NICE guidance - cholinesterase inhibitors ( donepezil , galantamine , rivastigmine ) and memantine for the treatment of Alzheimer's disease

Last edited 05/2022 and last reviewed 06/2022

The review and re-appraisal of donepezil, galantamine, rivastigmine and memantine for the treatment of Alzheimer's disease has resulted in a change in the guidance.

Specifically:

• the three acetylcholinesterase (AChE) inhibitors donepezil, galantamine and rivastigmine are now recommended as options for managing mild as well as moderate Alzheimer's disease
  
  
• memantine is now recommended as an option for managing moderate Alzheimer's disease for people who cannot take AChE inhibitors, and
  • as an option for managing severe Alzheimer's disease
  • note that memantine may be used in combination an AChE inhibitor (1)
    • for people with an established diagnosis of Alzheimer's disease who are already taking an AChE inhibitor (1):
      • consider memantine in addition to an AChE inhibitor if they have moderate disease
      • offer memantine in addition to an AChE inhibitor if they have severe disease
        
        
• treatment should be under the following conditions:
  • prescribers should only start treatment with donepezil, galantamine, rivastigmine or memantine on the advice of a clinician who has the necessary knowledge and skills. This could include:
    • secondary care medical specialists such as psychiatrists, geriatricians and neurologists
    • other healthcare professionals such as GPs, nurse consultants and advanced nurse practitioners with specialist expertise in diagnosing and treating Alzheimer's disease
  • once a decision has been made to start an AChE inhibitor or memantine, the first prescription may be made in primary care
  • for people with an established diagnosis of Alzheimer's disease who are already taking an AChE inhibitor, primary care prescribers may start treatment with memantine (given advice above) without taking advice from a specialist clinician
  • AChE inhibitors in people with Alzheimer's disease should not be stopped because of disease severity alone
    
    
• if prescribing an AChE inhibitor (donepezil, galantamine or rivastigmine), treatment should normally be started with the drug with the lowest acquisition cost. However, an alternative AChE inhibitor could be prescribed if it is considered appropriate when taking into account adverse event profile, expectations about adherence, medical comorbidity, possibility of drug interactions and dosing profiles
  
  
• when using assessment scales to determine the severity of Alzheimer's disease, healthcare professionals should take into account any physical, sensory or learning disabilities, or communication difficulties that could affect the results and make any adjustments they consider appropriate. Healthcare professionals should also be mindful of the need to secure equality of access to treatment for patients from different ethnic groups, in particular those from different cultural backgrounds

• when assessing the severity of Alzheimer's disease and the need for treatment, healthcare professionals should not rely solely on cognition scores in circumstances in which it would be inappropriate to do so. These include:
  • if the cognition score is not, or is not by itself, a clinically appropriate tool for assessing the severity of that patient's dementia because of the patient's learning difficulties or other disabilities (for example, sensory impairments), linguistic or other communication difficulties or level of education or
  • if it is not possible to apply the tool in a language in which the patient is sufficiently fluent for it to be appropriate for assessing the severity of dementia or
  • if there are other similar reasons why using a cognition score, or the score alone, would be inappropriate for assessing the severity of dementia. In such cases healthcare professionals should determine the need for initiation or continuation of treatment by using another appropriate method of assessment.

Reference:

1. NICE (March 2011). Donepezil, galantamine, rivastigmine and memantine for the treatment of Alzheimer's disease. (Accessed 15 March 2022).
2. NICE (June 2018). Dementia: assessment, management and support for people living with dementia and their carers. (Accessed 15 March 2022).