Health Column: Treating Alzheimer’s dementia with medications
MOHLER’S MEDICATION MAXIMS
Free Press Health Columnist
A radiant, smiling grandpa is frolicking with his grandchildren on a sunny, wildflower-covered hillside. In the television version, serene violin music wafts in the background. This is the unrealistic gist of the ads for the two most commonly prescribed Alzheimer’s drugs. Oh, if only it were so! The ads are misleading, at best, and frankly devious at worst.
Aricept, available as generic donepezil ($111/ month) is FDA approved for mild to severe dementia and Namenda XR ($300/ month) is approved only for severe dementia. The makers of Namenda are losing their patent soon, have quit making plain Namenda and have starting making only the new, but unimproved XR concoction, hoping they will wrap up the market before generic manufacturing kicks in.
An early study did show that Aricept delayed nursing home placement for four to five months or so in a small group of patients. Unfortunately, no study has ever been able to reproduce those results. Comprehensive reviews of studies of all the prescription drugs for Alzheimer’s dementia show the same basic results. The clinical trials demonstrate that the drugs are often statistically better than placebos, but almost never clinically better.
Remember that statistical improvement is the FDA criterion for new drug approval. What does that mean? On paper, looking at scales of how patients function on a drug may show statistical improvement with the drug; but when you actually look at the effect of the drug on the patient’s everyday life — his speech, memory and behavior — there is not only no improvement, but no slowing of the progressive deterioration, characteristic of the disease. Lastly, Aricept is fraught with nausea, vomiting and diarrhea, while Namenda may cause dizziness, headache, confusion and anxiety.
Clinical data suggests that these medications are pricey, not very effective, and often associated with some unpleasant side-effects. So why are these drugs so frequently prescribed? Dementia is a devastating illness. Patients are robbed of their personhood. Families lose their loved ones. Patients, families and physicians all grasp for something, anything that will reverse or slow the course of the illness. The pressures for the physician to act … to prescribe … to fix the problem are huge. I recall my irrational hopeful thoughts, as I wrote prescriptions for Aricept, that just maybe this was the one patient who would get a good response, knowing that I was creating false hope.
What about over-the-counter drugs? The list is long. Anti-oxidants in red grapes, ginkgo, Coenzyme Q10, garlic, amino acids like tyrosine, and B vitamins have all been promoted as treatments for Alzheimer’s dementia. None of these preparations have show any useful effects when studied in a rigorous manner.
In January 2014, a study from VA hospitals demonstrated that patients with mild to moderate Alzheimer’s disease taking 2,000 international units (IU) of Vitamin E a day showed improvement in functioning and some delay in the amount of caregiver help required. Although there was not an increased death rate in the Vitamin E group in this study, previous research has demonstrated that patients who take more than 400 IU a day have an increased rate of death.
In August 2014, we do not have good answers to deal with this very malignant illness. Researchers indicate that a vaccine is a long way down the road.
GJ Free Press health columnist Dr. Mohler has practiced family medicine in Grand Junction for 39 years. He has a particular interest in pharmaceutical education. Phil works part-time for Rocky Mountain Health Plans. Email him at firstname.lastname@example.org.
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