006;4(suppl A):S9S24.Google Scholar
3. Cholinesterase inhibitors for AD (Review). The Cochrane Collaboration. John Wiley and Sons. 2006. Birks, J. Cholinesterase inhibitors for Alzheimer’s disease. Cochrane Database Syst Rev. 2006;(1):CD005593.Google Scholar
4.Trinh, NH, Hoblyn, J, Mohanty, S, Yaffe, K. Efficacy of cholinesterase inhibitors in the treatment of neuropsychiatric symptoms and functional impairment in Alzheimer disease: a meta-analysis. JAMA. 2003;289(2):210216.Google Scholar
5.Doody, RS, Tariot, PN, Pfeiffer, E, et al.Meta-analysis of six-month memantine trials in Alzheimer’s disease. Alzheimers Dement. 2007;3(1):717.Google Scholar
6.Schneider, LS, Tariot, PN, Dagerman, KS, et al.Effectiveness of atypical antipsychotic drugs in patients with Alzheimer’s disease. N Engl J Med. 2006;355(15):15251538.Google Scholar
7.Bjelakovic, G, Nikolova, D, Gluud, LL, Simonetti, RG, Gluud, C. Mortality in randomized trials of antioxidant supplements for primary and secondary prevention: systematic review and meta-analysis. JAMA. 2007;297(8):842857.CrossRefGoogle ScholarPubMed
8.Pavlik, V, Doody, R, Rountree, S, Darby E. Vitamin E use is associated with improved survival in an AD cohort [abstract]. Neurology. 2008;70(suppl 1):A146.Google Scholar