Highlights
- •Practice guidelines and textbooks were reviewed to synthesize discontinuation recommendations of cholinesterase inhibitors (ChEI) in Alzheimer's disease.
- •Published randomized controlled trials of ChEI discontinuation lack consistency; the absence of consistent findings precludes conclusions about continuing treatment.
- •Practice and textbook recommendations offer no agreement about clinical findings or situations that warrant discontinuation.
- •The top recommendation to discontinue ChEIs was a lack of response or loss of treatment effectiveness, which can be impossible to ascertain in a progressive condition.
- •Starting and stopping ChEI treatment should be individualized, based on patient and family values and preferences, to include a balanced discussion of risks and benefits.
Cholinesterase inhibitors (ChEIs) are the primary pharmacological treatment for symptom
management of Alzheimer disease (AD), but they carry known risks during long-term
use, and do not guarantee clinical effects over time. The balance of risks and benefits
may warrant discontinuation at different points during the disease course. Indeed,
although there is limited scientific study of deprescribing ChEIs, clinicians routinely
face practical decisions about whether to continue or stop medications. This review
examined published practice recommendations for discontinuation of ChEIs in AD. To
characterize the scientific basis for recommendations, we first summarized randomized
controlled trials of ChEI discontinuation. We then identified practice guidelines
by professional societies and in textbooks and classified them according to 1) whether
they made a recommendation about discontinuation, 2) what the recommendation was,
and 3) the proposed grounds for discontinuation. There was no consensus in guidelines
and textbooks about discontinuation. Most recommended individualized discontinuation
decisions, but there was essentially no agreement about what findings or situations
would warrant discontinuation, or even about what domains to consider in this process.
The only relevant domain identified by most guidelines and textbooks was a lack of
response or a loss of effectiveness, both of which can be difficult to ascertain in
the course of a progressive condition. Well-designed, long-term studies of discontinuation
have not been conducted; such evidence is needed to provide a scientific basis for
practice guidelines. It seems reasonable to apply an individualized approach to discontinuation
while engaging patients and families in treatment decisions.
Key Words
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Article info
Publication history
Published online: October 10, 2017
Accepted:
September 29,
2017
Received in revised form:
September 8,
2017
Received:
June 8,
2017
Identification
Copyright
Published by Elsevier Inc. on behalf of American Association for Geriatric Psychiatry.
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- Cholinesterase Inhibitor Discontinuation: The Buck Stops HereThe American Journal of Geriatric PsychiatryVol. 26Issue 2
- PreviewPhysicians are very good at starting drug therapies; not so good at stopping them. This, in spite of the fact that our patients tell us regularly, in words and in deeds, that they don't like taking medications. But truth be told, physicians have good reasons to start and attempt to keep patients on chronic pharmacotherapies. Nowhere is this more evident than in the treatment of chronic conditions like hypertension and diabetes. But psychiatrists too have excellent evidence on the basis of which we recommend chronic pharmacotherapies, whether it is antidepressants for recurrent depression, mood stabilizers for bipolar disorder, or antipsychotics for schizophrenia.
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