Cochrane Briefs

Am Fam Physician. 2004 Nov 1;70(9):1681-1682.

Donepezil in the Treatment of Vascular Dementia

Clinical Question

Is donepezil effective in the treatment of vascular dementia?

Evidence-Based Answer

Donepezil in a dosage of 10 mg daily provides a small benefit in patients with mild to moderate vascular dementia and generally is well tolerated.

Practice Pointers

Donepezil, a cholinesterase inhibitor, is somewhat effective in the treatment of mild to moderate cognitive impairment caused by Alzheimer’s disease. Malouf and Birks examined the evidence from two similar manufacturer-sponsored studies of donepezil in a total of 1,219 patients with vascular cognitive impairment (sometimes called “multi-infarct dementia” or “vascular dementia”). Both studies were randomized, double blinded, and placebo controlled. Validated diagnostic criteria were used to identify patients with probable vascular dementia. Given the challenge of diagnosing dementia subtypes before death, however, a substantial number of patients probably had mixed vascular and Alzheimer’s dementia.1

Patients who took donepezil performed slightly better on tests of cognitive function, such as the Mini-Mental State Examination (weighted mean difference, 1.2 points at 24 weeks on this 30-point scale) and the Alzheimer’s Disease Assessment Scale cognitive subscale. Patients who took the 10-mg dosage did better than those who took the 5-mg dosage. Patients who took the 10-mg dosage (but not the 5-mg dosage) also did better than control patients on the Clinical Dementia Rating scale. There was no difference between groups on the Alzheimer’s Disease Functional Assessment and Change Scale, which focuses on activities of daily living. Compared with the lower dosage and placebo, the 10-mg dosage was associated with more adverse events (odds ratio for at least one adverse event, 1.95; 95 percent confidence interval, 1.20 to 3.15;P = .007). Most adverse events were minor, and the pooled dropout rate and the rate of severe adverse events were similar between groups.

Malouf R, Birks J. Donepezil for vascular cognitive impairment. Cochrane Database Syst Rev. 2004;(3):CD004395.

REFERENCE

1. Hogervorst E, Bandelow S, Combrinck M, Irani S, Smith AD. The validity and reliability of 6 sets of clinical criteria to classify Alzheimer’s disease and vascular dementia in cases confirmed post-mortem: added value of a decision tree approach. Dement Geriatr Cogn Disord. 2003;16:170–80.

NSAIDs vs. Opiates for Pain in Acute Renal Colic

Clinical Question

Are nonsteroidal anti-inflammatory drugs (NSAIDs) or opiates more effective for pain relief in patients with acute renal colic?

Evidence-Based Answer

Data from randomized controlled trials comparing NSAIDs with opiates show that NSAIDs are associated with lower pain scores, less need for additional rescue medication, and less vomiting (particularly when compared with meperidine).

Practice Pointers

Acute renal colic is one of the most painful conditions and often is associated with nausea and vomiting. Holdgate and Pollock identified studies that compared NSAIDs with opiates in adults with acute renal colic (fewer than 12 hours duration) and moderate to severe pain. They found 20 studies that included a total of 1,613 patients and compared a total of five NSAIDs and five opiates (each study compared one opiate with one NSAID).

Study quality was mediocre; although most studies blinded either patients or outcome assessors during the study period, only five studies clearly concealed allocation at the start of the study, and only three definitely used intention-to-treat analysis. Data from the trials could not be combined statistically because of differences in methodology and wide variability in results.

Pain scores were reported in 13 studies. Ten studies found that patients who took NSAIDs had lower pain scores; two studies found no difference, and one study reported lower pain scores in patients who took opiates. There was no difference between treatment groups in complete pain relief at 30 or 60 minutes. Additional “rescue” analgesia was needed more often in patients randomized to opiates (25.4 versus 18.9 percent; P = .007; number needed to treat, 15). Vomiting was more common in patients randomized to opiates (19.5 versus 5.8 percent; P < .00001; number needed to harm, seven). Meperidine caused more vomiting than other opiates; there was no difference in the risk of vomiting between other opiates and NSAIDs.

The Institute for Clinical Systems Improvement's guideline on acute pain management suggests that NSAIDS are often adequate for mild or moderate pain.1) It recommends that opioids be added to pain therapy in these patients only if pain is not controlled adequately with NSAIDs alone.

Holdgate A, Pollock T. Nonsteroidal anti-inflammatory drugs (NSAIDs) versus opioids for acute renal colic. Cochrane Database Syst Rev. 2004;(3):CD004137.

REFERENCE

1. Institute for Clinical Systems Improvement (ICSI). Assessment and management of acute pain. Accessed online September 24, 2004, at: http://www.icsi.org/knowledge/detail.asp?catID=29"&amp;"itemID=152


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