Table 3.

Approved^* pharmacologic treatments for dementia attributed to AD

	Acetylcholinesterase inhibitors			NMDA** receptor antagonist	Combination drugs
	Donepezil	Rivastigmine	Galantamine	Memantine	Memantine and donepezil
STAGE INDICATED	All stages of dementia	Mild-to moderate***	Mild-to moderate	Moderate-to-severe	Moderate-to-severe
DOSAGE TITRATION AND TARGET	Tablet or orally disintegrating tablet: starting dose is 5 mg once daily for 6 weeks; if tolerated, increase to 10 mg once daily (typical target dose); if tolerated and needed, may increase to 23 mg once daily (note: 23 mg dose available as brand-name tablet only).	Capsule: starting dose is 1.5 mg twice daily for two weeks; if tolerated, increase to 3 mg twice daily for 2 weeks, then 4.5 mg twice daily for 2 weeks, then 6 mg twice daily. Maximum recommended dose: 6 mg twice daily. Transdermal patch: starting dose is 4.6 mg/24 hours patch once daily for 4 weeks; if tolerated, increase to 9.5 mg/24 hours for ≥4 weeks; if tolerated and needed, increase to 13.3 mg/24 hours. Recommended effective dose: 9.5 to 13.3 mg/24 hours patch.	Extended-release capsule: starting dose is 8 mg once daily for 4 weeks; if tolerated, increase to 16 mg once daily for ≥4 weeks; if tolerated and needed, increase to 24 mg once daily. Recommended target dose range: 16 to 24 mg once daily. Immediate-release tablet or oral solution: starting dose is 4 mg twice daily for 4 weeks; if tolerated, increase to 8 mg twice daily for ≥4 weeks; if tolerated and needed, increase to 12 mg twice daily. Recommended target dose range: 8 to 12 mg twice daily.	Extended-release capsule: starting dose is 7 mg once daily for one week; if tolerated, may increase to 14 mg once daily, then 21mg once daily, and then 28 mg once daily, at a minimum of 1 week intervals. Recommended target dose: 28 mg once daily. Tablet or oral solution: starting dose is 5 mg once daily for one week; if tolerated, may increase to 5 mg twice daily, then 5 mg in am and 10 mg in pm, and then 10 mg twice daily, at a minimum of 1 week intervals. Recommended target dose: 10 mg twice daily.	Capsule: target dose is 28 mg memantine extended-release with 10 mg donepezil, once daily in the evening. For patients with severe renal impairment: maximum dose is 14 mg memantine extended-release with 10 mg donepezil once daily.
ADVANTAGES	Among drugs listed, this has been available for the longest time and, with prescriber familiarity, remains commonly used; available as generic drug and covered by most health insurance plans.	Also available as a skin patch application, which is a good option for when a patient has barriers to using an oral route of administration; also indicated for mild-to-moderate dementia associated with Parkinson disease.	The most recent option for use in mild-to-moderate stage.	May be used in combination with one of the acetylcholinesterase inhibitors, or as monotherapy.	Singe pill combination is best for patients already exposed to one or both of these individual drugs in the past, and who have not experienced adverse effects.
ADVERSE EFFECTS	Nausea, vomiting, loss of appetite, increased frequency of bowel movements, vivid dreams, insomnia; use with caution in patients with peptic ulcer disease, respiratory disease, seizure disorder and urinary tract obstruction; contraindicated in bradycardia. Patch formulation (for rivastigmine) can cause local skin irritation and reactions.			Headache, constipation, confusion and dizziness; use with caution in patients with cardiovascular disease, seizure disorder, and severe hepatic and renal impairment.	(see both cells to the left).

^*Approved by the US Food and Drug Administration (FDA); refer to current, established sources of data (e.g., www.pdr.net/drug-summary) for most-to-date prescribing information, including for indications, dosages, adverse effects, risks, and contraindications; note that tacrine, another anticholinesterase inhibitor, was the first drug approved for AD in the US, but is no longer in use because of related toxicity

^**NMDA: N-Methyl-D-Aspartic acid

^***Note that a transdermal patch formulation is also approved for the severe stage of dementia