Drug Topics - August 4, 2008 - (Page 5) 5 Of Interest to Pharmacists First dementia treatment guidelines issued jointly by ACP, AAFP Heidi Belden, Pharm.D. F ive drugs approved for the treatment dementia and that, while some studies have of dementia are the focus of new phardemonstrated the benefit of medication, climacologic guidelines published on the nicians should base the decision to initiate a subject. The American College of Physitrial with a cholinesterase inhibitor or mecians (ACP) and the American Academy of mantine on individualized assessment. CliniFamily Practitioners (AAFP) have issued a cians should ultimately balance the potential Sunny Linnebur, joint guide based on a review that included risk versus the modest benefit of treatment. Pharm.D., 59 randomized, controlled trials published and Kristen (top) “One thing you have to consider is the Cook, between 1986 and November 2006. The Pharm.D., believe quality of life you are gaining from introducmedications reviewed for efficacy include that medications ing a new medication,” Cook said. “If I have for dementia four cholinesterase inhibitors—donepezil, a patient in clinic with mild dementia who should be rivastigmine, galantamine (Razadyne, Jans- individualized for is struggling with nausea and weight loss patients. sen), and tacrine (Cognex, Sciele)—as well as already, I will be more hesitant to recomthe neuropeptide-modifying agent, memanmend a cholinesterase inhibitor right away." tine (Namenda, Forest Laboratories). More careful consideration needs to be given Following a review of the studies at hand, to the additional risk of weight loss versus guideline authors concluded that there is no improvements in cognition or quality of life, convincing evidence that one drug is more she said. efficacious than another and that treatment “As the guideline states, we currently should be based on a drug’s adverse-effect have no way to predict which patients profile, ease of use, and cost. might have a clinically important response,” Not surprised by the finding was Sunny Linnebur added. Clinicians should provide Linnebur, Pharm.D., FASCP, BCPS, CGP, an associate this information to patients or caregivers or both and professor at the University of Colorado’s School of Pharma- allow them to make the decision regarding treatment, cy in Denver. “Two studies have found slight differences she believes. between cholinesterase inhibitors, but the differences were One finding that stood out to investigators was the not consistently demonstrated among outcomes,” she said. presence of serious adverse effects with the use of tacrine, “In clinical practice, the choice of cholinesterase inhibitor is including evidence of liver damage—elevated alanine typically based on formulary preference and cost.” aminotransferase levels and other hepatic abnormali“There is also the issue of, ‘How do we measure if one ties—found among seven studies comparing the drug to of these medications works?’” Kristen Cook, Pharm.D., either placebo or idebenone. In light of its safety profile, BCPS, assistant professor at the University of Nebraska guideline authors do not support the use of tacrine. Medical Center, said. The evaluated studies also did not shed any light on Several different instruments are used to assess the an optimal duration or evidence to guide a session of efficacy in different domains and are not consistent, she therapy, according to guideline authors. Linnebur said said. “The definition of clinical significance can vary that in her clinic most patients choose treatment, but greatly depending on who is defining it. For a caregiver, some do not continue it long term due to the high cost it may mean being able to help prepare dinner. Howev- and difficulties in assessing treatment response. er, this may not translate to being clinically significant Finally, the new ACP Clinical Practice Guidelines on the instruments we use to measure efficacy,” she said. point to an urgent need for further research on the “The subjectivity of how we measure these outcomes clinical efficacy of the drugs used to treat the condimakes it difficult to compare medications." tion. Current Pharmacologic Treatment of Dementia: According to the authors of the new guidelines, treat- A Clinical Practice Guideline for the ACP and the ment should be individualized to the patient. The new AAFP was published in the March 4 issue of the guide also points out that current evidence does not Annals of Internal Medicine and is available online at support prescribing medications to every patient with www.annals.org/cgi/content/full/148/5/370. http://www.annals.org/cgi/content/full/148/5/370
Table of Contents Feed for the Digital Edition of Drug Topics - August 4, 2008 Drug Topics - August 4, 2008 Contents To Prevent Drug Errors, Go to the Source Researchers Still Studying Impact of Glycemia on Heart Disease First Dementia Treatment Guidelines Released Drug Topics - August 4, 2008 Drug Topics - August 4, 2008 - Contents (Page 1) Drug Topics - August 4, 2008 - Contents (Page 2) Drug Topics - August 4, 2008 - To Prevent Drug Errors, Go to the Source (Page 3) Drug Topics - August 4, 2008 - Researchers Still Studying Impact of Glycemia on Heart Disease (Page 4) Drug Topics - August 4, 2008 - First Dementia Treatment Guidelines Released (Page 5)
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