The National Institute of Clinical Excellence (NICE) has lately overturned its
decision to restrict the use of acetycholinesterase inhibitors and memantine
in patients diagnosed with Alzheimer’s disease (AD). It is estimated that such
a policy U-turn will offer access to a significant number of individuals who
were previously denied these medications. This short article will focus on
the latest developments and recommendations by NICE on the use of these
pharmacological agents in the managment of AD.peer-reviewe

Scerri, Charles

English

OAR@UM

CLINICAL UPDATECHARLES SCERRIThe National Institute of Clinical Excellence (NICE) has lately overturned its decision to restrict the use of acetycholinesterase inhibitors and memantine in patients diagnosed with Alzheimer’s disease (AD). It is estimated that such a policy U-turn will offer access to a significant number of individuals who were previously denied these medications. This short article will focus on the latest developments and recommendations by NICE on the use of these pharmacological agents in the managment of AD.NICE 2011 recommendations on the management of Alzheimer’s disease by acetylcholinesterase inhibitors & memantineAD is the most common form of dementia accounting for about 50-70% of the cases. It is the most common neurodegenerative disorder in the elderly with a prevalence rate that increases exponentially from 2-3% in the general population at the age of 65 years to that exceeding 40% after the age of 85 years. Given the trend towards an increase in the elderly population worldwide, the prevalence of AD is expected to double in the next forty years. In Malta, it is estimated that currently the number of individuals with dementia almost reaches 4,500. This figure is expected to almost double, reaching 2% of the Maltese population by the year 20501. In addition to the huge costs involved in the medical management of AD, its psychosocial burden on caregivers and society in general is enormous.Pathologically, AD is characterised by the presence of amyloid plaques and neurofibrillary tangles in the brain coupled with significant loss of cholinergic tracts in areas associated with learning and memory. The disease is a multistage process initially characterised by a decline in short-term memory, faulty judgment and personality changes. At later stages, memory decline worsens and activities of daily living and communication skills become gradually impaired. In the final stages, the patient becomes mute, withdrawn, incontinent and unable to walk with the consequence of becoming bedridden and prone to illness and infection.continued on page15Acetylcholinesterase inhibitors (AChEIs) were the first pharmacological agents for the management of AD approved by the relevant health authorities. Locally, three AChEIs are clinically available: donepezil, rivastigmine and galantamine. Their major therapeutic effect is reported to be their ability to maintain cognitive function compared to placebo over a three year period or less2,3. These drugs are particularly useful in mild to moderate stages of AD. A later addition to the list of drugs recommended for use in AD patients was memantine, a compound that appears to block pathologic neural toxicity associated with prolonged glutamate release4. In randomised clinical trials, this drug demonstrated the ability to delay cognitive decline and is recommended for the use in moderate to severe AD.In  2006, NICE advised that donepezil, rivastigmine and galantamine should only be used to treat moderate stage AD and that memantine should be reserved for clinical studies involving individuals with moderately severe to severe AD. This meant that in the UK, these drugs could not be used to treat the disease in its mild form via the NHS. As expected, these restrictions were met with strong resistance and various organisations across the UK voiced their concerns about this approach, highlighting the need for NICE to reassess its views. These included Alzheimer’s Society, Age Concern, Counsel and Care, Dementia Care Trust, the Royal College of Nursing, the Royal College of Psychiatrists and the British Geriatrics Society.Even Alzheimer’s Europe called for NICE to revise its recommendations and allow patients at all stages of the disease to have access to the various drug treatments.The discussion on the use of such drugs continued and after considering evidence from a number of recent scientific publications on the cost-effectiveness of these agents as well as feedback from drug manufacturers, professional and patients groups and other consultees, NICE reversed its 13Invitation to participate in a surveyAs part of an MSc in Public Health Medicine, one of our members is carrying out a study on Medication Errors. You are being invited to participate in a short, completely anonymous survey which may be found on http://www.thesynapse.net/articles/viewarticle.asp?artid=13424. Your cooperation is greatly appreciated. Since the beginning of 2010, TheSynapse magazine front page has featured a photograph of Maltese plants which were renowned for their medicinal properties. We have been lucky enough to be given permission to use these pictures by none other than Guido Bonett who holds various prestigious nature photography awards. We are pleased to announce the launch of a Photography competition for members of TheSynapse where we invite submissions from all members of the medical professions, including students. The best six photographs will be used for the front page of TheSynapse magazine for 2012. Obviously the photographer will be acknowledged. The theme of the photography competition will be Malta and Medicine and you can submit any photo that fits into this broad category. The photographs will be uploaded on to a specific website and anyone can vote for the best picture. Votes from the website will account for 50% of total votes whereas the other 50% will be from a panel of expert and well renowned local photographers who will act as judges. Details of the website address and prizes will be announced in the coming weeks. The Photo Contest Rules, Terms and Conditions may be acessed on www.thesynapse.netVictor Grech’s piece (“Lydgate, brain drain and the Maltese medical profession”, The Synapse Magazine, 03/11) touches on a difficult subject indeed.  I am not (as stated) a retired doctor, but am now a freelance surgical pathologist and teacher of disease mechanisms who chose to terminate employment by the state monopolies for health services and medical teaching.   Some of my reasons for resigning my University position, and to turn down an offered post-age-61 NHS contract, had to do with the content of Professor Grech’s feature.  I was tired of working far longer hours than some colleagues in other specialities in both the NHS and medical school set-ups.  I did wonder whether paying consultants, and senior university teachers, a fee per item of service, rather than a straight salary, would quickly dispose of waiting lists and university teachers’ absenteeism. The MAM’s main concern has been, for several decades, the maintenance of the “half-day-hospital” status quo (no out-patient sessions in the afternoons, etc) because private practice time is more highly priced than salary and pension rates by top-earning clinicians, who regard “ownership” of teaching hospital beds more remunerative.  MAM has never expressed any concern about colleagues who have worked significant number of years for both the British and Maltese NHS and then discover, at age 61, that a good part (if not all) of their Maltese 2/3 pension is withheld, because current Maltese social security law does not permit them to enjoy the two pensions they’ve contributed to.   An important omission in Victor Grech’s piece is the recognition of Malta’s small size problem.  Some might be patting themselves on the back for churning out around 80 new doctors annually, for local postgraduate training programmes, and for the expansion of consultant posts (but still half-day-hospital work pattern).  The UK “release valve” for our doctor over-production might gradually close (a population of only 400,000 would not need 80 new doctors annually).  A consequence of that might be unethical attempts at “expanding the private market” by punishing unwitting patients with unnecessary expensive tests and procedures for body malfunctions which could otherwise be corrected by nutritional and lifestyle changes (if only the medical school had taught them how to do it).  Another problem related to our small size is perhaps best illustrated by a friend of mine who paid to have some ceramic-work lessons and was told that not all the professional skill secrets of the trade were available for sale.  I’m sure readers would understand the consequences of similar attitudes in medical postgraduate education.  Another problem exacerbated by our small size and private practice is possible obstruction to repatriation of highly skilled doctors, or obstructions to their promotion to senior positions once they return.  Readers will forgive me for not having the time to find and quote the precise references, but they might remember that lawyer Giovanni Bonello contributed a few articles to the Maltese Medical Journal, one of which highlighted how local doctors prevented other Maltese doctors from returning after training overseas at the time of the Crusaders, and another one how some of them acquired land as a gift from the Grandmaster.  PRoF ALBERT CILIA-VINCENTI Letter to the editorNoTICE BoARDDoctor WantedEthnically Maltese speaking General Medical Practitioner required to work in Copernicus Clinic, Keilor Downs, Melbourne Australia, in a modern computerised  clinic with nurse and auxiliary staff. Will eventually replace retiring doctor. On-site lodging available. Please call +61416296337 or email vsammut@copernicusclinic.com.Attention Consultants and other Medical Specialists Clinic space available. No rental fee. For more information please call 79060903. If you want to advertise your conference free of charge simply click on http://www.thesynapse.net/events/list.asp 6th Biennial Primary Health Department Conference 2011 to be held on 11/10/2011 Malta’s Primary Health Department wishes to invite prospective delegates to submit abstracts for the 6th Biennial Primary Health Department Conference 2011 “Primary Health in Malta - from the Cradle to the Grave?” that will take place at the Westin Dragonara Resort, St Julian’s, on Tuesday, 11th October, 2011. The Organising Committee intends to apply for CME / CPD points to be awarded to participants. For further details please click http://www.thesynapse.net/events/view.asp?eventID=131 for the call for abstracts which closes on the 29th July 2011.  Kindly book this date in your dairy!MEMbErs’ COrNErdecision through the publication of a technology appraisal report in March 20115. Recommendations set out in this guidance report include:• The three acetylcholinesterase inhibitors (AChEIs) donepezil, galantamine and rivastigmine are recommended as options for managing mild to moderate AD;• Memantine is recommended as an option for managing AD for people with moderate or severe AD;• Treatment should be recommended only by specialists and when considered to have a worthwhile effect on the cognitive, functional and behavioural symptoms;• Patients should be reviewed regularly and treatment adjusted depending on the symptoms as reviewed by a specilised team. The carer’s view should also be consulted at follow-up;• Although treatment with AChEIs should be started with the drug with the lower acquisition cost, an alternative AChEI could be prescribed if found to be appropriate based on adverse event profile, patient compliance, medical comorbidity and dosing regimens;• Communication difficulties and sensory or learning disabilities should be taken into consideration when assessment scales are used to determine the severity of AD;• Healthcare professionals should not rely solely on cognition scores in circumstances in which it would be inappropriate to do so, such as in sensory impairments, communication difficulties or level of education.In conclusion, these latest recommendations by NICE are in line with accumulating evidence showing that these drugs enhance activities of daily living, reduce behavioural disturbances, slow cognitive impairment and decrease caregiver stress thus delaying institutionilisation. Unfortunately in Malta, AD is not among the list of chronic disorders on the Fifth Schedule of the Social Security Act and therefore these drugs are only available in the community as an out-of-pocket expense. It is hoped that the local health authorties follow the example of the majority of countries in the European Union and reimburse AD drugs to all those individuals suffering from this debiliating disease.  References1 Abela S,  Mamo J, Aquilina C, Scerri C. Estimated prevalence of dementia in the Maltese Islands. Malta Medical Journal 2007; 19(2):23-6.2 Mohs RC, Doody RS, Morris JC et al. “312” Study Group. A 1-year, placebo-controlled preservation of function survival study of donepezil in AD patients [published correction appears in Neurology 2001: 57: 1942]. Neurology 2001; 57:481-8.3 Raskind MA, Peskind ER, Truyen L, Kershaw P, Damaraju CV. The cognitive benefits of galantamine are sustained for at least 36 months: a long-term extension trial. Archives of Neurology 2004; 61:252-6.4 Danysz W, Parsons CG, Mobius HJ. Neuroprotective and symtomalogical action of memantine relevant for Alzheimer’s disease – a unified glutamatergic hypothesis on the mechanism of action. Neurotoxicity Research 2000; 2:85-98.5 National Institute of Clinical Excellence. Donepezil, galantamine, rivastigmine and memantine for the treatment of Alzheimer’s disese: NICE technology appraisal guidance 217. Available from: www.nice.org.uk/nicemedia/live/13419/53619/53619.pdf NICE 2011 recommendations on the management of Alzheimer’s disease by acetylcholinesterase inhibitors & memantinecontinued from page13Thesynapse Magazine 2012 Photography Competition1514

312” Study Group. A 1-year, placebocontrolled preservation of function survival study of donepezil in AD patients [published correction appears in Neurology

Estimated prevalence of dementia in the Maltese Islands. Malta Medical Journal

The cognitive benefits of galantamine are sustained for at least 36 months: a long-term extension trial. Archives of Neurology

NICE 2011 recommendations on the management of Alzheimer’s disease by acetylcholinesterase inhibitors and memantine

https://www.um.edu.mt/library/oar/bitstream/handle/123456789/12789/NICE%202011%20recommendations.pdf?sequence=1&isAllowed=y

NICE 2011 recommendations on the management of Alzheimer’s disease by acetylcholinesterase inhibitors and memantine

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