JY is a 75-year-old man who was diagnosed with mild Alzheimer’s disease (AD) 1 week ago with a Mini Mental Status Exam (MMSE) score of 19. His wife, PY, comes to the pharmacy with her husband’s prescription for donepezil (Aricept), but she believes the doctor made a mistake. She recalls seeing an advertisement for a medication named memantine (Namenda) for use in the treatment of AD. PY asks the pharmacist why the doctor wrote a prescription for donepezil and not memantine.
How should the pharmacist respond to PY?
Answer: Case One The treatment of AD is based on a patient’s stage of cognitive decline. Various mental status examinations, such as the MMSE, are used in practice to diagnose and monitor a patient’s disease course. The MMSE is an 11-item test with a maximum score of 30 that quantifies a patient’s orientation, registration, attention, calculation, recall, and language. Mild cognitive decline is classified by an MMSE score of >18, moderate cognitive decline as a score of 10 to 18, and severe cognitive decline as a score of <10.
Medications used to treat the cognitive symptoms of AD include the cholinesterase inhibitors donepezil, rivastigmine (Exelon), and galantamine (Razadyne), and the N-methyl-D-aspartate receptor antagonist memantine. Donepezil is FDA-approved to treat all stages of AD, rivastigmine and galantamine are approved to treat mild to moderate stages, and memantine is approved to treat moderate to severe stages. Current treatment guidelines recommend that cholinesterase inhibitors be offered to patients with mild to moderate AD.
The pharmacist should reassure PY that donepezil is an appropriate medication considering her husband’s MMSE score, the drug’s approved indication, and AD treatment guidelines.
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