4.1 Dementia

Last edited: 29-01-2024

First line drugs	Second line drugs	Specialist drugs	Secondary care drugs
Recommended in both primary and secondary care	Alternatives (often in specific conditions) in both primary and secondary care	Where a specialist input is needed (see introduction for definition)	Prescribing principally within secondary care only

NICE advise that healthcare professionals such as GPs, nurse consultants and advanced nurse practitioners with specialist expertise in diagnosing and treating Alzheimer's disease could be included in those considered as appropriate to initiate treatment

Anticholinesterases

The following drugs may be prescribed where prescribers have undertaken additional training to become competent in this area. Within BNSSG, GPs who have undertaken the additional 'Prescribing in Dementia' training available on Remedy or GPs working in practices signed up to the dementia local enhanced service can be considered 'specialists' for the purposes of initiation of the following drugs.

Donepezil (TLS Blue)

Galantamine - includes prolonged-release capsules (TLS Blue)

Rivastigmine - includes patches (TLS Blue)

Also formulary for the treatment of cognitive impairment in patients with Parkinson's disease - not included in dementia LES

NMDA Receptor Antagonists

Memantine (TLS Blue)

NICE TA217 - Donepezil, galantamine, rivastigmine and memantine for the treatment of Alzheimer’s disease (review)

Donepezil, galantamine and rivastigmine are now recommended within NICE guidance as options for managing mild as well as moderate Alzheimer’s disease. Only GPs within BNSSG who have received appropriate training should initiate treatment; treatment should only be continued if it is considered to be having a worthwhile effect on cognitive, global, functional or behavioural symptoms. Treatment should be reviewed by an appropriate specialist team, unless there are locally agreed protocols for shared care
Memantine is now recommended as an option for managing moderate Alzheimer’s disease for people who cannot take AChE inhibitors and as an option for managing severe Alzheimer’s disease
Donepezil, galantamine and rivastigmine are only available within NICE guidance for patients with moderate Alzheimer's disease where diagnosis, assessment and review takes place in specialist clinics and shared-care protocols are in place which indicate clear treatment end points
As per NICE guidance if prescribing an AChE inhibitor treatment should be started with the one with the lowest acquisition cost (taking into account required daily dose and the price per dose once shared care had started). However, if this is not suitable for the patient another drug could be chosen

Contact Us

Got a question or comment about the Joint Formulary?

Please use the email address below to contact us and we will endeavour to respond within 2 working days.

BNSSG.formulary@nhs.net