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Hong YJ, Han HJ, Youn YC, Park KW, Yang DW, Kim S, Kim HJ, Kim HJ, Lee Y, Kwon M, Lee JH. Effects of Body Weight on the Safety of High-Dose Donepezil in Alzheimer's Disease: Post hoc Analysis of a Multicenter, Randomized, Open-Label, Parallel Design, Three-Arm Clinical Trial. Dement Geriatr Cogn Disord 2021; 50:289-295. [PMID: 34518459 DOI: 10.1159/000518470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Accepted: 07/11/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Donepezil 23 mg is considered for Alzheimer's disease (AD) to optimize cognitive benefits; however, increased adverse events (AEs) can negatively influence drug adherence. We investigated whether body weight (BW) differs based on the presence of AEs, and which baseline factors were relevant to the safety of high-dose donepezil. METHODS This study was a post hoc analysis of a multicenter randomized trial between 2014 and 2016. We included patients with moderate to severe AD treated with 10 mg/day of donepezil, and the daily dose was escalated to 23 mg with/without dose titration. Dose titration indicates 15 mg/day of donepezil before escalation or 10 mg and 23 mg/day on alternate days before escalation during the first 4 weeks. The patients were divided into 2 groups based on occurrence of AEs of special interest (AESIs) to compare baseline characteristics. We also assessed relationships between BW and AESIs. RESULTS Among the 160 participants in the safety population, the baseline BWs differed between the AESI (+) (n = 67) and AESI (-) (n = 93) groups. Baseline BW was inversely correlated with the occurrence of AESIs (p = 0.020), and this relationship was prominent in the no-dose titration group (p = 0.009) but absent in the dose-titration groups (p > 0.05). CONCLUSIONS BW is the most important factor that correlated with cholinergic AEs. Hence, stepwise dose titration should be considered, particularly in patients with low BW, to minimize the inverse relationship between BW and the occurrence of AEs ("Clinicaltrials.gov" No. NCT02550665 registered on September 15, 2015).
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Affiliation(s)
- Yun Jeong Hong
- Neurology, Uijeongbu St. Mary's Hospital, The Catholic University of Korea, Seoul, Republic of Korea
| | - Hyun Jeong Han
- Neurology, Dementia and Neurocognitive Center, Myongji Hospital, Hanyang University College of Medicine, Ilsan, Republic of Korea
| | - Young Chul Youn
- Neurology, Chung-Ang University Hospital, Seoul, Republic of Korea
| | - Kyung Won Park
- Neurology, Dong-A University College of Medicine, Busan, Republic of Korea
| | - Dong Won Yang
- Neurology, The Catholic University of Korea, Seoul, Republic of Korea
| | - SangYun Kim
- Neurology, Seoul National University College of Medicine & Neurocognitive Behavior Center, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Hwa Jung Kim
- Preventive Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Hyung-Ji Kim
- Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Yoojin Lee
- Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Miseon Kwon
- Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jae-Hong Lee
- Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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Ruangritchankul S, Chantharit P, Srisuma S, Gray LC. Adverse Drug Reactions of Acetylcholinesterase Inhibitors in Older People Living with Dementia: A Comprehensive Literature Review. Ther Clin Risk Manag 2021; 17:927-949. [PMID: 34511919 PMCID: PMC8427072 DOI: 10.2147/tcrm.s323387] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Accepted: 08/16/2021] [Indexed: 12/30/2022] Open
Abstract
The rising of global geriatric population has contributed to increased prevalence of dementia. Dementia is a neurodegenerative disease, which is characterized by progressive deterioration of cognitive functions, such as judgment, language, memory, attention and visuospatial ability. Dementia not only has profoundly devastating physical and psychological health outcomes, but it also poses a considerable healthcare expenditure and burdens. Acetylcholinesterase inhibitors (AChEIs), or so-called anti-dementia medications, have been developed to delay the progression of neurocognitive disorders and to decrease healthcare needs. AChEIs have been widely prescribed in clinical practice for the treatment of Alzheimer's disease, which account for 70% of dementia. The rising use of AChEIs results in increased adverse drug reactions (ADRs) such as cardiovascular and gastrointestinal adverse effects, resulting from overstimulation of peripheral cholinergic activity and muscarinic receptor activation. Changes in pharmacokinetics (PK), pharmacodynamics (PD) and pharmacogenetics (PGx), and occurrence of drug interactions are said to be major risk factors of ADRs of AChEIs in this population. To date, comprehensive reviews in ADRs of AChEIs have so far been scarcely studied. Therefore, we aimed to recapitulate and update the diverse aspects of AChEIs, including the mechanisms of action, characteristics and risk factors of ADRs, and preventive strategies of their ADRs. The collation of this knowledge is essential to facilitate efforts to reduce ADRs of AChEIs.
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Affiliation(s)
- Sirasa Ruangritchankul
- Division of Geriatric Medicine, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Prawat Chantharit
- Division of Infectious Diseases, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Sahaphume Srisuma
- Ramathibodi Poison Center and Division of Clinical Pharmacology and Toxicology, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Leonard C Gray
- Centre for Health Services Research, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
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Walczak-Nowicka ŁJ, Herbet M. Acetylcholinesterase Inhibitors in the Treatment of Neurodegenerative Diseases and the Role of Acetylcholinesterase in their Pathogenesis. Int J Mol Sci 2021; 22:9290. [PMID: 34502198 PMCID: PMC8430571 DOI: 10.3390/ijms22179290] [Citation(s) in RCA: 62] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Revised: 08/24/2021] [Accepted: 08/25/2021] [Indexed: 12/21/2022] Open
Abstract
Acetylcholinesterase (AChE) plays an important role in the pathogenesis of neurodegenerative diseases by influencing the inflammatory response, apoptosis, oxidative stress and aggregation of pathological proteins. There is a search for new compounds that can prevent the occurrence of neurodegenerative diseases and slow down their course. The aim of this review is to present the role of AChE in the pathomechanism of neurodegenerative diseases. In addition, this review aims to reveal the benefits of using AChE inhibitors to treat these diseases. The selected new AChE inhibitors were also assessed in terms of their potential use in the described disease entities. Designing and searching for new drugs targeting AChE may in the future allow the discovery of therapies that will be effective in the treatment of neurodegenerative diseases.
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Affiliation(s)
| | - Mariola Herbet
- Chair and Department of Toxicology, Faculty of Pharmacy, Medical University of Lublin, Jaczewskiego 8bStreet, 20-090 Lublin, Poland;
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Hsu TW, Stubbs B, Liang CS, Chen TY, Yeh TC, Pan CC, Chu CS. Efficacy of serotonergic antidepressant treatment for the neuropsychiatric symptoms and agitation in dementia: A systematic review and meta-analysis. Ageing Res Rev 2021; 69:101362. [PMID: 34000464 DOI: 10.1016/j.arr.2021.101362] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Revised: 05/10/2021] [Accepted: 05/12/2021] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Serotonergic dysfunction may be involved in the etiology of overall neuropsychiatric symptoms (NPS) and agitation in patients with dementia; therefore, we aim to perform a systematic review and meta-analysis to investigate the efficacy of serotonergic antidepressants in such populations. METHODS We systematically searched PubMed, Medline, Embase, and Cochrane Library to obtain randomized controlled trials (RCTs) from the date of their inception until December 11, 2020 to examine the effect of serotonergic antidepressants on the outcomes of interest in patients with dementia. Data were pooled using a random-effects model. Co-primary outcomes were mean changes in overall NPS and agitation as a specific symptom of NPS. Secondary outcomes were mean changes in depressive symptoms, cognition, and care burden. RESULTS Fourteen randomized controlled trials were eligible (n = 1,374; mean age = 76.8 years; mean proportion of female = 61.9 %). Serotonergic antidepressants significantly reduced the overall NPS (k = 12, n = 1276, Hedges' g = -0.49, 95 % confidence intervals [CIs] = -0.74 to -0.24, p < 0.001) and agitation severity (k = 9, n = 749, Hedges' g = -0.28, 95 % CIs = -0.43 to -0.14, p < 0.001), both with small effect size in patients with dementia. For secondary outcome, serotonergic antidepressants also significantly improved depressive symptoms, cognition, and care burden with small to very small effect sizes (depressive symptoms, k = 8, n = 938, Hedges' g = -0.32, 95 % CIs = -0.49 to -0.15, p < 0.001;cognition, k = 6, n = 983, Hedges' g = 0.15, 95 % CIs = 0.002 to 0.29, p = 0.046; care burden, k = 7, n = 961, Hedges' g = -0.24, 95 % CIs = -0.41 to -0.07, p = 0.005). Subgroup analysis showed that both selective serotonin reuptake inhibitors (SSRIs) and non-SSRIs significant reduced agitation and depressive symptoms (For agitation, SSRIs, k = 6, n = 605, Hedges' g = -0.25, 95 % CIs = -0.41 to -0.09, p=0.002; non-SSRIs, k = 3, n = 144, Hedges' g = -0.41, 95 % CIs = -0.74 to -0.08, p = 0.016; For depression, SSRIs, k = 6, n = 736, Hedges' g = -0.29, 95 % CIs = -0.48 to -0.09, p=0.004; non-SSRIs, k = 343, n = 144, Hedges' g = -0.43, 95 % CIs = -0.78 to -0.09, p = 0.016), whereas only SSRIs reduced overall NPS (k = 9, n = 1109, Hedges' g = -0.49, 95 % CIs = -0.78 to -0.20, p = 0.001) and care burden (k = 5, n = 740, Hedges' g = -0.29, 95 % CIs = -0.50 to -0.08, p=0.007). CONCLUSION The present meta-analysis indicates that serotonergic antidepressants effectively alleviate overall NPS, agitation, depressive symptoms, and care burden, and improve cognitive function.
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Affiliation(s)
- Tien-Wei Hsu
- Department of Psychiatry, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Brendon Stubbs
- Physiotherapy Department, South London and Maudsley NHS Foundation Trust, London, UK; Institute of Psychiatry, Psychology and Neuroscience, King's College London, UK; Faculty of Health, Social Care and Education, Anglia Ruskin University, Chelmsford, UK
| | - Chih-Sung Liang
- Department of Psychiatry, Beitou Branch, Tri-Service General Hospital, School of Medicine, National Defense Medical Center, Taipei, Taiwan; Graduate Institute of Medical Sciences, National Defense Medical Center, Taipei, Taiwan
| | - Tien-Yu Chen
- Department of Psychiatry, Tri-Service General Hospital, School of Medicine, National Defense Medical Center, Taipei, Taiwan; Institute of Brain Science, National Yang Ming Chiao Tung University, Taipei 112, Taiwan
| | - Ta-Chuan Yeh
- Department of Psychiatry, Tri-Service General Hospital, School of Medicine, National Defense Medical Center, Taipei, Taiwan; Institute of Brain Science, National Yang Ming Chiao Tung University, Taipei 112, Taiwan; Department of Psychiatry, Penghu Branch, Tri-Service General Hospital, Penghu, Taiwan
| | - Chih-Chuan Pan
- Department of Psychiatry, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Che-Sheng Chu
- Department of Psychiatry, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan; Center for Geriatric and Gerontology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan; Non-invasive Neuromodulation Consortium for Mental Disorders, Society of Psychophysiology, Taipei, Taiwan; Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.
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Jia J, Wei C, Chen W, Jia L, Zhou A, Wang F, Tang Y, Xu L. Safety and Efficacy of Donepezil 10 mg/day in Patients with Mild to Moderate Alzheimer’s Disease. J Alzheimers Dis 2020; 74:199-211. [PMID: 31985467 DOI: 10.3233/jad-190940] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Jianping Jia
- Department of Neurology, Xuan Wu Hospital of Capital Medical University, Beijing, China
| | - Cuibai Wei
- Department of Neurology, Xuan Wu Hospital of Capital Medical University, Beijing, China
| | - Wei Chen
- Department of Psychiatry, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China
| | - Longfei Jia
- Department of Neurology, Xuan Wu Hospital of Capital Medical University, Beijing, China
| | - Aihong Zhou
- Department of Neurology, Xuan Wu Hospital of Capital Medical University, Beijing, China
| | - Fen Wang
- Department of Neurology, Xuan Wu Hospital of Capital Medical University, Beijing, China
| | - Yi Tang
- Department of Neurology, Xuan Wu Hospital of Capital Medical University, Beijing, China
| | - Luoyi Xu
- Department of Psychiatry, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China
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Hong YJ, Han HJ, Youn YC, Park KW, Yang DW, Kim S, Kim HJ, Kim JE, Lee JH. Safety and tolerability of donepezil 23 mg with or without intermediate dose titration in patients with Alzheimer's disease taking donepezil 10 mg: a multicenter, randomized, open-label, parallel-design, three-arm, prospective trial. ALZHEIMERS RESEARCH & THERAPY 2019; 11:37. [PMID: 31039806 PMCID: PMC6492390 DOI: 10.1186/s13195-019-0492-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Accepted: 04/09/2019] [Indexed: 11/10/2022]
Abstract
BACKGROUND High-dose donepezil is currently prescribed for patients with Alzheimer's disease (AD) who showed poor or waning response to a lower dose at the risk of increasing cholinergic side effects. However, the adverse events (AEs) depending on the method of dose escalation have not been clarified yet. This study aimed to find out whether dose titration before escalating to donepezil 23 mg is preferred. We investigated safety and tolerability of donepezil 23 mg during the first 12 weeks of dose escalation in patients with moderate to severe AD. METHODS This study was a 12-week, multicenter, randomized, open-label prospective trial. We included patients with moderate to severe AD who were treated with a stable dose of donepezil 10 mg/day. Patients were randomized into 3 groups according to the dose escalation method: 15 mg of donepezil for 4 weeks before escalating to 23 mg (group 1), 10 mg and 23 mg on alternate days for 4 weeks prior to escalation (group 2), and direct escalation to 23 mg (group 3). Safety analyses included incidence, severity, timing of AEs, relationship to the study drug, and premature study discontinuation due to AEs between the groups. RESULTS Among 175 enrolled, 110 patients completed the study. Baseline characteristics were similar among the groups. Using safety population (N = 160), cholinergic gastrointestinal symptoms including anorexia and nausea were the most common AEs and titration groups showed significantly fewer cases of nausea as compared with those in no-titration group. CONCLUSIONS In this study, dose titration before escalating to donepezil 23 mg/day showed better safety in terms of cholinergic AEs. We suggest that dose titration during the first 4 weeks can be recommended for patients with moderate to severe AD. TRIAL REGISTRATION Clinicaltrials.gov , NCT02550665. Retrospectively registered on 15 Sep 2015.
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Affiliation(s)
- Yun Jeong Hong
- Neurology, The Catholic University of Korea, Uijeongbu St. Mary's Hospital, Uijeongbu, South Korea.,Neurology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
| | - Hyun Jeong Han
- Neurology, Dementia and Neurocognitive Center, Hanyang University College of Medicine, Myongji Hospital, Ilsan, South Korea
| | - Young Chul Youn
- Neurology, Chung-Ang University Hospital, Seoul, South Korea
| | - Kyung Won Park
- Neurology, Dong-A University College of Medicine, Busan, South Korea
| | - Dong Won Yang
- Neurology, The Catholic University of Korea, Seoul St. Mary's Hospital, Seoul, South Korea
| | - SangYun Kim
- Neurology, Seoul National University College of Medicine & Neurocognitive Behavior Center, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Hwa Jung Kim
- Preventive Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
| | - Ji Eun Kim
- Neurology, University of Ulsan College of Medicine, Gangneung Asan Hospital, Gangneung, South Korea
| | - Jae-Hong Lee
- Neurology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea.
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Ge Y, Li Q, Nie Y, Gao J, Luo K, Fang X, Wang C. Dexmedetomidine improves cognition after carotid endarterectomy by inhibiting cerebral inflammation and enhancing brain-derived neurotrophic factor expression. J Int Med Res 2019; 47:2471-2482. [PMID: 31014147 PMCID: PMC6567697 DOI: 10.1177/0300060519843738] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objectives Carotid endarterectomy (CEA) is efficient in preventing stroke for patients with significant carotid stenosis, but results in mild cognitive dysfunction. Dexmedetomidine is neuroprotective in stroke models. We hypothesized that dexmedetomidine may improve cognition after CEA. Methods Forty-nine patients scheduled for elective CEA were randomly assigned to intravenous dexmedetomidine treatment group (n = 25) and control group C (normal saline, n = 24). Mini-Mental State Examination (MMSE) and Montreal Cognitive Assessment (MOCA), as well as lactate, TNF-α, IL-6, and BDNF levels in blood, were assessed before, during, and after surgery. Results MMSE and MOCA scores showed subtle decline in both groups at 24 hours postoperatively; this decline remained at 48 hours postoperatively in group C. Both scores were higher in group D than in group C at 48 and 72 hours postoperatively. TNF-α and IL-6 were lower from 5 minutes post-clamping through 24 hours postoperatively in group D; lactate was lower at 5 minutes post-clamping in group D. BDNF was higher from 5 minutes post-clamping through 1 hour postoperatively in both groups, and remained high in group D at 24 hours postoperatively. Conclusions Dexmedetomidine improved recovery of cognition after CEA, potentially due to reduced inflammation and enhanced BDNF expression.
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Affiliation(s)
- Yali Ge
- 1 Department of Anesthesiology, Northern Jiangsu People's Hospital, Yangzhou City, Jiangsu Province, China
| | - Qian Li
- 2 Department of Anesthesiology, Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China
| | - Yuyan Nie
- 2 Department of Anesthesiology, Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China
| | - Ju Gao
- 1 Department of Anesthesiology, Northern Jiangsu People's Hospital, Yangzhou City, Jiangsu Province, China
| | - Ke Luo
- 3 Department of Anesthesiology, Second Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Xiangzhi Fang
- 1 Department of Anesthesiology, Northern Jiangsu People's Hospital, Yangzhou City, Jiangsu Province, China
| | - Cunjing Wang
- 1 Department of Anesthesiology, Northern Jiangsu People's Hospital, Yangzhou City, Jiangsu Province, China
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CGY-1, a biflavonoid isolated from cardiocrinum giganteum seeds, improves memory deficits by modulating the cholinergic system in scopolamine-treated mice. Biomed Pharmacother 2019; 111:496-502. [DOI: 10.1016/j.biopha.2018.12.100] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Revised: 12/19/2018] [Accepted: 12/23/2018] [Indexed: 12/26/2022] Open
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Abstract
BACKGROUND Alzheimer's disease is the most common cause of dementia in older people. One approach to symptomatic treatment of Alzheimer's disease is to enhance cholinergic neurotransmission in the brain by blocking the action of the enzyme responsible for the breakdown of the neurotransmitter acetylcholine. This can be done by a group of drugs known as cholinesterase inhibitors. Donepezil is a cholinesterase inhibitor.This review is an updated version of a review first published in 1998. OBJECTIVES To assess the clinical efficacy and safety of donepezil in people with mild, moderate or severe dementia due to Alzheimer's disease; to compare the efficacy and safety of different doses of donepezil; and to assess the effect of donepezil on healthcare resource use and costs. SEARCH METHODS We searched Cochrane Dementia and Cognitive Improvement's Specialized Register, MEDLINE, Embase, PsycINFO and a number of other sources on 20 May 2017 to ensure that the search was as comprehensive and up-to-date as possible. In addition, we contacted members of the Donepezil Study Group and Eisai Inc. SELECTION CRITERIA We included all double-blind, randomised controlled trials in which treatment with donepezil was administered to people with mild, moderate or severe dementia due to Alzheimer's disease for 12 weeks or more and its effects compared with those of placebo in a parallel group of patients, or where two different doses of donepezil were compared. DATA COLLECTION AND ANALYSIS One reviewer (JSB) extracted data on cognitive function, activities of daily living, behavioural symptoms, global clinical state, quality of life, adverse events, deaths and healthcare resource costs. Where appropriate and possible, we estimated pooled treatment effects. We used GRADE methods to assess the quality of the evidence for each outcome. MAIN RESULTS Thirty studies involving 8257 participants met the inclusion criteria of the review, of which 28 studies reported results in sufficient detail for the meta-analyses. Most studies were of six months' duration or less. Only one small trial lasted 52 weeks. The studies tested mainly donepezil capsules at a dose of 5 mg/day or 10 mg/day. Two studies tested a slow-release oral formulation that delivered 23 mg/day. Participants in 21 studies had mild to moderate disease, in five studies moderate to severe, and in four severe disease. Seventeen studies were industry funded or sponsored, four studies were funded independently of industry and for nine studies there was no information on source of funding.Our main analysis compared the safety and efficacy of donepezil 10 mg/day with placebo at 24 to 26 weeks of treatment. Thirteen studies contributed data from 3396 participants to this analysis. Eleven of these studies were multicentre studies. Seven studies recruited patients with mild to moderate Alzheimer's disease, two with moderate to severe, and four with severe Alzheimer's disease, with a mean age of about 75 years. Almost all evidence was of moderate quality, downgraded due to study limitations.After 26 weeks of treatment, donepezil compared with placebo was associated with better outcomes for cognitive function measured with the Alzheimer's Disease Assessment Scale-Cognitive (ADAS-Cog, range 0 to 70) (mean difference (MD) -2.67, 95% confidence interval (CI) -3.31 to -2.02, 1130 participants, 5 studies), the Mini-Mental State Examination (MMSE) score (MD 1.05, 95% CI 0.73 to 1.37, 1757 participants, 7 studies) and the Severe Impairment Battery (SIB, range 0 to 100) (MD 5.92, 95% CI 4.53 to 7.31, 1348 participants, 5 studies). Donepezil was also associated with better function measured with the Alzheimer's Disease Cooperative Study activities of daily living score for severe Alzheimer's disease (ADCS-ADL-sev) (MD 1.03, 95% CI 0.21 to 1.85, 733 participants, 3 studies). A higher proportion of participants treated with donepezil experienced improvement on the clinician-rated global impression of change scale (odds ratio (OR) 1.92, 95% CI 1.54 to 2.39, 1674 participants, 6 studies). There was no difference between donepezil and placebo for behavioural symptoms measured by the Neuropsychiatric Inventory (NPI) (MD -1.62, 95% CI -3.43 to 0.19, 1035 participants, 4 studies) or by the Behavioural Pathology in Alzheimer's Disease (BEHAVE-AD) scale (MD 0.4, 95% CI -1.28 to 2.08, 194 participants, 1 study). There was also no difference between donepezil and placebo for Quality of Life (QoL) (MD -2.79, 95% CI -8.15 to 2.56, 815 participants, 2 studies).Participants receiving donepezil were more likely to withdraw from the studies before the end of treatment (24% versus 20%, OR 1.25, 95% CI 1.05 to 1.50, 2846 participants, 12 studies) or to experience an adverse event during the studies (72% vs 65%, OR 1.59, 95% 1.31 to 1.95, 2500 participants, 10 studies).There was no evidence of a difference between donepezil and placebo for patient total healthcare resource utilisation.Three studies compared donepezil 10 mg/day to donepezil 5 mg/day over 26 weeks. The 5 mg dose was associated with slightly worse cognitive function on the ADAS-Cog, but not on the MMSE or SIB, with slightly better QoL and with fewer adverse events and withdrawals from treatment. Two studies compared donepezil 10 mg/day to donepezil 23 mg/day. There were no differences on efficacy outcomes, but fewer participants on 10 mg/day experienced adverse events or withdrew from treatment. AUTHORS' CONCLUSIONS There is moderate-quality evidence that people with mild, moderate or severe dementia due to Alzheimer's disease treated for periods of 12 or 24 weeks with donepezil experience small benefits in cognitive function, activities of daily living and clinician-rated global clinical state. There is some evidence that use of donepezil is neither more nor less expensive compared with placebo when assessing total healthcare resource costs. Benefits on 23 mg/day were no greater than on 10 mg/day, and benefits on the 10 mg/day dose were marginally larger than on the 5 mg/day dose, but the rates of withdrawal and of adverse events before end of treatment were higher the higher the dose.
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Affiliation(s)
- Jacqueline S Birks
- University of OxfordCentre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal SciencesBotnar Research Centre, Windmill RoadOxfordUKOX3 7LD
| | - Richard J Harvey
- Deakin University and Private PracticeMedical Schoolc/o Telepsychiatrist OnlinePO Box 117North GeelongVictoriaAustralia3215
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Meng Y, Volpini M, Black S, Lozano AM, Hynynen K, Lipsman N. Focused ultrasound as a novel strategy for Alzheimer disease therapeutics. Ann Neurol 2017; 81:611-617. [PMID: 28395123 DOI: 10.1002/ana.24933] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Revised: 04/06/2017] [Accepted: 04/07/2017] [Indexed: 01/04/2023]
Affiliation(s)
- Ying Meng
- Division of Neurosurgery, Sunnybrook Research Institute, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario, Canada
| | - Matthew Volpini
- Division of Neurosurgery, Sunnybrook Research Institute, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario, Canada
| | - Sandra Black
- Division of Neurology, Sunnybrook Research Institute, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario, Canada
| | - Andres M Lozano
- Division of Neurosurgery, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Kullervo Hynynen
- Sunnybrook Research Institute, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario, Canada
| | - Nir Lipsman
- Division of Neurosurgery, Sunnybrook Research Institute, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario, Canada
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Homma A, Atarashi H, Kubota N, Nakai K, Takase T. Efficacy and Safety of Sustained Release Donepezil High Dose versus Immediate Release Donepezil Standard Dose in Japanese Patients with Severe Alzheimer's Disease: A Randomized, Double-Blind Trial. J Alzheimers Dis 2017; 52:345-57. [PMID: 26967222 DOI: 10.3233/jad-151149] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Donepezil is an established treatment for mild, moderate, and severe Alzheimer's disease (AD). An international study demonstrated superior efficacy of sustained release (SR) 23 mg/day donepezil over immediate release (IR) 10 mg/day donepezil for cognitive function, but not global function in moderate-to-severe AD. OBJECTIVE To demonstrate the superiority of SR 23 mg/day donepezil over IR 10 mg/day donepezil in Japanese patients with severe AD (SAD). METHODS In this multicenter, randomized, double-blind, parallel-group study, Japanese outpatients with SAD were randomly assigned to continue IR 10 mg/day or switch to SR 23 mg/day for 24 weeks. Endpoints included the Severe Impairment Battery (SIB), Clinician's Interview-Based Impression of Change Plus Caregiver Input (CIBIC-plus), and safety. RESULTS Overall, 166 and 185 patients were randomized to receive IR 10 mg/day and SR 23 mg/day, respectively. SR 23 mg/day was not statistically superior to IR 10 mg/day by SIB (least squares mean difference [LSMD]: 0.0; 95% confidence interval [CI]: -1.7, 1.8; p = 0.981) or CIBIC-plus (LSMD: 0.2; 95% CI: 0.0, 0.4; p = 0.080). Common adverse events in the SR 23 mg group were decreased appetite, vomiting, diarrhea, and contusion. Safety findings were consistent with known safety profiles of donepezil. CONCLUSION SR 23 mg/day donepezil was not superior to IR 10 mg/day donepezil regarding the efficacy endpoints for Japanese SAD. Considering that a 10 mg/day dose is approved for SAD in Japan, the present findings suggest that IR 10 mg/day donepezil is the optimal dosage for Japanese patients with SAD.
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Affiliation(s)
- Akira Homma
- Tokyo Dementia Care Research and Training Center, Tokyo, Japan
| | - Hirotsugu Atarashi
- Nippon Medical School Tama-Nagayama Hospital, Nippon Medical School, Tokyo, Japan
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12
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Giulietti A, Vignini A, Nanetti L, Mazzanti L, Di Primio R, Salvolini E. Alzheimer's Disease Risk and Progression: The Role of Nutritional Supplements and their Effect on Drug Therapy Outcome. Curr Neuropharmacol 2016; 14:177-90. [PMID: 26415975 PMCID: PMC4825948 DOI: 10.2174/1570159x13666150928155321] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Revised: 07/28/2015] [Accepted: 08/27/2015] [Indexed: 12/13/2022] Open
Abstract
Alzheimer's disease (AD) is the most common neurodegenerative disease in the elderly population. Despite significant advancements in understanding the genetic and molecular basis of AD, the pathology still lacks treatments that can slow down or reverse the progression of cognitive deterioration. Recently, the relationship between nutrient deficiency and dementia onset has been highlighted. AD is in fact a multifactorial pathology, so that a multi-target approach using combinations of micronutrients and drugs could have beneficial effects on cognitive function in neurodegenerative brain disorders leading to synaptic degeneration. Primarily, this review examines the most recent literature regarding the effects of nutrition on the risk/progression of the disease, focusing attention mostly on antioxidants agents, polyunsaturated fatty acids and metals. Secondly, it aims to figure out if nutritional supplements might have beneficial effects on drug therapy outcome. Even if nutritional supplements showed contrasting evidence of a likely effect of decreasing the risk of AD onset that could be studied more deeply in other clinical trials, no convincing data are present about their usefulness in combination with drug therapies and their effectiveness in slowing down the disease progression.
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Affiliation(s)
| | | | | | - L Mazzanti
- Department of Clinical Sciences, Faculty of Medicine, Università Politecnica delle Marche, Via Tronto 10/A, Ancona, Italy.
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Sabbagh M, Han S, Kim S, Na HR, Lee JH, Kandiah N, Phanthumchinda K, Suthisisang C, Senanarong V, Pai MC, Narilastri D, Sowani AM, Ampil E, Dash A. Clinical Recommendations for the Use of Donepezil 23 mg in Moderate-to-Severe Alzheimer's Disease in the Asia-Pacific Region. Dement Geriatr Cogn Dis Extra 2016; 6:382-395. [PMID: 27703471 PMCID: PMC5040883 DOI: 10.1159/000448214] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Background The ‘Asia-Pacific Expert Panel (APEX) for donepezil 23 mg’ met in November 2015 to review evidence for the recently approved high dose of donepezil and to provide recommendations to help physicians in Asia make informed clinical decisions about using donepezil 23 mg in patients with moderate-to-severe Alzheimer's disease (AD). Summary In a global phase III study (study 326) in patients with moderate-to-severe AD, donepezil 23 mg/day demonstrated significantly greater cognitive benefits versus donepezil 10 mg/day, with a between-treatment difference in mean change in the Severe Impairment Battery score of 2.2 points (p < 0.001) in the overall population and 3.1 points (p < 0.001) in patients with advanced AD. A subanalysis of study 326 demonstrated that the benefits and risks associated with donepezil 23 mg/day versus donepezil 10 mg/day in Asian patients with moderate-to-severe AD were comparable to those in the global study population. Key Message Donepezil 23 mg is a valuable treatment for patients with AD, particularly those with advanced disease. The APEX emphasized the importance of patient selection (AD severity, tolerability of lower doses of donepezil, and absence of contraindications), a stepwise titration strategy for dose escalation, and appropriate monitoring and counseling of patients and caregivers in the management of patients with AD.
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Affiliation(s)
- Marwan Sabbagh
- Alzheimer's and Memory Disorders Division, Barrow Neurological Institute, Phoenix, Ariz., USA
| | - SeolHeui Han
- Department of Neurology, Konkuk University School of Medicine, Seoul, Republic of Korea
| | - SangYun Kim
- Department of Neurology, Neurocognitive Behavior Center of Seoul National University Bundang Hospital, Seoul, Republic of Korea; Department of Neurology, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Hae-Ri Na
- Department of Neurology, Bobath Memorial Hospital, Seongnam, Republic of Korea
| | - Jae-Hong Lee
- Department of Neurology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Nagaendran Kandiah
- Department of Neurology, National Neuroscience Institute and Duke-NUS Medical School, Singapore
| | - Kammant Phanthumchinda
- Division of Neurology, Department of Medicine, Chulalongkorn University, Bangkok, Thailand
| | | | - Vorapun Senanarong
- Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Ming-Chyi Pai
- Division of Behavioral Neurology, Department of Neurology, Medical College and Hospital, National Cheng Kung University, Tainan City, Taiwan, ROC
| | - Diatri Narilastri
- Department of Neurology, Medicine Faculty University of Indonesia, CiptoMangunkusumo Hospital, Jakarta, Indonesia
| | | | | | - Amitabh Dash
- Eisai Pharmaceuticals India Pvt. Ltd., Mumbai, India
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Deardorff WJ, Grossberg GT. Pharmacotherapeutic strategies in the treatment of severe Alzheimer's disease. Expert Opin Pharmacother 2016; 17:1789-800. [PMID: 27450461 DOI: 10.1080/14656566.2016.1215431] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
INTRODUCTION Alzheimer's disease (AD) is a slowly progressive neurodegenerative disease. Patients with severe AD often require assistance with daily functioning and have a substantially higher probability of admission to nursing homes compared to the general population. AREAS COVERED Medications approved by the US Food and Drug Administration for the treatment of severe AD include the cholinesterase inhibitors (ChEIs), donepezil (10 and 23 mg/day) and rivastigmine (transdermal patch, 13.3 mg/24 hours), and the N-methyl-D-aspartate receptor antagonist memantine (immediate- and extended-release formulations). This article will review the efficacy, safety, and tolerability data of these agents in the treatment of severe AD. Issues related to combination therapy, neuropsychiatric symptoms, and treatment discontinuation are also discussed. EXPERT OPINION AD therapeutics provide benefits on measures of cognition, functioning, behavior, and global status even in the severe stages of AD. Combination therapy with memantine and ChEIs may provide additive benefits compared with ChEI monotherapy. Decisions regarding discontinuation of these medications should be made on a case-by-case basis, with some evidence suggesting that discontinuation may worsen cognition and functional impairment. It is recommended that patients entering the terminal stages of AD discontinue all medications not necessary for comfort.
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Affiliation(s)
| | - George T Grossberg
- a Department of Psychiatry , St. Louis University School of Medicine , St Louis , MO , USA
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15
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GE YALI, LI XIAOBO, GAO JU, ZHANG XICHENG, FANG XIANGZHI, ZHOU LUOJING, JI WEI, LIN SHUNYAN. Beneficial effects of intravenous dexmedetomidine on cognitive function and cerebral injury following a carotid endarterectomy. Exp Ther Med 2016; 11:1128-1134. [PMID: 26998048 PMCID: PMC4774506 DOI: 10.3892/etm.2016.2978] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2015] [Accepted: 11/25/2015] [Indexed: 12/27/2022] Open
Abstract
The present study aimed to investigate the effects of dexmedetomidine (DEX) on cognition following a carotid endarterectomy (CEA). In addition, the neuroprotective effects of DEX against ischemia-reperfusion injury during CEA were analyzed. Patients due to undergo elective CEA under general anesthesia were randomly assigned to either the DEX-treated group (group D; n=25) or the control group (group C; n=25). Patients in group D were treated with 0.3 µg/kg DEX pre-CEA, followed by 0.3 µg/kg/h DEX intraoperatively up to 30 min prior to the completion of surgery, and the patients in group C received an equal volume of normal saline. Cognitive function was assessed prior to CEA (T0), and at 24, 48, and 72 h, 7 days and 1 month post-surgery (T1-5, respectively), using the Mini-Mental State Examination (MMSE). Blood samples were drawn from the ipsilateral jugular bulb of all patients at 20 min prior to anesthesia (t0), and at 10 min following tracheal intubation, 15 min following clamping and unclamping of the carotid artery, and at 6 and 24 h postoperatively (t1-5, respectively). The protein expression levels of markers of cerebral ischemia and injury, namely S100 calcium-binding protein B (S100B) and neuron-specific enolase (NSE), and the concentration of the oxidative stress marker malondialdehyde (MDA), were analyzed. Patients in group D exhibited elevated MMSE scores at T2 and T3 post-CEA, as compared with group C. Furthermore, the protein expression level of S100B and the concentration of MDA in the jugular bulb of group D patients were markedly decreased compared with those in group C at t3-5 and t3, respectively. The results of the present study suggested that DEX was able to enhance the recovery of cognition following CEA, and this was associated with decreased cerebral damage and antioxidative effects.
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Affiliation(s)
- YA-LI GE
- Department of Anesthesiology, Subei People's Hospital of Jiangsu Province, Yangzhou, Jiangsu 225001, P.R. China
| | - XIAOBO LI
- Department of Neurology, Subei People's Hospital of Jiangsu Province, Yangzhou, Jiangsu 225001, P.R. China
| | - JU GAO
- Department of Anesthesiology, Subei People's Hospital of Jiangsu Province, Yangzhou, Jiangsu 225001, P.R. China
| | - XICHENG ZHANG
- Department of Vascular Surgery, Subei People's Hospital of Jiangsu Province, Yangzhou, Jiangsu 225001, P.R. China
| | - XIANGZHI FANG
- Department of Anesthesiology, Subei People's Hospital of Jiangsu Province, Yangzhou, Jiangsu 225001, P.R. China
| | - LUOJING ZHOU
- Department of Scientific Research, Subei People's Hospital of Jiangsu Province, Yangzhou, Jiangsu 225001, P.R. China
| | - WEI JI
- Department of Anesthesiology, Subei People's Hospital of Jiangsu Province, Yangzhou, Jiangsu 225001, P.R. China
| | - SHUNYAN LIN
- Department of Anesthesiology, Subei People's Hospital of Jiangsu Province, Yangzhou, Jiangsu 225001, P.R. China
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Kuzmickienė J, Kaubrys G. Cognitive Results of CANTAB Tests and Their Change Due to the First Dose of Donepezil May Predict Treatment Efficacy in Alzheimer Disease. Med Sci Monit 2015; 21:3887-99. [PMID: 26656642 PMCID: PMC4684140 DOI: 10.12659/msm.896327] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Background Ability to predict the efficacy of treatment in Alzheimer disease (AD) may be very useful in clinical practice. Cognitive predictors should be investigated alongside with the demographic, genetic, and other predictors of treatment efficacy. The aim of this study was to establish whether the baseline measures of CANTAB tests and their changes due to the first donepezil dose are able to predict the efficacy of treatment after 4 months of therapy. We also compared the predictive value of cognitive, clinical, and demographic predictors of treatment efficacy in AD. Material/Methods Seventy-two AD patients (62 treatment-naïve and 10 donepezil-treated) and 30 controls were enrolled in this prospective, randomized, rater-blinded, follow-up study. Treatment-naïve AD patients were randomized to 2 groups to take the first donepezil dose after the first or second CANTAB testing, separated by 4 hours. Follow-up Test 3 was performed 4 months after the initial assessment. Results The groups were similar in age, education, gender, Hachinski index, and depression. General Regression Models (GRM) have shown that cognitive changes after the first dose of donepezil in PAL (t-values for regression coefficients from 3.43 to 6.44), PRMd (t=4.33), SWM (t=5.85) test scores, and baseline results of PAL (t=2.57–2.86), PRM (t=3.08), and CRT (t=3.42) tests were significant predictors of long-term donepezil efficacy in AD (p<0.05). Conclusions The cognitive changes produced by the first donepezil dose in CANTAB PAL, PRM, and SWM test measures are able to predict the long-term efficacy of donepezil in AD. Baseline PAL, PRM, and CRT test results were significant predictors.
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Affiliation(s)
- Jurgita Kuzmickienė
- Clinic of Neurology and Neurosurgery, Faculty of Medicine, Vilnius University; Center of Neurology, Vilnius University Hospital Santariskiu Klinikos, Vilnius, Lithuania
| | - Gintaras Kaubrys
- Clinic of Neurology and Neurosurgery, Faculty of Medicine, Vilnius University; Center of Neurology, Vilnius University Hospital Santariskiu Klinikos, Vilnius, Lithuania
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Deardorff WJ, Feen E, Grossberg GT. The Use of Cholinesterase Inhibitors Across All Stages of Alzheimer's Disease. Drugs Aging 2015; 32:537-47. [PMID: 26033268 DOI: 10.1007/s40266-015-0273-x] [Citation(s) in RCA: 84] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Current pharmacological therapy for Alzheimer's disease (AD) includes the cholinesterase inhibitors (ChEIs) donepezil, rivastigmine, and galantamine and the N-methyl D-aspartate receptor antagonist memantine. Based on the results of randomized controlled trials and several meta-analyses, ChEIs appear to show modest but statistically significant improvements on several measures, including cognition and global functioning. Given their modest effects, there is a lack of consensus among clinicians regarding issues related to initiation, optimal duration, and discontinuation of ChEI therapy across the spectrum of AD. There is evidence from long-term observational controlled studies that early initiation and persistent exposure to AD therapy lead to delays in nursing home admission and significantly slower rates of cognitive and functional impairment. In the moderate to severe stages of AD, therapeutic trials of higher dose ChEIs and the addition of memantine are recommended for patients who are no longer responding to lower doses. While side effects are generally mild and gastrointestinal in nature, these events can lead to significant morbidity in more susceptible patients with advanced disease. Patients should thus be regularly monitored for any potential serious side effects of ChEI therapy, which also may include syncope and bradycardia. At the terminal stages of AD, such as when patients become hospice eligible, attempts to cautiously discontinue all medications not necessary for quality of life, including AD drugs, should be made.
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Abstract
Alzheimer's disease (AD) is an age-related progressive dementia, which is increasing in prevalence world-wide. Typically affecting short-term memory at onset, this devastating illness advances to impair all aspects of cognition, as well as non-cognitive domains. Although much effort has been made in recent years to develop disease-modifying treatments, medications which provided promising results in pre-clinical research have so far faltered in human clinical trials. Attention has recently shifted into trying to identify preventative measures that may delay the onset of the illness. Preventative factors include physical activity, proper diet, cognitive stimulation and the management of conditions such as hypertension, diabetes and obesity. However, it remains imperative to identify approaches that may help patients already diagnosed with the illness. Alongside pharmacological research, much work has been done on uncovering strategies which may slow down the progression of AD. This review aims to summarize evidence supporting or refuting methods impacting on the progression of the disease. AD remains a chronic and serious condition, therefore any intervention delaying the onset of moderate/severe symptoms will have a significant impact on patients and their families.
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Ehret MJ, Chamberlin KW. Current Practices in the Treatment of Alzheimer Disease: Where is the Evidence After the Phase III Trials? Clin Ther 2015; 37:1604-16. [PMID: 26122885 DOI: 10.1016/j.clinthera.2015.05.510] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Revised: 05/29/2015] [Accepted: 05/30/2015] [Indexed: 12/26/2022]
Abstract
PURPOSE The purpose of this systematic review was to review the current place in therapy of the 4 medications, donepezil, rivastigmine, galantamine, and memantine, approved for the treatment of Alzheimer disease (AD) since the publication of Phase III trials. METHODS A systematic literature search of MEDLINE and EMBASE was conducted for articles published in the past 10 years. The search was performed using the following Medical Subject Headings and text key words: Alzheimer's disease, treatment, donepezil, galantamine, rivastigmine, memantine, dementia of the Alzheimer's type, and dementia. FINDINGS Studies that evaluated new doses, indications, and dose formulations remain a large part of the current literature. Donepezil gained approval for the treatment of severe AD and became available in a 23-mg/d dose formulation. Rivastigmine became available in a patch formulation. Memantine became available as an extended-release capsule. Use of a combination product formulation was recently approved, memantine extended release/donepezil. Controversy among clinicians remains regarding when to initiate therapy, appropriate duration of therapy, and how and when to discontinue the treatment of AD. IMPLICATIONS Only drugs that affect cholinergic function have shown consistent, but modest, clinical effects, even in late-phase trials. There is a need for a better appreciation of the various risk factors and drug targets for the treatment of AD. The wide range of targets makes it unlikely that affecting only 1 of those targets (eg, cholinergic function or N-methyl-d-aspartate) will lead to a more than minimally effective treatment option, regardless of when a treatment is started and discontinued. There is substantial opportunity for the continued growth and development of drugs and clinical trial expansion for the treatment of AD.
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Affiliation(s)
- Megan J Ehret
- Pharmacy Practice, University of Connecticut, Storrs, Connecticut.
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Zhang Y, Lin C, Zhang L, Cui Y, Gu Y, Guo J, Wu D, Li Q, Song W. Cognitive Improvement during Treatment for Mild Alzheimer's Disease with a Chinese Herbal Formula: A Randomized Controlled Trial. PLoS One 2015; 10:e0130353. [PMID: 26076022 PMCID: PMC4468068 DOI: 10.1371/journal.pone.0130353] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2015] [Accepted: 05/14/2015] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES To explore the efficacy of Chinese herbal formula compared with donepezil 5 mg/day in patients with mild Alzheimer's disease (AD). METHODS Patients with mild AD meeting the criteria were randomized into Chinese herbal formula Yishen Huazhuo decoction (YHD) group and donepezil hydrochloride (DH) group during the 24-week trial. The outcomes were measured by ADAS-cog, MMSE, ADL, and NPI with linear mixed-effect models. RESULTS 144 patients were randomized. The mean scores of ADAS-cog and MMSE in both YHD group and DH group both improved at the end of the 24-week treatment period. The results also revealed that YHD was better at improving the mean scores of ADAS-cog and MMSE than DH. Linear mixed-effect models with repeated measures showed statistical significance in time × group interaction effect of ADAS-cog and also in time × group interaction effect of MMSE. The data showed YHD was superior to DH in improving the scores and long term efficacy. CONCLUSIONS Our study suggests that Chinese herbal formula YHD is beneficial and effective for cognitive improvement in patients with mild AD and the mechanism might be through reducing amyloid-β (Aβ) plaque deposition in the hippocampus. TRIAL REGISTRATION Chinese Clinical Trial Registry ChiCTR-TRC-12002846.
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Affiliation(s)
- Yulian Zhang
- Department of Acupuncture and Cerebropathy, Second Affiliated Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Cuiru Lin
- Department of Acupuncture and Cerebropathy, Second Affiliated Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Linlin Zhang
- Department of Geriatric, Longhua Hospital of Shanghai University of Traditional Chinese Medicine, Tianjin, China
| | - Yuanwu Cui
- Department of Acupuncture and Cerebropathy, Second Affiliated Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Yun Gu
- Department of Geriatric, Longhua Hospital of Shanghai University of Traditional Chinese Medicine, Tianjin, China
| | - Jiakui Guo
- Department of Acupuncture and Cerebropathy, Second Affiliated Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Di Wu
- Department of Traditional Chinese Medicine, Tianjin Huanhu Hospital, Tianjin, China
| | - Qiang Li
- Graduate Institutes, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Wanshan Song
- Department of Acupuncture and Cerebropathy, Second Affiliated Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, China
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Kennedy RE, Cutter GR, Wang G, Schneider LS. Using baseline cognitive severity for enriching Alzheimer's disease clinical trials: How does Mini-Mental State Examination predict rate of change? ALZHEIMERS & DEMENTIA-TRANSLATIONAL RESEARCH & CLINICAL INTERVENTIONS 2015; 1:46-52. [PMID: 27695707 PMCID: PMC5040516 DOI: 10.1016/j.trci.2015.03.001] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background Post hoc analyses from clinical trials in Alzheimer's disease (AD) suggest that more cognitively impaired participants respond differently from less impaired on cognitive outcomes. We examined pooled clinical trials data to assess the utility of enriching trials using baseline cognition. Methods We included 2882 participants with mild to moderate AD in seven studies from a meta-database. We used mixed effects models to estimate the rate of decline in Alzheimer's disease Assessment Scale-cognitive (ADAS-Cog) scores among Mini-Mental State Examination (MMSE) groups. Findings Baseline MMSE category was associated with baseline scores and rate of decline on the ADAS-Cog, adjusting for age and education (both P < .001). Greater baseline cognitive impairment was associated with more rapid progression. Interpretations Although we found significant differences in rate of decline, most differences between individuals were from baseline ADAS-Cog values. Since enrichment based on MMSE would reduce the recruitment pool while adding only slightly to detecting differences in rate of progression, it is not advised.
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Affiliation(s)
- Richard E. Kennedy
- Department of Medicine, University of Alabama, Birmingham, Birmingham, AL, USA
| | - Gary R. Cutter
- Department of Biostatistics, University of Alabama-Birmingham, Birmingham, USA
| | - Guoqiao Wang
- Department of Biostatistics, University of Alabama-Birmingham, Birmingham, USA
| | - Lon S. Schneider
- Departments of Psychiatry and Neurology
- Corresponding author. Tel.: +1-323-442-7600; Fax: +1-205-934-7354.
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Yang K, Tan Y, Wang F, Zhang Q, Sun P, Zhang Y, Yao N, Zhao Y, Wang X, Fan A, Hua Q. The improvement of spatial memory deficits in APP/V717I transgenic mice by chronic anti-stroke herb treatment. Exp Biol Med (Maywood) 2014; 239:1007-1017. [PMID: 24872438 DOI: 10.1177/1535370214532757] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
In China, herbal medicine has an extensive history for the treatment of cerebrovascular diseases. Clinical studies have shown that stroke patients are more likely to experience significant memory decline in comparison to their healthy counterparts. Cognition is improved in stroke patients treated with herbal medicine active components, Geniposide (GP) and Geniposide Rg1 (GRg1) (together, called TLJN). However, the effect of TLJN in Alzheimer disease remains unknown. Therefore, we investigated the behavioral effect of TLJN in male and female APP/V717I transgenic (Tg) mice. We conducted two different treatment strategies: (1) pretreatment strategy: medically treated at the age of 3 months which lasted for 3 months; (2) early treatment strategy: medically treated at the age of 6 months which lasted for 4 months. In open field test, locomotor activity and anxiety-like behavior were not affected after TLJN administration in Tg mice. In Morris Water Maze test, spatial learning processes in both genders were improved by TLJN treatments. Furthermore, retrieval processes were significantly improved in the pretreatment strategy for only male mice, which also showed a trend for improved retrieval processes with early treatment. In the inhibitory avoidance test, TLJN enhanced learning processes. In addition, gender differences were found in Tg mice exposed to TLJN treatments. In Tg male mice, significant efficacy was seen at high and middle doses, and in Tg female mice, a low dose was more effective.
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Affiliation(s)
- Kaiyu Yang
- Beijing University of Chinese Medicine, School of Preclinical Medicine, No.11 N.3 Ring Eastern Road, Beijing 100029, China Dalian No.4 people hospital, Pharmacy, Dalian 210200, China
| | - Yan Tan
- Beijing University of Chinese Medicine, School of Preclinical Medicine, No.11 N.3 Ring Eastern Road, Beijing 100029, China
| | - Feng Wang
- Beijing University of Chinese Medicine, School of Preclinical Medicine, No.11 N.3 Ring Eastern Road, Beijing 100029, China
| | - Qi Zhang
- Beijing University of Chinese Medicine, School of Preclinical Medicine, No.11 N.3 Ring Eastern Road, Beijing 100029, China
| | - Ping Sun
- Beijing University of Chinese Medicine, School of Preclinical Medicine, No.11 N.3 Ring Eastern Road, Beijing 100029, China
| | - Ying Zhang
- Beijing University of Chinese Medicine, School of Preclinical Medicine, No.11 N.3 Ring Eastern Road, Beijing 100029, China Nankai hospital, Tianjin 300100, China
| | - Na Yao
- Beijing University of Chinese Medicine, School of Preclinical Medicine, No.11 N.3 Ring Eastern Road, Beijing 100029, China
| | - Yanan Zhao
- Beijing University of Chinese Medicine, School of Preclinical Medicine, No.11 N.3 Ring Eastern Road, Beijing 100029, China
| | - Xu Wang
- Beijing University of Chinese Medicine, School of Preclinical Medicine, No.11 N.3 Ring Eastern Road, Beijing 100029, China
| | - Angran Fan
- Beijing University of Chinese Medicine, School of Preclinical Medicine, No.11 N.3 Ring Eastern Road, Beijing 100029, China
| | - Qian Hua
- Beijing University of Chinese Medicine, School of Preclinical Medicine, No.11 N.3 Ring Eastern Road, Beijing 100029, China
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