The Availability of Antidementia Drugs in Europe
The Availability of Antidementia Drugs in Europe
Existing Treatments for Alzheimer’s Disease in Europe
No drug treatments can cure Alzheimer’s disease or the other common forms of dementia. However, drug treatments have been developed that can temporarily slow the progression of symptoms in some people with Alzheimer’s disease. Donepezil, rivastigmine and galantamine all work in a similar way and are known as acetylcholinesterase inhibitors (AchIs). Memantine1 works in a different way from the other three.2
Acetylcholinesterase Inhibitors
Research has shown that the amount of a chemical called acetylcholine diminishes in the brains of people with Alzheimer’s disease. Acetylcholine is one of the many chemicals that nerve cells use to communicate and is a neurotransmitter that plays a critical role in memory and learning processes.
Donepezil, rivastigmine and galantamine have a common mode of action – all three drugs prevent an enzyme known as acetylcholinesterase from breaking down acetylcholine in the brain. However, rivastigmine inhibits both acteylcholinesterase and butyrylcholinesterase, the two enzymes that break down acetylcholine in the brain. Galantamine also appears to act on the nicotinic neuronal receptors in the brain, making them release more acetylcholine. Increased concentrations of acetylcholine lead to improved communication between the nerve cells involved in memory and learning, which may in turn temporarily improve or stabilise some of the key symptoms of Alzheimer’s disease.
It is possible that one of these drugs might suit a particular individual better than another. A specialist may be able to advise whether there is any advantage associated with a particular drug.
At present, AchIs are used only in people with mild to moderate Alzheimer’s disease. They are not effective for everyone and may only temporarily improve memory or delay memory loss. Research is being undertaken to find out whether any of these drugs may be effective in the later stages of Alzheimer’s disease.3
In February 2006, following a positive opinion from the Committee for Medicinal Products for Human Use (CHMP) of the European Medicines Agency (EMEA), the European Commission granted rivastigmine EU Marketing Authorisation for the symptomatic treatment of mild to moderately severe dementia associated with idiopathic Parkinson’s disease (PDD).
- Donepezil is marketed in Europe under the name Aricept, rivastigmine as Exelon, galantamine as Reminyl and memantine as Ebixa or Axura.
- Alzheimer’s Society UK, Information sheet on Drug treatments for Alzheimer’s disease – Aricept, Exelon, Reminyl and Ebixa, August 2003.
- Alzheimer’s Society UK, op. cit.
- Alzheimer’s Society UK, op. cit.
- Reimbursement of donepezil is limited to the generic versions of this product.
- Although individual health trusts are free to reimburse memantine, the Scottish Medicines Consortium rejected their use through the NHS and the opinion of NICE was pending when this publication went to print.
- The MMSE (Folstein et al., 1975) is a quick test that gives an overall estimate of a person’s intellectual capacity and can therefore be used to give a rough assessment of the progress of dementia over time. It gives a score from 30 (full mental capacity) to 0 (severe impairment).
- Oude Voshaar RC, Burns A, Olde Rikkert MGM, Alarming arbitrariness in EU prescription and reimbursement criteria for antidementia drugs, Int J Geriatr Psychiatry, 2006; 21:29–31.
- Unless obtained from our member organisations, we included data from Oude Voshaar, et.al., op. cit.
- Unless obtained from our member organisations, we included data from R.C. Oude Voshaar et al., op.cit.
- Although an application for reimbursement can be made by any doctor on behalf of a patient, the diagnosis must have been made by a specialist (neurologist, psychiatrist or geriatrician).
- Any doctor can prescribe antidementia drugs, but reimbursement can only be given if the diagnosis has been established by a specialist.
- Although prescriptions can be filled in by any doctor, the diagnosis needs to be confirmed by a specialist.
- Norway specifies that treatment decisions should be made by a doctor with an interest in and knowledge of dementia, but does not restrict treatment decisions to specialist doctors.
- For patients with MMSE scores higher than 26, more extensive neuropsychological examinations have to be carried out that indicate cognitive decline consistent with Alzheimer’s disease.
- The NICE guidance in existence (September 2006) allows general practitioners to continue treatment under shared care protocols.
- Wilkinson D, et al., Inequalities in dementia care across Europe: An Agenda for Change, Int J Clin Pract, 2005;59(S146):17–24.
- Waldemar G, Phung KTT, Burns A, et al., Access to diagnostic evaluation and treatment for dementia in Europe, Int J Geriatr Psychiatry, in press.
- Wilkinson D, op. cit.
- Waldemar G, op. cit.
