Guidelines for the appropriate use of cholinesterase inhibitors in patients with Alzheimer's disease

The cholinesterase inhibitors are the only available scientifically proven symptomatic treatments for dementia of the Alzheimer's type. The guidelines we present summarise the current updated knowledge on the available drugs, including tacrine, donepezil, rivastigmine, metrifonate and galantamine (galanthamine). Each of these drugs have been proven to be more effective than placebo in improving symptoms in well designed, double-blind, placebo-controlled studies. Although tacrine was the first drug approved by the US Food and Drug Administration, it needs frequent monitoring of alanine amino transferase levels. Hence, donepezil emerged as a frequently prescribed drug for dementia of the Alzheimer's type, secondary to its ease of use and lack of significant adverse effects. More studies are needed regarding long term efficacy, head-to-head comparisons and effects upon behavioural disturbances in dementia of the Alzheimer's type. These guidelines will provide the starting point for a wider clinical use because, although available and clinically effective, the cholinesterase inhibitors are under-prescribed by clinicians in the pharmacological treatment of Alzheimer's disease.