FPIN's Help Desk Answers

Alzheimer Disease: Monotherapy vs. Combination Therapy


Am Fam Physician. 2017 Apr 1;95(7):452.

Clinical Question

Is the combination of memantine with donepezil more effective in the treatment of Alzheimer disease than either drug alone?

Evidence-Based Answer

Combination treatment with memantine and donepezil results in a small improvement in cognitive function that is of uncertain clinical significance in patients with moderate to severe Alzheimer disease, but no improvement in patients with mild to moderate disease. (Strength of Recommendation: B, based on a meta-analysis of randomized controlled trials.)

Evidence Summary

A meta-analysis of three double-blind randomized controlled trials evaluated the use of combination therapy with memantine plus donepezil (two studies) or memantine plus donepezil, galantamine, or rivastigmine in patients with Alzheimer disease.1 Data were analyzed for 1,043 patients diagnosed with likely Alzheimer disease based on the National Institute of Neurological and Communicative Disorders and Stroke and the Alzheimer's Disease and Related Disorders Association criteria or Mini-Mental State Examination (MMSE). The two studies of memantine plus donepezil included patients with moderate to severe Alzheimer disease. One study included patients with mild to moderate dementia. Patients receiving monotherapy (cholinesterase inhibitor alone [two studies] or memantine alone [one study]) were compared with those using a combination of a cholinesterase inhibitor plus either memantine or placebo. Patients were followed for 24 to 52 weeks. Post-therapy cognitive outcomes were measured using the MMSE, the Alzheimer's Disease Assessment Scale–Cognitive Subscale, or the Severe Impairment Battery. Analysis of pooled results of all three studies found no difference between combination and monotherapy. A subgroup analysis limited to patients with moderate to severe dementia found a small but significant cognitive improvement with combination therapy compared with donepezil alone (standard mean difference = 0.45; 95% confidence interval, 0.27 to 0.63). There

Author disclosure: No relevant financial affiliations.

Address correspondence to Amber Avila, MD, at aavila@siumed.edu. Reprints are not available from the authors.


1. Muayqil T, et al. Systematic review and meta-analysis of combination therapy with cholinesterase inhibitors and memantine in Alzheimer's disease and other dementias. Dement Geriatr Cogn Dis Extra. 2012;2(1):546–572.

2. Gareri P, et al. Retrospective study on the benefits of combined Memantine and cholinEsterase inhibitor treatMent in AGEd Patients affected with Alzheimer's disease. J Alzheimers Dis. 2014;41(2):633–640.

Help Desk Answers provides answers to questions submitted by practicing family physicians to the Family Physicians Inquiries Network (FPIN). Members of the network select questions based on their relevance to family medicine. Answers are drawn from an approved set of evidence-based resources and undergo peer review. The strength of recommendations and the level of evidence for individual studies are rated using criteria developed by the Evidence-Based Medicine Working Group (http://www.cebm.net/?o=1025).

The complete database of evidence-based questions and answers is copyrighted by FPIN. If interested in submitting questions or writing answers for this series, go to http://www.fpin.org or e-mail: questions@fpin.org.

Copyright Family Physicians Inquiries Network. Used with permission.

This series is coordinated by John E. Delzell Jr., MD, MSPH, Assistant Medical Editor.

A collection of FPIN's Help Desk Answers published in AFP is available at https://www.aafp.org/afp/hda.



Want to use this article elsewhere? Get Permissions

CME Quiz

More in AFP

Editor's Collections

Related Content

More in Pubmed


Jan 15, 2018

Access the latest issue of American Family Physician

Read the Issue

Email Alerts

Don't miss a single issue. Sign up for the free AFP email table of contents.

Sign Up Now

Navigate this Article