Dementia
26
Table 10. Pharmacologic Treatment of Dementia
Characteristic Donepezil (Aricept) $$
Rivastigmine (Exelon)
$$ (oral), $$$$ (transdermal)
FDA-
approved
indication
Mild to moderate and
severe Alzheimer's
dementia
Mild to moderate Alzheimer's dementia
and Parkinsonian dementia
Dosing Initiate at 5 mg daily,
increase to 10 mg aer 4–6
weeks.
For moderate-severe
dementia, may increase
to 23 mg daily aer ≥3
months.
*Note: Donepezil is
also available as a orally
disintegrating tablet
(ODT) 5 mg and 10 mg
Oral: Twice daily; start with 1.5 mg
every 12 h and gradually titrate up to
minimally effective dosage (up to 6 mg
every 12 h) as tolerated.
Patch: For naive patients – 4.6 mg/24 h
once-daily patch for 4 wk; aer 4 wk
titrate up to 9.5 mg/24 h once-daily
patch.
To convert dose: If less than 6 mg total
oral daily dose, use 4.6 mg/24 h once-
daily patch for 4 wk; aer 4 wk titrate
up to 9.5 mg/24 h once-daily patch.
Note:
1. Available in 13.3 mg/24 h patch.
2. Aer 4 wks on the 9.5 mg/24 h patch,
the dose can be increased.
3. Rivastigmine also available in oral
solution (2 mg/mL).
Adverse
effects
Defined as those occurring
at a frequency of at least
5% in patients receiving
10 mg/day and twice the
placebo rate:
Nausea, diarrhea, insomnia,
vomiting, muscle cramp,
fatigue, and anorexia
Defined as those occurring at a
frequency of at least 5% and twice
the placebo rate: Nausea, vomiting,
anorexia, dyspepsia, and asthenia.
With the patch, the vast majority of
patients participating in the controlled
clinical trial had either no observed
skin irritation or mild to moderate skin
reactions.
Elimination
half-life (hrs)
70–80 Oral: 1.5 hours
Transdermal: 3 hours aer patch
removal
Metabolism Liver Kidney
Food
interaction
No Administer oral formulation with food
Protein
binding
96% 40%
STEP 17: Consider appropriate pharmacological
management
