RDASH Older People’s Mental Health Services

Shared Care Protocol for the Prescription of Acetylcholinesterase inhibitors for Alzheimer’s disease dementia

1.  REFERRAL CRITERIA

Patients that are suspected to be suffering from Alzheimer’s disease will be referred to the memory service for assessment. They will also be under the care of their sector consultant psychiatrist (Dr Seymour, Dr Wright, Dr Linnington or Dr Garneti). Prescribing responsibility will only be transferred to the general practitioner when these assessments are complete and the patient’s dose has been stabilised. The patient may also be prescribed an acetylcholinesterase inhibitor for the treatment of Parkinson’s disease dementia and Lewy Body dementia which would also be covered by this shared care agreement.

2.  AREAS OF RESPONSIBILITY

GP responsibilities / Secondary mental health care responsibilities
Identifying patients who are suspected to be suffering from Alzheimer’s disease dementia.
Referral to specialist mental health services for diagnosis and assessment
Prescribing of donepezil, rivastigmine or galantamine following initiation by specialist mental health services once the dose has been stabilized together with documented evidence of clinical effectiveness. / Diagnosis of Alzheimer’s disease dementia.
Assessment of mental state.
Initiation of treatment with donepezil, rivastigmine or galantamine.
Dose adjustment to maintenance.
Assessment of effectiveness of drug regularly after reaching maintenance dose.
Reassessment on a regular basis to ensure continuing benefit.
Stopping the drug if it is ineffective or no longer indicated.

3.  COMMUNICATION AND SUPPORT

Hospital Contacts: Fax No: 01709 828756
Dr Jerry Seymour, Consultant psychiatrist
Tel No: 01709 447354 Email:
Dr Simon Wright, Consultant psychiatrist
Tel No: 01709 447356 Email:
Dr Kavita Garneti, Consultant psychiatrist, Dr Helen Linnington, Consultant psychiatrist
Telephone No: 01709 447355 Email:
Chrissy Taylor, Memory Services Manager, Howarth House,
Brinsworth Lane,Rotherham,S60 5BX Tel number: 01709 302955 Email:
Out of hours contacts and procedures; On call Psychiatric staff via the access team
Tel number: 01709 302670

4.  CLINICAL INFORMATION

Prescribed indications / The symptomatic treatment of mild to moderate Alzheimer’s Disease
Therapeutic summary / Alzheimer’s disease is associated with reduced production of acetylcholine. All three drugs are acetylcholinesterase inhibitors and raise the concentration of acetylcholine at the sites of acetylcholine neurotransmission. Galantamine also enhances the action of acetylcholine on nicotinic receptors. Rivastigmine also inhibits butrylcholinesterase. As the endogenous acetylcholine that is produced is preserved for longer whilst on one of these drugs, the symptoms of the disease are alleviated to a varying degree
Dose & Route of administration / Donepezil: Initially 5mg daily, continued for a month. The dose may be increased to 10mg daily after this time if necessary
Galantamine: As tablets or liquid initially 4mg bd with meals, continued for one month. The dose is then increased to a therapeutic dose of 8mg bd and then 12mg bd in selected patients if necessary. As modified release (Reminyl XL) 8mg mane after food for 1 month then 16mg mane for one month then 24mg mane in selected patients if necessary for reasons of compliance
Rivastigmine: Initially as capsule or liquid, 1.5mg bd, increased if tolerated after four weeks to a therapeutic dose of 3mg bd. Subsequent increases to 4.5mg bd then 6mg bd should be undertaken if appropriate at four weekly intervals depending on patient tolerability. Maximum dose: 6mg bd
Rivastigmine transdermal patch: Initially 4.6mg one application every 24 hours for one month then titrated to 9.5mg one application every 24 hours.
Liquids should only be used where there are difficulties with administering tablet or capsule preparations.
Rivastigmine patch should only be used where there is evidence of poor tolerability or a severe adverse event to a past cholinesterase inhibitor up to the maximum dose (including oral rivastigmine) or there are issues with oral compliance in general.
Duration of treatment / The drug should potentially be stopped if the MMSE falls below 10, but withdrawal aggression may occur. Patients with MMSE <10 are eligible for Memantine treatment (see Shared Care Agreement)
Adverse effects / They should not be prescribed to those with significant cardiac conduction defects in particular complete heart block, complete left bundle branch block, bifascicular block. They should be used in caution in patients with symptomatic peptic ulcer disease or GORD, asthma, or epilepsy.
Side effects include asthenia, anorexia, dizziness, nausea, somnolence, vomiting, abdominal pain, accidental trauma, agitation, confusion, depression, diarrhoea, dyspepsia, headache, insomnia, bronchospasm, urinary tract infection, syncope, rash, pruritis, myalgia.
Nausea and vomiting are the commonest and can be helped by domperidone 10mg tds.
Diarrhoea may be helped by loperamide 2mg prn or codeine 30mg prn.
Monitoring Requirements / Regular review of cognitive, behavioural and functional status
Clinically relevant drug interactions / Drugs that reduce heart rate e.g. β blockers (additional risk of bradycardia), succinylcholine type muscle relaxation may be prolonged. Increased side-effects may occur if the donepezil and galantamine are given concomitantly with potent inhibitors of CYP2D6 or CYP3A4 (eg quinidine, paroxetine, fluoxetine, fluvoxamine, ketoconazole and ritonavir)
Supply of ancillary equipment / None
Supply, storage and reconstitution instructions / The drugs are not subject to any special supply, storage or reconstitution instructions
Prepared by / Simon Wright Consultant Psychiatrist
Sue Wright Senior Pharmaceutical & Prescribing Adviser
References / National Institute for Clinical Excellence. Dementia FAD 2011
http://www.medicines.org.uk/emc/
http://bnf.org/bnf/index.htm

Updated March 2011 Dr Simon Wright Consultant Psychiatrist, Ms Sue Wright Senior prescribing advisor Rotherham.