Medicine Information Article:

Acetylcholinesterase Inhibitors (AChEIs)for the Treatment of Moderate and

Checklist of Treatments for Alzheimer's Disease

Part 1 of 8

For approximately ten years, I have cared for a parent with slowly advancing Alzheimer's disease. Contrary to all of the horror stories portrayed in the national media, I have found that the burden of caring for an Alzheimer's sufferer is less onerous than I originally expected. The primary reason that my burden has been lightened is that I give my mother a potent cocktail mix of drugs and vitamins to combat the disease. Her comparatively slow decline can be attributed to the efficacy of taking a multi-faceted approach to treating this incurable disease.

I subscribe to several news sources that provide daily updates on the latest reported findings and news about Alzheimer's drugs in development, the latest clinical trials, and treatments using over the counter vitamins and medications. Numerous people have asked me for advice on caring for a family member afflicted with Alzheimer's disease, and I have put together this checklist of therapies that should be administered daily to the Alzheimer's patient, unless there is clear and convincing evidence that an individual patient will have an adverse reaction to one of these medications.

At the outset, please note that wandering behavior is NOT normal for Alzheimer's patients; it is a sign of depression that can often be treated and corrected with an antidepressant. Diarrhea accidents and urine accidents are not normal for Alzheimer's patients, and again, these symptoms can be treated with readily available medications. Too many doctors are quick to jump to conclusions that every ailment afflicting an Alzheimer's patient is due to the disease. Any doctor who tells you that Alzheimer's patients normally wake up in the middle of the night, or sleep too much, or lose their appetites, and nothing can be done about it, should be fired. I am happy to debate the merits of my approach with anyone - medically qualified or not - who claims that there are only one or two classes of drugs available to treat Alzheimer's sufferers.

1. Acetylcholinesterase Inhibitors (AChEIs). A broad class of drugs inhibit the enzyme that breaks down the neurotransmitter, acetylcholine, in the brain. This class of drugs is fairly old as far as Alzheimer's therapies go; the first of these drugs became available in the 1995/96 period. One of the most popular of these drugs was also the second one in its class: donepezil HCL sold under the brand name "Aricept." Some newer drugs in this same class include galantamine hydrobromide, sold under the brand name Reminyl, and rivastigmine tartrate, sold under the brand name Exelon. In addition to being an AChEI, Reminyl also stimulates the nicotinic receptors, which means it should make a person more alert. We tried all three drugs and found Aricept worked best for my mother.

To make a long story short, Alzheimer's patients do not have enough of the chemical acetylcholine in their brains. Ideally, we would like to have a drug that generates new and abundant supplies of acetylcholine in the brain, but those drugs are still in development. As a second-best alternative, pharmaceutical firms developed drugs that would inhibit the body's natural enzyme that breaks down acetylcholine, thereby giving Alzheimer's patients a chance to maximize the use of what little acetylcholine is still produced in their brains.

Aricept, in the yellow 10 mg pills, has a long lasting effect and should be taken once a day. Reminyl is taken twice a day and has a shorter duration of efficacy. For whatever reasons, my mother responded better to Aricept than to Reminyl in terms of short term memory for completing daily functions, e.g., making her own breakfast. We could not detect any sign that Reminyl made her more alert. She began taking Aricept just months after it was approved by the FDA, which corresponded to the time she was originally diagnosed with Alzheimer's. A board-certified neurologist told us in 1997 it was best to take this drug at night, so that it could be dissolved in her system overnight and work at its peak when she awoke the next morning.

However, subsequent research has shown that all people need some breakdown of acetylcholine in their brains while sleeping to reach the deeper, more restful stages of sleep. Therefore, medical scientists now say that Aricept and other AChEIs should be taken in the morning, not at bedtime.

Contrary to news articles you may read, AChEIs are useful in the advanced stages of the disease, not just in the early stages. Even advanced-stage patients need as much acetylcholine as they can get. Some clinical studies are now underway to see whether the long-term, chronic consumption of AChEIs can slow the progression of Alzheimer's disease, even if they cannot stop the pathology of the disease.

Michael A. S. Guth, Ph.D., J.D., is a pharmaceutical economics researcher currently investigating treatments for Alzheimer's disease, hyperlipidemia, and osteoporosis / bone mineralization. More information about his research work is shown on his web page http://riskmgmt.biz/economist/pharmecon/pharmecon.htm. Utilizing a strong quantitative and statistical background, critique and discover the weakness in any medical study drawing statistical inferences from (clinical trial) data.

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