Feb 1, 2014

Ask Carole Larkin - FDA Medications Approved for Alzheimer's?

Carole Larkin discusses the currently available medications for Alzheimer's, contraindications, and side effects.

There are 5 medicines that the FDA has approved for treatment of Alzheimer’s disease.

Alzheimer's Medication

The first 4 drugs are for early stage; and, so far only 1 is approved for middle to late stage Alzheimer's. None of the medicines cure the disease.

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Carole Larkin
Carole Larkin MA, CMC, CAEd, DCP, QDCS, EICS is an expert in Alzheimer’s and related Dementia care. She is a Certified Geriatric Care Manager who specializes in helping families with Alzheimer’s and related dementia issues. Carole can consults with families via telephone nationwide on problems related to dementia. Her company, ThirdAge Services LLC, is located in Dallas, TX.
None of the medicines stop the disease process from continuing in the long term, though they slow the progress of the disease for a period of time.

The current time frame for slowing the disease has been estimated to be between 18 months and 36 months depending on the individual.

The medications may hold the memory loss steady and/or positively impact some of the common Alzheimer’s “behaviors”, meaning anxiety, paranoia, aggressiveness and other “negative behaviors”.

The current estimate is that about 30% of people who are taking the medicines are helped by the medicines, but 70% are not helped by them

Alzheimer’s medicines approved by the FDA for early stage are:
  1. Razadyne (galantamine, Reminyl)
  2. Exelon (rivastigmine)
  3. Aricept (donepezil)
  4. Cognex (tacrine) not prescribed much anymore.
If your care partner is taking one of the medications listed below please note -- they can and do affect the working of the Alzheimer’s medicines.

Medicines that could make the Alzheimer’s medicines too strong and cause worse side effects include:
  1. Tagamet (cimetidine) - for Acid Reflux and ulcers
  2. Nizoral (Ketoconazole) – for Dandruff, Dermatitis, fungal and yeast infections
  3. Norvir (ritonavir) – for HIV/AIDS
  4. Paxil (paroxetine) – for anxiety and/or depression
  5. Erythromycin – antibiotic
Medicines that cut the effectiveness of the Alzheimer’s medicines are:
  1. Benadryl - Antihistamine
  2. Detrol - Bladder control drugs
Alzheimer’s medicine approved by the FDA for middle-late stage is:
  1. Namenda (memantine)
Medicines that interact negatively and can make the person sick are:
  1. Sodium Bicarbonate – baking soda, antacid
  2. Diamox (acetazolamide) – pulmonary edema, Sleep Apnea or Ataxia (lack of muscle coordination)
Researchers and a number of neurologists have recommended that persons with Alzheimer’s take one of the medicines for early stage; and, the medicine for middle stage together (during the same day), if they can tolerate the side effects of the medicines.

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The most common side effects of these medicines have to do with the gastrointestinal system, such as nausea, vomiting, stomach pain, and diarrhea. There are other side effects as well.

Many care partners when faced with one or more of these side effects appearing in their loved one after just a day or two abandon the attempt to use the medicine, but it may take up to several weeks to build up enough tolerance to the drug so that the side effects stop.

That is why doctors titrate, or build up the level of the drug slowly (from 5 mg to 10 mg for example).

While understandable that people don’t want to see their loved one suffer with the side effects for very long, it could be that the medicine is not given a decent chance to build up to high enough levels in the system to do its job. Maybe that’s why there isn’t a higher percent of effectiveness.

Also, for a percentage of the population (in the USA) the cost of the medicines enters into the decision whether to try these medicines or not. Currently all of the medicines for early stage have gone generic, greatly reducing the cost of the prescriptions. Namenda (for middle to late stage) will go generic in 2015.

Question: Should my loved one be taking all the Alzheimer’s medicines?

Answer: Most certainly they are worth a try (meaning having the person on the drug for 2-3 months) if a couple of conditions exist.
  1. It’s early in the disease progression.

    The problem is that many people don’t recognize the disease soon enough, or are in denial about the existence of the disease in their care partner, so that the opportunity for the early stage medicines to work is already gone.

    The medicines work on living cells, not on cells that are near or at death.

    The person may have so many dead cells in the brain that giving medicine to the live ones is essentially too little, too late.

    If that’s the case, what’s the point of spending the money on drugs, no matter what the price of the drugs are, cheap or not?

    Also many people think that their care partner is later in the disease than they actually are. Because they don’t know much about the disease, they think that early signs of the disease are actually middle or late signs of the disease (for example: asking questions over and over again, having trouble paying bills or taking medicine properly.) The care partner mistakenly thinks that their person is “too far gone” and won’t even try the medicines.

    Going to a Neurologist, Neuropsychologist, Geriatric Psychiatrist or Geriatrician can tell you what stage your care partner is in. You could read The Seven Stages of Alzheimer's “to get an idea". Or, you can search the Internet for additional information.
  2. If the caregiver or person with Alzheimer’s can afford it.

    If buying the Alzheimer’s drugs, means that the person can’t afford his or her heart medication or thyroid medication or medication for their breathing, well by all means don’t buy the Alzheimer’s medicine! If buying the Alzheimer’s medicine means there isn’t enough money for food, rent, utilities and other basics of life, of course the Alzheimer’s medicines shouldn’t be bought. First things first!
Question: If the person is already on one or more of the Alzheimer’s drugs, the question becomes, when should they be taken off of them?

Answer: Because the estimate of how long they do well on the drugs is currently between 18 and 36 months, you could try it at the 3 year mark.

The only way you know if the drugs have been doing any good is if when they are taken off the drugs, they take a sudden and sharp downturn in cognition (as expressed by things they are able to do for themselves, like dress, or feed or bathe themselves) and or memory.

With the downturn you’ll know if they were being helped by taking the meds, but even if you put them back on the medicines again, know that the odds are that they will never return to the level they were at before they were taken off the drugs.

To state the obvious, it’s quite a dilemma for the care partner. That’s when the care partner should know what stage of the disease the person is at when they were taken off the drugs. If they are at the late stage, it just may not be useful to even attempt to put them back on the drugs. That again means either testing by a specialist in Alzheimer’s or more education on the care partner’s part.

Also to be considered is if the care partner or person with Alzheimer’s can afford it.

There will be more medical costs awaiting the person with the disease than there were before. That’s the nature of this disease. Costs for physical ailments do rise as the disease goes on either because the cognitive problems have caused a deterioration in the person’s ability to be self aware of the things that need to be done for their other illnesses (like comply with a prescription taking regimen) or because the disease itself can cause failures in other organs and body systems, in the late stages.

Finally taking someone off the Alzheimer’s drugs inevitably involves the care partner’s inherent ability to take risks themselves, as the decision maker. Also the care partner needs to be aware of their own guilt in making the decision to take their care partner off the drugs. Whatever decision is made it should be made for logical reasons, not for emotional reasons.

Since there is no clear right answer to the taking off/putting back on answer, it seems to me that the best a care partner can do is learn as much as possible about the disease and about the medicines, make their (informed) decision, own that decision, and then grant themselves grace by embedding in their psyche,

“I’m confident that I made the best decision for my loved one I could have, at the time.”

Because you did…

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