FACTS AND STATS - Creighton University · 2018. 11. 13. · FACTS AND STATS Most common form of...
Transcript of FACTS AND STATS - Creighton University · 2018. 11. 13. · FACTS AND STATS Most common form of...
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Michele A. Faulkner, Pharm.D., FASHP
Professor of Pharmacy Practice and Medicine
Creighton University
Copyright M. Faulkner, 2018
FACTS AND STATS
Most common form of dementia
Prevalence of AD doubles for every 5 year interval beyond age 65 74.1 million in the US by 2030
Sixth leading cause of death in the US Deaths increased by 123% from 2000-2015
No proven method of prevention
No cure
Inadequate treatment modalities
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WHO IS AT RISK?
Advanced age
Atherosclerosis
Down’s Syndrome
Family History
Head injury
Hypercholesterolemia
Hyperglycemia/Diabetes Mellitus
Hypertension
Amyloid beta (Aß) in the brain Clumps of protein that stick together and build up between
nerve cells
Tau proteins Forms neurofibrillary tangles in the brain of AD patients
preventing transmission of necessary substances from one part of a cell to another
Cellular damage Cell death
Brain shrinkage
Decreased in neurotransmittersNeurofibrillary Tangles
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MEDICATION MIMICS
Anticholinergics Antihistamines
Skeletal muscle relaxants
Tricyclic (and other) antidepressants
Psychoactive agents Antipsychotics
Benzodiazepines
Corticosteroids
Sedative hypnotics
H2-receptor antagonists
Antihistamines Chlorpheniramine Clemastine Diphenhydramine
Antidepressants Tricyclics (amitriptyline, nortriptyline,
desipramine, imipramine, etc.) Paroxetine
Antipsychotics Clozapine Olanzapine Perphenazine Quetiapine Thioridazine Trifluoperazine
Central anticholinergics Amantadine Benztropine Trihexyphenidyl Orphenadrine
Bladder and GI antispasmotics Darifenacin Dicyclomine Flavoxate Oxybutynin Tolterodine
Antiemetics Hydroxyzine Meclizine Promethazine Scopolamine
Drugs with high anticholinergic properties (Anticholinergic Cognitive Burden scale score 3)
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ACB score 1
Alprazolam
Atenolol
Bupropion
Captopril
Codeine
Colchicine
Fentanyl
Metoprolol
Nifedipine
Prednisone
Triamterene
ACB score 2
Carbamazepine
Cyclobenzaprine
Meperidine
Oxcarbazepine
Cholinesterase Inhibitors
• Donepezil• Galantamine• Rivastigmine
Mild-moderate
Alzheimer’s disease
• Cholinesterase Inhibitors• Donepezil
• NMDA Receptor Antagonist
• Memantine
Moderate-severe
Alzheimer’s disease
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Medications must be titrated to a minimum effective dose in order to receive the maximum benefit
Counsel patients and caregivers to take as prescribed, and don’t discontinue without discussion with the prescriber
Discuss side-effects in detail, and provide strategies for mitigation
It may be necessary to switch medications due to lack of effectiveness
Patients may respond differently to on cholinesterase inhibitor compared with another
Effectiveness may wane over time
Combination therapy in moderate-severe AD demonstrates minimal benefit
No recommendations can currently be made on the basis of pharmacogenomics
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• Even mild depression may impair a patient’s ability to function• Recurrent depression has been linked to development of
dementia• Avoid anticholinergics• Consider positive aspects of side-effect profile (sedative
properties, influence on weight)
Depression
• Use sedative agents with caution and utilize shorter acting agents• Consider antidepressants with anti-anxiolytic properties
Anxiety
• Best data with risperidone• Quetiapine has not been shown to positively affect
neuropsychiatric symptoms in AD patients• Use of antipsychotics in dementia patients has been linked to an
increase in stroke and overall mortality• Non-antipsychotic options
• Citalopram and dextromethorphan-quinidine have demonstrated the ability to decrease agitation in AD patients
• Consider whether agitation might be due to another cause (e.g. uncontrolled pain)
Psychosis
Over 50% of institutionalized patients with advanced dementia receive at least one medication deemed of questionable benefit 90-day expenditure for unnecessary
medications is >$800 on average
Feeding tube placement increases the likelihood of inappropriate medication use
Cholinesterase inhibitors and memantine are often continued
Non-essential medications unrelated to AD should be discontinued e.g. lipid lowering agents, agents for
osteoporosis
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Cholinesterase
Inhibitors
Inidcation Dosage Form(s) Dosing Titration
Donepezil Mild‐moderate AD
Moderate‐severe AD
Immediate release tablets/
orally disintegrating tablets
5mg/day (minimum
maintenance dose)
10mg/day
Increase to 10mg/day after 4 weeks
May increase to 23mg/day after at
least three months at 10mg/day dose
Galantamine Mild‐moderate AD Immediate release tablets/ oral
solution
Extended release capsules
4mg twice daily
4mg/day
Increase by 4mg twice daily every 4
weeks up to 24mg/day (minimum
maintenance dose is 16mg/day)
Increase by 4mg/day every 4 weeks
(same parameters as above)
Rivastigmine Mild‐moderate AD
Moderate‐severe AD
Immediate release
capsules/oral solution
Topical patch
Topical patch
1.5mg twice daily
4.6mg/24h applied daily
Increase to 3mg twice daily every 2
weeks up to 12mg/day (minimum
maintenance dose is 6mg/day)
Increase to 9.5mg/24h after 4 weeks
(minimum maintenance dose), and
then to 13.3mg/24h if therapeutic
benefit from lower dose wanes
13.3mg/24h (minimum maintenance
dose) titrated as per mild‐moderate AD
NMDA
Receptor
Antagonists
Indication Dosage Form(s) Dosing Titration
Memantine Moderate‐
severe AD
Immediate release
tablets/oral solution
Extended release
capsules
5mg/day
7mg/day
Increase to 5mg
twice daily, and then
by 5mg/day weekly
alternating between
AM and PM doses to
a dose of 20mg/day
(minimum
maintenance dose)
Increase by 7mg/day
weekly to a dose of
28mg (minimum
maintenance dose)
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