Download Protocol - Doncaster LMC

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.
Diagnosis of Alzheimer’s disease dementia.
Assessment of mental state.
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.
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: [email protected]
Dr Simon Wright, Consultant psychiatrist
Tel No: 01709 447356 Email: [email protected]
Dr Kavita Garneti, Consultant psychiatrist, Dr Helen Linnington, Consultant psychiatrist
Telephone No: 01709 447355 Email: [email protected] [email protected]
Chrissy Taylor, Memory Services Manager, Howarth House,
Brinsworth Lane,Rotherham,S60 5BX Tel number: 01709 302955 Email: [email protected]
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.