Treating Alzheimer's in the Era of Managed Care

Am J Geriatr Pharmacother

A panel of experts has released new recommendations for the treatment of Alzheimer’s disease (AD) that represent the first updated guidelines in 5 years (. 2006; 4[suppl A]:S9-S24). The guidelines are intended for clinical physicians, as well as for medical and pharmacy directors in managed care.

N

Treatment developments since the previous guidelines were published “include memantine [Namenda], an -methyl-d-aspartate [NMDA] antagonist approved for moderate-to-severe Alzheimer’s disease,” says lead author Howard M. Fillit, MD. “Along with the cholinesterase inhibitors [ChEIs], treatment is now available for all stages of disease, and combination therapy with both classes of drugs can be used.”

More healthcare dollars are spent on AD than any other medical condition, except heart disease and cancer. Annual direct and indirect costs of treating AD surpass $100 billion. However, Dr Fillit, executive director of the Alzheimer’s Drug Discovery Foundation and Institute for the Study of Aging, notes that “patients in managed care that are treated with FDA-approved Alzheimer’s medications have lower rates of hospital utilization and generate less annual costs.”

Some 30 million Medicare recipients have drug coverage; >5.8 million Americans are enrolled in Medicare Advantage managed care plans.

Available evidence on the 3 most often used ChEIs—donepezil (Aricept), galantamine (Razadyne), and rivastigmine (Exelon)—shows that all 3 are similarly effective in patients with mild-to-moderate AD, the panel concluded. (Memantine is not currently approved for patients with mild disease.)

Choice of ChEI should be based on the individual patient. If dose increases may be a problem, donepezil may be best, since it is the only antidementia therapy (ChEI or memantine) that does not require dose titration. For many patients, the once-daily dosing of donepezil and galantamine may be preferable to the twice-daily dosing of rivastigmine and memantine.

Memantine has the most benign side-effect profile. All ChEIs have similar tolerability, with nausea, vomiting, diarrhea, upset stomach, and sleep disturbances most commonly reported. Some data suggest that rivastigmine may be associated with more gastro-intestinal events.

The panel recommendations include:

• Since early diagnosis is critical, consider screening for cognitive impairment in all patients beginning at age 75 years

• When cognitive impairment is identified, use a structured approach to diagnosis, including evaluations of cognition, function, and behavior

• Base initial treatment on disease stage (Table), not on care setting (eg, community, long-term care facility)

• Use AD guidelines for patients with mixed dementia, pure vascular dementia, dementia with Lewy bodies, and Parkinson’s dementia; but refer patients with frontotemporal dementia to a specialist

• Avoid hormones, nutraceuticals, vitamins, or other medications to treat dementia

• Reevaluate newly diagnosed patients within 2 months, then every ≥6 months thereafter

• Counsel patients, caregivers about expectations

• Consider reversible causes (eg, comorbidities, other medications) in unexpectedly rapid deterioration with antidementia drugs

• Consider stopping ChEI/memantine for patients who advance to profound disease

• Distinguish NMDA antagonists and ChEIs as 2 separate classes under Part D formulary guidelines, since patients may need both

• Prescribe antidementia agents as a preferred formulary

• Medicare managed care organizations should not use administrative barriers (eg, preauthorization, appeals) that limit access to antidementia therapy.

Guideline coauthor Rachel S. Doody, MD, PhD, of Baylor College of Medicine in Houston, notes, “It is important that patients and caregivers discuss these treatment and care management options for Alzheimer’s disease with their physician.”

Some 4.5 million Americans have AD. One in 10 people aged >65 years has AD or related dementias. Prevalence rises to 25% after age 75 and to 40% after age 80.