October 5, 2001
New drugs can slow Alzheimer's disease
BY SHERI PORTER
Diagnose your patients who have Alzheimer's disease and get them started on new medications that can delay the progression of the disease, advised Thomas Rosenthal, M.D., of Buffalo, N.Y., during Wednesday's clinical seminar on the disease.
The new medications all fall in the acetylcholinesterase inhibitor class of medicines. During the two-hour session, Rosenthal responded to questions about when to start these medications and when to stop them. He discussed side effects and cost. And Rosenthal readily acknowledged the shortcomings of the drugs.
The drugs are expensive and, at best, only temporarily delay the progression of the disease, said Rosenthal, who serves as professor and chair of the family practice department at the University of Buffalo.
"Death is a normal part of Alzheimer's disease," he said. "But if you can delay institutionalization for six months, it (the drug) is probably cost-effective."
But physicians are balking at prescribing a costly medication -- $130 to $140 a month -- that offers so little benefit. "Should I be pushing these drugs harder?" asked a physician from the audience. "Maybe I don't know because I'm not convinced myself."
Rosenthal asked for a show of hands: How many in the room, he asked, have prescribed a cholinesterase inhibitor at least 20 times? Only six hands went up. "That's up from one or two hands that went up a year ago," said Rosenthal. "We're taking a measured approach to using these medications. We're learning they're not a cure-all."
Once you make the decision to prescribe a cholinesterase inhibitor, "you want to move slowly on these meds," said Rosenthal. He suggested that physicians increase the patient's dose every four to six weeks.
"With all of these medications, you want to start on a low dose and build up to get around the gastrointestinal problems," said Rosenthal.
He also suggested the medications be prescribed for nighttime usage since sleeping patients won't notice nausea, a common side effect.
Physicians should carefully monitor the patient's progress as the dosage is increased. "I go until the response is satisfactory to the family, and then I hold," said Rosenthal. And when should treatment stop? Studies show that after nine to 15 months on a cholinesterase inhibitor, people with Alzheimer's disease begin to show a decline, said Rosenthal. He suggested using the patient's Folstein Mini-Mental State Examination score as a guide, continuing the medication until the patient scores lower than 12 points out of a possible 30 on the mental test.
Even as Rosenthal advises colleagues on the use of cholinesterase inhibitors, he's looking forward to better treatments for patients with Alzheimer's disease. "These drugs are not where we're going," he said. "I think in five years, we'll be looking at a different class of drugs."
"The future is in prevention," concluded Rosenthal. "In five years, we'll see pharmacological treatments that will block amyloid deposition. The challenge will then be to identify patients who are laying down amyloid deposits." *
FP Report is published by the AAFP News Department.
Copyright © 2001 by American Academy of Family Physicians.
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