Common use of CLINICAL INFORMATION Clause in Contracts

CLINICAL INFORMATION. Indication(s) Acetylcholinesterase inhibitors (donepezil, galantamine and rivastigmine) are licensed for the treatment of mild to moderate Alzheimer’s disease. Additionally, rivastigmine is licensed for the treatment of mild to moderate dementia in ▇▇▇▇▇▇▇▇▇’▇ disease. Memantine is licensed for the treatment of moderate to severe Alzheimer's disease. Place in therapy Acetylcholinesterase inhibitors are recommended as 1st line treatment (donepezil being the preferred formulary choice) for mild to moderate Alzheimer’s disease (and rivastigmine for the treatment of mild to moderate dementia in ▇▇▇▇▇▇▇▇▇’▇ disease). Memantine may be used 2nd line for moderate severity Alzheimer’s dementia where acetylcholinesterase inhibitors are ineffective or not tolerated. It may also be used in the treatment of severe Alzheimer’s disease. Combination treatment with memantine and an acetylcholinesterase inhibitor is not recommended. Therapeutic summary Donepezil, galantamine & rivastigmine: acetylcholinesterase inhibition Memantine: moderate affinity and uncompetitive n-methyl- D-aspartate receptor antagonism Donepezil Daily (oral) 5 10 Galantamine (modified release) Daily (oral) 8 16 24 Galantamine Twice daily (oral) 4 8 12 Rivastigmine* Twice daily (oral) 1.5 3 4.5 6 Rivastigmine patch* Daily (clean dry skin) 4.6 9.5 Memantine Daily (oral) 5 10 15 20 *Manufacturer advises that treatment with rivasitgmine should be temporarily interrupted if gastrointestinal adverse reactions are observed until these adverse reactions resolve (gastrointestinal disturbances less likely with patches, refer to BNF for guidance on switching between capsules and patches). Treatment can be resumed at the same dose if treatment is not interrupted for more than three days. Otherwise treatment should be re- titrated from 1.5mg twice daily or the 4.6 mg/24 h patch. Dose of rivastigmine patch may be increased to 13.3mg/24hrs after 6 months if required Duration of treatment The Psychiatrist will decide when treatment should be stopped. This is considered if:  Poor concordance  Major adverse effects  Patient asks to stop  Medication not effective (global, functional & behavioural condition is below a level where the drug is considered to have a worthwhile effect e.g. which may be an SMMSE <10)

CLINICAL INFORMATION. Indication(s) Acetylcholinesterase inhibitors (donepezil, galantamine and rivastigmine) are licensed for the treatment of mild to moderate Alzheimer’s disease. Additionally, rivastigmine is licensed for the treatment of mild to moderate dementia in ▇▇▇▇▇▇▇▇▇’▇ disease. Memantine is licensed for the treatment of moderate to severe Alzheimer's disease. Place in therapy Acetylcholinesterase inhibitors are recommended as 1st line treatment (donepezil being the preferred formulary choice) for mild to moderate Alzheimer’s disease (and rivastigmine for the treatment of mild to moderate dementia in ▇▇▇▇▇▇▇▇▇’▇ disease). Memantine may be used 2nd line for moderate severity Alzheimer’s dementia where acetylcholinesterase inhibitors are ineffective or not tolerated. It may also be used in the treatment of severe Alzheimer’s disease. Combination treatment with memantine and an acetylcholinesterase inhibitor is not recommended. Therapeutic summary Donepezil, galantamine & rivastigmine: acetylcholinesterase inhibition Memantine: moderate affinity and uncompetitive n-methyl- D-aspartate receptor antagonism Donepezil Daily (oral) 5 10 Galantamine (modified release) Daily (oral) 8 16 24 Galantamine Twice daily (oral) 4 8 12 Rivastigmine* Twice daily (oral) 1.5 3 4.5 6 Rivastigmine patch* Daily (clean dry skin) 4.6 9.5 Memantine Daily (oral) 5 10 15 20 *Manufacturer advises that treatment with rivasitgmine should be temporarily interrupted if gastrointestinal adverse reactions are observed until these adverse reactions resolve (gastrointestinal disturbances less likely with patches, refer to BNF for guidance on switching between capsules and patches). Treatment can be resumed at the same dose if treatment is not interrupted for more than three days. Otherwise treatment should be re- re-titrated from 1.5mg twice daily or the 4.6 mg/24 h patch. Dose of rivastigmine patch may be increased to 13.3mg/24hrs after 6 months if required Duration of treatment The Psychiatrist will decide when treatment should be stopped. This is considered if:  Poor concordance  Major adverse effects  Patient asks to stop  Medication not effective (global, functional & behavioural condition is below a level where the drug is considered to have a worthwhile effect e.g. which may be an SMMSE <10)