The National Institute for Health and Clinical Excellence (NICE) has issued a revised Technology Appraisal (TA-217) on the use of donepezil, galantamine, rivastigmine and memantine for the treatment of Alzheimer’s disease, and makes the following recommendations (taken directly from source):

1. The three acetylcholinesterase (AChE) inhibitors donepezil, galantamine and rivastigmine are recommended as options for managing mild to moderate Alzheimer’s disease under all of the conditions specified in 3 and 4 below (previously, the 3 AChEs were only recommended for moderate severity disease)

2. Memantine is recommended as an option for managing Alzheimer’s disease for people with:

– moderate Alzheimer’s disease who are intolerant of or have a contraindication to AChE inhibitors or

– severe Alzheimer’s disease.

– Treatment should be under the conditions specified in 3.
(Memantine was previously not recommended for moderate to severe disease except as part of a clinical trial)

3. Treatment should be under the following conditions:

– Only specialists in the care of patients with dementia (that is, psychiatrists including those specialising in learning disability, neurologists, and physicians specialising in the care of older people) should initiate treatment. Carers’ views on the patient’s condition at baseline should be sought.

– Treatment should be continued only when it is considered to be having a worthwhile effect on cognitive, global, functional or behavioural symptoms.

– Patients who continue on treatment should be reviewed regularly using cognitive, global, functional and behavioural assessment. Treatment should be reviewed by an appropriate specialist team, unless there are locally agreed protocols for shared care. Carers’ views on the patient’s condition at follow-up should be sought.

4. If prescribing an AChE inhibitor (donepezil, galantamine or rivastigmine), treatment should normally be started with the drug with the lowest acquisition cost (taking into account required daily dose and the price per dose once shared care has started). However, an alternative AChE inhibitor could be prescribed if it is considered appropriate when taking into account adverse event profile, expectations about adherence, medical comorbidity, possibility of drug interactions and dosing profiles.

5. When using assessment scales to determine the severity of Alzheimer’s disease, healthcare professionals should take into account any physical, sensory or learning disabilities, or communication difficulties that could affect the results and make any adjustments they consider appropriate. Healthcare professionals should also be mindful of the need to secure equality of access to treatment for patients from different ethnic groups, in particular those from different cultural backgrounds.

The guideline also makes recommendations for assessing the severity of disease (please see link for details).