Effects of donepezil, galantamine and rivastigmine in 938 Italian patients with Alzheimer's disease: a prospective, observational study.
Acetylcholinesterase inhibitors (AChEIs) have been used to improve cognitive status and disability in patients with mild to moderate Alzheimer's disease (AD). However, while the efficacy of AChEIs (i.e. how they act in randomized controlled trials) in this setting is widely accepted, their effectiveness (i.e. how they behave in the real world) remains controversial. To compare the effects of three AChEIs, donepezil (Aricept), galantamine (Reminyl) and rivastigmine (Exelon), in an Italian national, prospective, observational study representative of the 'real world' clinical practice of AChEI treatment for AD. 938 patients with mild to moderate AD collected within the framework of the Italian National Cronos Project (CP), involving several UVAs (AD Evaluation Units) spread over the entire national territory, who were receiving donepezil, galantamine or rivastigmine were followed for 36 weeks by measuring: (i) function, as determined by the Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL) scales; (ii) cognition, as measured by the Mini-Mental State Examination (MMSE) and the Alzheimer's Disease Assessment Scale-cognitive subscale (ADAS-cog) [primary outcome measures]; and (iii) behaviour, as measured on the Neuropsychiatric Inventory (NPI) and Clinical Dementia Rating (CDR) scale. Moreover, all patients were genotyped for apolipoprotein E (apoE) genetic variants. No statistically significant improvement in the primary outcome measures (MMSE and ADAS-Cog) was observed with drug therapy at 36 weeks, at which point all groups had lost, on average, 1 point on the MMSE and gained 2-3 points on the ADAS-Cog scale compared with baseline. On the secondary outcome measures at week 36, all treatment groups showed a significant worsening on the ADL and IADL scales compared with baseline, while on the NPI scale there were no significant differences from baseline except for the galantamine-treated group which worsened significantly. Moreover, patients receiving galantamine worsened significantly compared with the donepezil-treated group on the IADL scale. ApoE epsilon4 allele did not influence the effect of drug therapy. Over a 36-week follow-up period, no significant difference in the effects of donepezil, galantamine and rivastigmine on a variety of functional and cognitive parameters was observed in a large number of apoE-genotyped patients with mild to moderate AD recruited within the framework of a national project representative of the scenario usually encountered in actual clinical practice in Italy. The limitations (possibility of administration of lower drug doses than are used in clinical trials, relatively short follow-up period and the lack of randomization) and strengths (large number of patients, concomitant observation of the three drugs and the number of parameters assessed, including apoE genotype) of the present study are acknowledged. Our type of naturalistic study should complement clinical trials because 'real world' practice operates in the face of the numerous variables (e.g. health status and co-morbidities) associated with a complex disease such as AD in elderly people.
Santoro
Aurelia
A
Department of Experimental Pathology, University of Bologna, Via S. Giacomo 12, Bologna, Italy. aurelia.santoro@unibo.it
Siviero
Paola
P
Minicuci
Nadia
N
Bellavista
Elena
E
Mishto
Michele
M
Olivieri
Fabiola
F
Marchegiani
Francesca
F
Chiamenti
Andrea Maria
AM
Benussi
Luisa
L
Ghidoni
Roberta
R
Nacmias
Benedetta
B
Bagnoli
Silvia
S
Ginestroni
Andrea
A
Scarpino
Osvaldo
O
Feraco
Emidio
E
Gianni
Walter
W
Cruciani
Guido
G
Paganelli
Roberto
R
Di Iorio
Angelo
A
Scognamiglio
Mario
M
Grimaldi
Luigi Maria Edoardo
LM
Gabelli
Carlo
C
Sorbi
Sandro
S
Binetti
Giuliano
G
Crepaldi
Gaetano
G
Franceschi
Claudio
C
D000203:Activities of Daily Living; D000368:Aged; D000544:Alzheimer Disease / Q000188:drug therapy* / Q000235:genetics; D001057:Apolipoproteins E / Q000235:genetics; D002800:Cholinesterase Inhibitors / Q000627:therapeutic use*; D003071:Cognition / Q000187:drug effects; D000077265:Donepezil; D005260:Female; D005702:Galantamine / Q000627:therapeutic use*; D014644:Genetic Variation; D005838:Genotype; D006801:Humans; D007189:Indans / Q000627:therapeutic use*; D007558:Italy; D008297:Male; D017063:Outcome Assessment, Health Care; D048448:Phenylcarbamates / Q000627:therapeutic use*; D010880:Piperidines / Q000627:therapeutic use*; D011446:Prospective Studies; D011569:Psychiatric Status Rating Scales; D000068836:Rivastigmine; D012720:Severity of Illness Index; D013997:Time Factors; D016896:Treatment Outcome
D001057:Apolipoproteins E; D002800:Cholinesterase Inhibitors; D007189:Indans; D048448:Phenylcarbamates; D010880:Piperidines; D005702:Galantamine; D000077265:Donepezil; D000068836:Rivastigmine