Alzheimer's Society

Important note on the NICE revised guidance on anti-Alzheimer's drugs. To be read in conjunction with the Alzheimer's Society's information sheets 400, 401, 403, 407, 408, 425 and 426.

The National Institute for Clinical Excellence (NICE) revised guidance on anti-Alzheimer's drugs, issued in November 2006, recommends that people in the moderate stages of Alzheimer's disease should be given treatment with donepezil (Aricept), galantamine (Reminyl) and rivastigmine (Exelon). This differs from the previous NICE guidance that indicated these drugs could be prescribed to people in the early to moderate stages of Alzheimer's disease.The new NICE guidance also states that memantine (Ebixa) should not be prescribed.

The new NICE guidance states clearly that doctors' first priority must be to make decisions in the best interests of their patients. In addition, NICE's clinical care guideline on the care and treatment of people with dementia, published alongside the guidance, stresses that there must be a degree of flexibility around what constitutes the moderate stages of Alzheimer's disease.

The NICE revised guidance also states that people with dementia with Lewy bodies may be offered Aricept, Exelon or Reminyl if they find their noncognitive symptoms very distressing.

Summary of the NICE guidance

Donepezil, galantamine and rivastigmine are recommended as options for moderate Alzheimer's disease only, and if:

• treatment is started by a doctor who specialises in the care of people with dementia
• patients who are started on one of the drugs are checked every six months, usually by a specialist team
• the check-up includes a test called the Mini Mental State Examination (MMSE) and assessment of the patient's behaviour and ability to cope with daily life
• the views of carers on the patient's condition are discussed at the start of drug treatment and at check-ups
• the drug is no longer supplied if the patient's MMSE score falls below 10 points, or if the drug isn't working
• the least expensive of the three drugs is prescribed first. However, if it is not suitable for the patient another drug could be chosen.

Memantine is not recommended as an option for people with moderately severe to severe Alzheimer's disease unless it is being used as part of a clinical trial (research).

Patients prescribed donepezil, galantamine or rivastigmine before the implementation of the NICE guidelines for mild Alzheimer's disease, or memantine for moderately severe severe Alzheimer's disease, will continue to receive their prescription. Treatment should continue until the patient, carers and/or specialist decide it is the right time to stop.

Plus Reminyl dose changes

From July 2006 Reminyl 4mg tablets (twice-daily starting dosage) are discontinued and supplies are limited. The other higher strength Reminyl tablets for maintenance treatment (twice-daily 8mg and 12mg) and Reminyl XL once-daily capsules continue to be available. Reminyl will also remain available as a 4mg/ml (twice-daily) oral solution. Reminyl XL is available in 8mg, 16mg and 24mg capsules. The recommended starting dose for Reminyl XL capsules is 8mg/day.

Printed copies of the guidance CG42 Dementia: Understanding NICE guidance can be ordered from NICE, tel: 020 7067 5800 or download from: http://www.nice.org.uk./

The Alzheimer's Society continues to campaign for drugs to be made freely available to anyone who may benefit from them.

Information sheet 478

Last updated: January 2007
Last reviewed: January 2007