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Nguyen-Thi PT, Vo TK, Le HT, Nguyen NTT, Nguyen TT, Van Vo G. Translation from Preclinical Research to Clinical Trials: Transdermal Drug Delivery for Neurodegenerative and Mental Disorders. Pharm Res 2024; 41:1045-1092. [PMID: 38862719 DOI: 10.1007/s11095-024-03718-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2023] [Accepted: 05/19/2024] [Indexed: 06/13/2024]
Abstract
Neurodegenerative diseases (NDs), particularly dementia, provide significant problems to worldwide healthcare systems. The development of therapeutic materials for various diseases has a severe challenge in the form of the blood-brain barrier (BBB). Transdermal treatment has recently garnered widespread favor as an alternative method of delivering active chemicals to the brain. This approach has several advantages, including low invasiveness, self-administration, avoidance of first-pass metabolism, preservation of steady plasma concentrations, regulated release, safety, efficacy, and better patient compliance. Topics include the transdermal method for therapeutic NDs, their classification, and the mechanisms that allow the medicine to enter the bloodstream through the skin. The paper also discusses the obstacles and potential outcomes of transdermal therapy, emphasizing the benefits and drawbacks of different approaches.
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Affiliation(s)
| | - Tuong Kha Vo
- Department of Sports Medicine, University of Medicine and Pharmacy (VNU-UMP), Vietnam National University Hanoi, Hanoi, 100000, Vietnam
| | - Huong Thuy Le
- Faculty of Pharmacy, Ton Duc Thang University, Ho Chi Minh City, 700000, Vietnam
| | - Nhat Thang Thi Nguyen
- Faculty of Chemical Engineering, Industrial University of Ho Chi Minh City, Ho Chi Minh City, 71420, Vietnam.
| | - Thuy Trang Nguyen
- Faculty of Chemical Engineering, Industrial University of Ho Chi Minh City, Ho Chi Minh City, 71420, Vietnam
| | - Giau Van Vo
- Degenerative Diseases Program, Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA, 92037, USA.
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Chiew AL, Holford AG, Chan BSH, Isoardi KZ. Rivastigmine for the management of anticholinergic delirium. Clin Toxicol (Phila) 2024; 62:82-87. [PMID: 38465631 DOI: 10.1080/15563650.2024.2319854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 02/09/2024] [Indexed: 03/12/2024]
Abstract
INTRODUCTION Anticholinergic agents are commonly taken in overdose, often causing delirium. The spectrum of anticholinergic delirium ranges from mild agitation to severe behavioural disturbance. Physostigmine is an effective treatment for anticholinergic delirium, but its availability is limited. As rivastigmine is readily available, it has been used to manage anticholinergic delirium; however, there is limited research investigating its use. METHOD This was a retrospective review of patients with anticholinergic delirium treated in two toxicology units with rivastigmine (oral capsule or transdermal patch) from January 2019 to June 2023. The primary outcome was the use of further parenteral treatment (sedation or physostigmine) for delirium post rivastigmine administration. RESULTS Fifty patients were administered rivastigmine for the management of anticholinergic delirium. The median age was 36 years (interquartile range: 25-49 years) and 27 (54 per cent) were females. Features consistent with anticholinergic toxicity included tachycardia in 44 (88 per cent) and urinary retention requiring catheterisation in 40 (80 per cent). Forty-three patients (86 per cent) were treated with physostigmine before rivastigmine administration. Twenty-two were managed with transdermal rivastigmine (most commonly 9.5 mg/24 hour patch), and 28 with oral rivastigmine 6 mg. Further parenteral sedation and/or physostigmine treatment were required more often in patients given transdermal than oral rivastigmine [16/22 (73 per cent) versus 9/28 (32 per cent), P = 0.010)]. No patients had bradycardia or gastrointestinal symptoms following rivastigmine administration. One patient with a history of epilepsy had a seizure, 1.5 hours post physostigmine administration and 7 hours post transdermal rivastigmine. DISCUSSION Rivastigmine has been increasingly used for the management of patients with anticholinergic delirium, due to the lack of availability of physostigmine. In this case series, rivastigmine transdermal patch appeared to be less effective than oral rivastigmine capsules, likely due to its slow onset of action and/or insufficient dose. CONCLUSION Rivastigmine can be used to treat anticholinergic delirium. In our case series oral rivastigmine appeared more effective than transdermal rivastigmine.
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Affiliation(s)
- Angela L Chiew
- Department of Clinical Toxicology, Prince of Wales Hospital, Randwick, Australia
- Faculty of Medicine, Prince of Wales Hospital Clinical School, University of NSW, Randwick, Australia
| | - Amanda G Holford
- Clinical Toxicology Unit, Princess Alexandra Hospital, Brisbane, Australia
- Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - Betty S H Chan
- Department of Clinical Toxicology, Prince of Wales Hospital, Randwick, Australia
- Faculty of Medicine, Prince of Wales Hospital Clinical School, University of NSW, Randwick, Australia
| | - Katherine Z Isoardi
- Clinical Toxicology Unit, Princess Alexandra Hospital, Brisbane, Australia
- Faculty of Medicine, University of Queensland, Brisbane, Australia
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Matsuzono K, Mita Y, Imai G, Fujimoto S. Improper Application of a Rivastigmine Patch to the Back of the Neck Induced Toxic Symptoms. Intern Med 2023; 62:3247-3250. [PMID: 36948626 PMCID: PMC10686733 DOI: 10.2169/internalmedicine.1236-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 02/13/2023] [Indexed: 03/24/2023] Open
Abstract
Rivastigmine is a highly effective drug for treating Alzheimer's disease. However, its addiction can be fatal, so proper use of this transdermal drug is needed. We herein report an 85-year-old woman with Alzheimer's disease who inappropriately placed rivastigmine patches on the back of her neck. She suffered from acute cholinergic syndrome, hypersalivation, anorexia, dyspnea, and vomiting. These symptoms disappeared when the improper use of rivastigmine patches was ceased. This case serves as a warning to physicians and pharmacists of the risk associated with the improper placement of rivastigmine patches.
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Affiliation(s)
- Kosuke Matsuzono
- Division of Neurology, Department of Medicine, Jichi Medical University, Japan
- Department of Internal Medicine, Imai Hospital, Japan
| | | | - Goro Imai
- Department of Internal Medicine, Imai Hospital, Japan
| | - Shigeru Fujimoto
- Division of Neurology, Department of Medicine, Jichi Medical University, Japan
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Gorthi SP, Gupta D. Alzheimer's Disease: Treatment Today and Tomorrow. Ann Indian Acad Neurol 2023; 26:326-333. [PMID: 37970257 PMCID: PMC10645267 DOI: 10.4103/aian.aian_254_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 06/07/2023] [Accepted: 06/12/2023] [Indexed: 11/17/2023] Open
Abstract
Background and Aims The scope of treatment in Alzheimer's Disease has widened in recent times with FDA approval of new drugs. This review looks at established treatments in AD as well as critically analyses the newer drugs available. Methods Data in this review was gathered from PubMed; Google Scholar and MEDLINE from January-March 2023. Search words used were 'Alzheimer's Disease treatment' and 'Dementia treatment'. Results Older time tested drugs like Acetyl Choline Receptor Inhibitors and NMDA Receptor antagonists remain the mainstay of pharmacological treatment in AD. Despite a lot of excitement about newer FDA approved drugs; we have to be cautious in their use. Aducanumab showed good reduction in CSF amyloid levels (biomarker of AD); but this did not necessarily translate into better clinical outcomes of patients. Conclusion Despite the recent advances and approval of drugs in treatment of AD, we have to exhibit caution while prescribing these drugs. Even with a sound mechanism of action, these drugs do not always show improvement in clinical outcomes. More clinical trials are required for development of drugs in treatment of AD which explore various different mechanisms of action.
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Affiliation(s)
- Sankar P. Gorthi
- Department of Neurology, Bharati Vidyapeeth Medical College (DTU) and Hospital, Pune, Maharashtra, India
| | - Dulari Gupta
- Department of Neurology, Bharati Vidyapeeth Medical College (DTU) and Hospital, Pune, Maharashtra, India
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Schurad B, Koch C, Schug B, Morte A, Vaqué A, De la Torre R, Iniesta M. Comparative Bioavailability Study of a Novel Multi-Day Patch Formulation of Rivastigmine (Twice Weekly) with Exelon® Transdermal Patch (Daily)- A Randomized Clinical Trial. Curr Alzheimer Res 2022; 19:541-553. [PMID: 36017827 DOI: 10.2174/1567205019666220823105059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 06/28/2022] [Accepted: 06/30/2022] [Indexed: 01/27/2023]
Abstract
BACKGROUND Rivastigmine, a reversible AChEI for symptomatic treatment of mild to moderately severe Alzheimer's dementia, is administered once daily transdermal patches, enabling an easier and continuous drug delivery. A novel multi-day (twice week) patch formulation was developed with greater convenience for patients' therapeutic management. OBJECTIVE To assess the bioequivalence under SS conditions of the multiple-day rivastigmine transdermal patch (Test Product, RID-TDS) in comparison to the once-daily Exelon® transdermal patch (Reference Product), both at a release rate of 9.5 mg/24 h. DESIGN Single-center, open-label, randomized, multiple-dose study in healthy male adults in a 2- period, 2-sequence-crossover design with multiple applications. METHODS Patches were applied on 11 consecutive days for Exelon® and a 4-3-4-day regimen for the multiday test patch (RID-TDS), separated by a 14-day wash-out period. The safety, local tolerability and inhibitory effect of rivastigmine on plasma BuChE activity were also evaluated. RESULTS 57 subjects completed the study according to the protocol. Calculated point estimates and 90% CI for all primary parameters (AUC96-264, Cmax96-264 and Cmin96-264) were within the predefined acceptance interval of 80.00-125.00%. They were 113.64% (107.33-120.33), 105.14% (98.38- 112.38) and 107.82% (97.78-118.89) respectively. Satisfactory adhesion (CI of mean adhesion above 90%) was demonstrated for RID-TDS but not for Exelon®. CONCLUSION Bioequivalence was demonstrated between RID-TDS mg twice a week and Exelon® once daily in SS. Patch adhesion favored RID-TDS despite the longer dosing interval. Both products were well tolerated.
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Affiliation(s)
| | - Cornelius Koch
- Luye Pharma AG, Miesbach, Germany.,SocraTec R&D GmbH, Erfurt, Germany
| | | | | | - Anna Vaqué
- ESTEVE Pharmaceuticals SA, Barcelona, Spain
| | - Rafael De la Torre
- Research Group in Integrated Pharmacology and Systems Neuroscience, Hospital del Mar Research Institute Doctors (IMIM), Barcelona, Spain
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7
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Han X, Liu J, Hu X, Wang W, Wang Q. Design of a Long-Acting Rivastigmine Transdermal Delivery System: Based on Computational Simulation. AAPS PharmSciTech 2022; 23:54. [PMID: 35028813 DOI: 10.1208/s12249-021-02207-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 11/22/2021] [Accepted: 12/21/2021] [Indexed: 11/30/2022] Open
Abstract
The purpose of our study was using a computational simulation to develop a long-acting patch of rivastigmine (RVS). A range of patch formulations were screened including pressure sensitive adhesive (PSA), pharmaceutical excipients, and controlled release membranes using transfer simulation based on a mathematical model. Diffusion dynamics parameters for simulated operations were acquired through in vitro release tests (IVRT) and in vitro skin permeation tests (IVPT). The mechanism of controlled release was studied by FTIR (Fourier transform infrared), DSC (differential scanning calorimeter) and molecular docking. Results of a rat in vitro permeation profile showed excellent correlation with the in vivo deconvolution profile (R2=0.998). Experiments testified to transfer of RVS at a relatively uniform speed with high skin permeation (2531.2±142.46 μg/cm2) in 72 h. Pharmacokinetic data obtained in vivo also confirmed stable plasma concentrations over 72 h for the optimized patch, and significant prolongation of both Tmax (11.20±1.79 h) and MRT0-t (33.91±5.33 h). Cmax was controlled with AUC0-t (267.34±24.46 h ng/ml), which was closely comparable to parameters of a commercial Exelon® Patch. The successful development of a long-acting patch of RVS thus underscores the potential of computer aided design in a context of promnesic transdermal delivery. Graphical abstract.
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Ruangritchankul S, Chantharit P, Srisuma S, Gray LC. Adverse Drug Reactions of Acetylcholinesterase Inhibitors in Older People Living with Dementia: A Comprehensive Literature Review. Ther Clin Risk Manag 2021; 17:927-949. [PMID: 34511919 PMCID: PMC8427072 DOI: 10.2147/tcrm.s323387] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Accepted: 08/16/2021] [Indexed: 12/30/2022] Open
Abstract
The rising of global geriatric population has contributed to increased prevalence of dementia. Dementia is a neurodegenerative disease, which is characterized by progressive deterioration of cognitive functions, such as judgment, language, memory, attention and visuospatial ability. Dementia not only has profoundly devastating physical and psychological health outcomes, but it also poses a considerable healthcare expenditure and burdens. Acetylcholinesterase inhibitors (AChEIs), or so-called anti-dementia medications, have been developed to delay the progression of neurocognitive disorders and to decrease healthcare needs. AChEIs have been widely prescribed in clinical practice for the treatment of Alzheimer's disease, which account for 70% of dementia. The rising use of AChEIs results in increased adverse drug reactions (ADRs) such as cardiovascular and gastrointestinal adverse effects, resulting from overstimulation of peripheral cholinergic activity and muscarinic receptor activation. Changes in pharmacokinetics (PK), pharmacodynamics (PD) and pharmacogenetics (PGx), and occurrence of drug interactions are said to be major risk factors of ADRs of AChEIs in this population. To date, comprehensive reviews in ADRs of AChEIs have so far been scarcely studied. Therefore, we aimed to recapitulate and update the diverse aspects of AChEIs, including the mechanisms of action, characteristics and risk factors of ADRs, and preventive strategies of their ADRs. The collation of this knowledge is essential to facilitate efforts to reduce ADRs of AChEIs.
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Affiliation(s)
- Sirasa Ruangritchankul
- Division of Geriatric Medicine, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Prawat Chantharit
- Division of Infectious Diseases, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Sahaphume Srisuma
- Ramathibodi Poison Center and Division of Clinical Pharmacology and Toxicology, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Leonard C Gray
- Centre for Health Services Research, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
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In Situ -Forming Microparticles for Controlled Release of Rivastigmine: In Vitro Optimization and In Vivo Evaluation. Pharmaceuticals (Basel) 2021; 14:ph14010066. [PMID: 33466880 PMCID: PMC7829814 DOI: 10.3390/ph14010066] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 01/07/2021] [Accepted: 01/12/2021] [Indexed: 11/26/2022] Open
Abstract
In this work, sucrose acetate isobutyrate (SAIB) and polylactic co-glycolic acid (PLGA) were used alone or in combination as a matrix-former (MF) to prepare long-acting injectable rivastigmine (RV) in situ-forming microparticles (ISM). RV-ISM were prepared by the emulsification of an internal phase, containing the drug and the matrix former(s), into an external oily phase containing a stabilizer. The statistical design, Central Composite Design (CCD), was adopted as a quality by design (QbD) approach to optimize the formulation of RV-ISM systems. The fabricated RV-ISM systems was designed to minimize the initial burst drug release and maximize the sustainment of RV release from the ISM and ease of injection. The influence of critical formulation variables such as the matrix-former to drug (MF/D) ratio and SAIB to PLGA (S/P) ratio in the internal phase with respect to critical quality attributes (CQAs), such as the percentage drug release within the first day (Q1), the time required for 50% drug release (T50%) and the rate of injection, were studied using the CCD. The optimal RV-ISM system with the highest desirability value (0.74) was predicted to have an MF/D ratio of 11.7:1 (w/w) and an S/P ratio of 1.64:1 (w/w). The optimal RV-ISM system was assessed for its release profile, injectability, rheological properties, morphology, effect on cell viability, tolerance to γ-sterilization and in vivo performance in male albino rabbits. In vitro release studies revealed that the optimal RV-ISM system released 100% of its drug content throughout a release period of 30 days with only 15.5% drug release within the first day (Q1) and T50% of 13.09 days. Moreover, the optimal system showed a high injection rate of 1.012 mL/min, pseudoplastic flow, uniform spherical globules with homogenous particle size, minimal cytotoxicity and high tolerability to γ-sterilization. In vivo pharmacokinetic (PK) studies revealed that the rate of absorption of RV from the optimal RV-ISM system was controlled compared to a drug solution following either intramuscular (IM) or subcutaneous (SC) injection. Furthermore, the optimal RV-ISM was found to follow flip-flop PK with poor correlation between in vitro release and in vivo findings. These findings suggest that the optimal RV-ISM is a promising tool to achieve a sustained release therapy for RV; however, further investigation is still required to optimize the in vivo performance of RV-ISM.
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Jia J, Ji Y, Feng T, Ye Q, Peng D, Kuang W, Ning Y, Liang Z, Fan D, Wei W, Li Y, Xiao S. Sixteen-Week Interventional Study to Evaluate the Clinical Effects and Safety of Rivastigmine Capsules in Chinese Patients with Alzheimer's Disease. J Alzheimers Dis 2020; 72:1313-1322. [PMID: 31744005 DOI: 10.3233/jad-190791] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Rivastigmine is a cholinesterase inhibitor, approved for the treatment of mild-to-moderate dementia of Alzheimer's type. OBJECTIVE To explore the efficacy and safety of the maximal tolerated dose of rivastigmine capsules in Chinese patients with mild-to-moderate Alzheimer's disease (AD). METHODS The study was a multicenter, open-label, single-arm, phase IV clinical study in mild-to-moderate drug-naïve AD patients treated with rivastigmine capsules. The primary endpoint was the changes in the total scores of Alzheimer's Disease Assessment Scale-Cognitive subscale (ADAS-Cog) from baseline to week 16. Secondary endpoints included changes in the scores of the following assessment scales and safety: Alzheimer's Disease Cooperative Study; Activities of Daily Living; Mini-Mental Status Examination (MMSE); Neuropsychiatry Index (NPI), and Caregiver Burden Inventory. RESULTS 222 patients were enrolled. Of these, 136 (75.1%) patients received and maintained the effective dose (≥6 mg/d) of rivastigmine for at least 4 weeks. The ADAS-Cog scale score improved in rivastigmine-treated patients at week 16 compared with baseline (p < 0.001) by 2.0 (95% CI: -3.0 to -1.1) points, which met the pre-defined superiority criteria. NPI-10 and NPI-12 scores improved by 3.6 and 4.0 points at week 16 (p = 0.001, p < 0.001), respectively. A total of 107 patients (59.1%) experienced adverse effects (AEs) during the study; common AEs included nausea (20.5%), vomiting (16.6%), anorexia (7.8%), dizziness (7.7%), and diarrhea (7.2%). CONCLUSION This was the first phase IV study on rivastigmine in mainland China. The study preliminarily demonstrated that rivastigmine capsules showed good tolerability and efficacy in mild-to-moderate AD patients with the maximal tolerated dose.
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Affiliation(s)
- Jianping Jia
- Innovation Center for Neurological Disorders and Department of Neurology, Xuanwu Hospital, Capital University of Medical Sciences, Beijing, China
| | - Yong Ji
- Department of Cognitive Disorder, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Disease, Beijing, China
| | - Tao Feng
- China National Clinical Research Center for Neurological Disease, Beijing, China.,Movement Disorders Center, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Qinyong Ye
- Department of Neurology, The Affiliated Union Hospital of Fujian Medical University, Fuzhou, China
| | - Dantao Peng
- Department of Neurology, China-Japan Friendship Hospital, Beijing, China
| | - Weihong Kuang
- Mental Health Center, West China Hospital of Sichuan University, Chengdu, China
| | - Yuping Ning
- Department of Psychiatry, Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, China
| | - Zhihou Liang
- Department of Neurology, Affiliated Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Dongsheng Fan
- Department of Neurology, Peking University Third Hospital, Beijing, China
| | - Wenshi Wei
- Department of Geriatrics, Huadong Hospital, Fudan University, Shanghai, China
| | - Yansheng Li
- Department of Neurology, Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Shifu Xiao
- Department of Geriatric Psychiatry, Alzheimer's Disease and Related Disorders' Center, Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, China
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Nguyen K, Hoffman H, Chakkamparambil B, Grossberg GT. Evaluation of rivastigmine in Alzheimer's disease. Neurodegener Dis Manag 2020; 11:35-48. [PMID: 33198569 DOI: 10.2217/nmt-2020-0052] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Dementia is the major cause of mortality and morbidity in older adults, with Alzheimer's disease (AD) being the most common cause. AD has a significant impact on economic and psychosocial status. Cholinesterase inhibitors (ChEIs) are currently the mainstay in the management of AD. Rivastigmine is the only ChEI that inhibits both acetylcholinesterase and butyrylcholinesterase enzymes in the brain. This dual inhibition makes it potentially more effective for AD patients. Its availability as both a transdermal formulation and oral capsule, may improve adherence rates and care giver satisfaction compared with other ChEIs. To date, the data from randomized clinical trials and post marketing observational studies have shown evidence for an impact on cognitive functions in AD with good safety and tolerability.
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Affiliation(s)
- Kevin Nguyen
- Department of Psychiatry and Behavioral Neuroscience, Saint Louis University School of Medicine, Saint Louis, MI 63104, USA
| | - Heidi Hoffman
- Department of Psychiatry and Behavioral Neuroscience, Saint Louis University School of Medicine, Saint Louis, MI 63104, USA
| | | | - George T Grossberg
- Department of Psychiatry and Behavioral Neuroscience, Saint Louis University School of Medicine, Saint Louis, MI 63104, USA
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Ortner M, Stange M, Schneider H, Schröder C, Buerger K, Müller C, Müller-Sarnowski F, Diehl-Schmid J, Förstl H, Grimmer T, Steimer W. Therapeutic Drug Monitoring of Rivastigmine and Donepezil Under Consideration of CYP2D6 Genotype-Dependent Metabolism of Donepezil. Drug Des Devel Ther 2020; 14:3251-3262. [PMID: 32848364 PMCID: PMC7431170 DOI: 10.2147/dddt.s247259] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2020] [Accepted: 06/26/2020] [Indexed: 11/28/2022] Open
Abstract
Background The efficacy of acetylcholinesterase inhibitors (AChE-I) might depend on blood concentration. While rivastigmine metabolism is independent of the cytochrome P450 system, its isoenzymes, especially CYP2D6, metabolize donepezil. CYP2D6 polymorphisms can cause altered enzyme activity resulting in lower or higher than expected drug concentrations of donepezil. Objective We investigated correlations between clinical efficacy and serum concentrations of rivastigmine and donepezil under special consideration of CYP2D6 genotype or gene dose–dependent metabolism of donepezil. Methods Serum concentrations of donepezil and rivastigmine were measured by liquid chromatography – tandem mass spectrometry (LC-MS/MS). Real-time quantitative polymerase chain reaction (PCR) and allele-specific PCR were performed to assess CYP2D6 genotype and gene dose. Results Patients treated with rivastigmine (n=28) or donepezil (n=48) were included in the study. Both gene dose and metabolism type significantly predicted the level of donepezil serum concentration (p=0.019 and p=0.013, respectively). In the rivastigmine group, changes of the word list delayed recall subtest before treatment and under stable medication were significantly associated with rivastigmine serum levels (β=0.465; p=0.018). Drug serum concentrations were outside the recommended range in a substantial percentage of participants, which might have contributed to poor correlations between changes in cognitive measures and drug concentrations. Donepezil serum concentrations significantly depended on CYP2D6 gene dose. Conclusion Testing AChE-I serum concentration should be considered in patients without clinical response to treatment or those with severe side effects. Patients with donepezil drug levels outside the recommended range might additionally profit from CYP2D6 genotyping or treatment with an AChE-I independent of CYP metabolism.
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Affiliation(s)
- Marion Ortner
- Department of Psychiatry and Psychotherapy, Technical University of Munich, School of Medicine, Klinikum rechts der Isar, Munich, Germany
| | - Marion Stange
- Department of Psychiatry and Psychotherapy, Technical University of Munich, School of Medicine, Klinikum rechts der Isar, Munich, Germany
| | - Heike Schneider
- Department of Psychiatry and Psychotherapy, Technical University of Munich, School of Medicine, Klinikum rechts der Isar, Munich, Germany
| | - Charlotte Schröder
- Institute for Clinical Chemistry and Pathobiochemistry, Technical University of Munich, School of Medicine, Klinikum rechts der Isar, Munich, Germany
| | - Katharina Buerger
- Institute for Stroke and Dementia Research (ISD), University of Munich, School of Medicine, Klinikum der Universität München, Munich, Germany
| | - Claudia Müller
- Institute for Stroke and Dementia Research (ISD), University of Munich, School of Medicine, Klinikum der Universität München, Munich, Germany
| | - Felix Müller-Sarnowski
- Department of Psychiatry and Psychotherapy, Technical University of Munich, School of Medicine, Klinikum rechts der Isar, Munich, Germany
| | - Janine Diehl-Schmid
- Department of Psychiatry and Psychotherapy, Technical University of Munich, School of Medicine, Klinikum rechts der Isar, Munich, Germany
| | - Hans Förstl
- Department of Psychiatry and Psychotherapy, Technical University of Munich, School of Medicine, Klinikum rechts der Isar, Munich, Germany
| | - Timo Grimmer
- Department of Psychiatry and Psychotherapy, Technical University of Munich, School of Medicine, Klinikum rechts der Isar, Munich, Germany
| | - Werner Steimer
- Institute for Clinical Chemistry and Pathobiochemistry, Technical University of Munich, School of Medicine, Klinikum rechts der Isar, Munich, Germany
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Malone K, Hancox JC. QT interval prolongation and Torsades de Pointes with donepezil, rivastigmine and galantamine. Ther Adv Drug Saf 2020; 11:2042098620942416. [PMID: 32874532 PMCID: PMC7436781 DOI: 10.1177/2042098620942416] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Accepted: 06/19/2020] [Indexed: 01/08/2023] Open
Abstract
Background Acetylcholinesterase inhibitors (AChEis) including donepezil, galantamine and rivastigmine are used to treat Alzheimer's disease (AD). This study aimed to evaluate evidence from the case report literature for an association between these agents and risk of QT interval prolongation and Torsades de Pointes (TdP) arrhythmia. Methods Published literature was mined with predetermined MeSH terms for each of donepezil, galantamine and rivastigmine, to identify cases of QT interval prolongation and TdP. Case reports were analysed using causality scales and a QT interval nomogram. Results A total of 13 case reports were found (10 for donepezil, 2 for galantamine and 1 for rivastigmine) with rate corrected QT interval (QTc) prolongation. Five cases with donepezil exhibited TdP. TdP was not reported in the cases with galantamine and rivastigmine. The use of a QT heart rate nomogram highlighted risk with donepezil compared with the other two drugs and the application of the Naranjo causality scale suggested probable or possible causation for all donepezil cases. All patients had at least two other risk factors for TdP, including modifiable risk factors such as electrolyte disturbances, bradycardia, co-administration of QT prolonging drugs. A number of recent cases involved recent changes in medication. Conclusion Our evaluation of the case report literature suggests that there is evidence for a causal association between donepezil and QTc/TdP risk. Attention to risk factors for QTc prolongation/TdP should be exercised when prescribing donepezil and modifiable risk factors corrected. Owing to the low number of cases with galantamine and rivastigmine, further work is needed to establish whether these drugs may be more suitable than donepezil for patients with other risk factors for TdP.
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Affiliation(s)
- Katie Malone
- School of Physiology, Pharmacology and Neuroscience, University of Bristol, University Walk, Bristol, UK
| | - Jules C Hancox
- School of Physiology, Pharmacology and Neuroscience, University of Bristol, University Walk, Biomedical Sciences Building, Bristol, BS8 1TD, UK
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Salimi A, Gobadian H, Sharif Makhmalzadeh B. Dermal pharmacokinetics of rivastigmine-loaded liposomes: an ex vivo- in vivo correlation study. J Liposome Res 2020; 31:246-254. [PMID: 32594811 DOI: 10.1080/08982104.2020.1787440] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The aim of the present study was to develop a topical liposomal formulation as a transdermal delivery of rivastigmine for the treatment of Alzheimer's disease as an alternative to the oral dosage form and to achieve smooth continuous drug delivery and maintain plasma levels within the therapeutic window. Rivastigmine-loaded liposomes were prepared by a thin layer hydration technique that was applied in ex vivo-in vivo correlation study. Permeability parameters through rat skin in ex vivo study and pharmacokinetic parameters in the in vivo study were evaluated. The ex vivo permeation study showed that liposomes provided steady-state flux 0.11 ± 0.01 mg/cm.h that were more than 2-fold the aqueous control. In the in vivo experiments, after topical application of optimized rivastigmine liposomes, the Cmax 208 ng/ml and AUC0-24 3605 (ng.h/ml) were also significantly higher than the control group (both p < 0.01). A point-to-point significant linear correlation was found between ex vivo and in vivo parameters, meaning in vivo pharmacokinetic parameters can be predicted by ex vivo permeation parameters. These data suggest that a liposomal formulation could be an effective carrier to enhance rivastigmine permeation through the skin and maintain plasma levels within the therapeutic window.
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Affiliation(s)
- Anayatollah Salimi
- Nanotechnology Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran.,School of Pharmacy, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Hanna Gobadian
- School of Pharmacy, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Behzad Sharif Makhmalzadeh
- Nanotechnology Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran.,School of Pharmacy, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
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15
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Abstract
Current treatment paradigm in Alzheimer’s disease (AD) involves multiple approaches combining pharmacological and nonpharmacological intervention to mitigate the clinical symptoms, slow the progressive loss of cognitive and functional abilities, or modify the disease course. So far, beyond anti-cholinesterase inhibitors (AChEIs), donepezil, rivastigmine, galantamine, and antagonist of N-methyl-D-aspartic acid (NMDA) receptor, there are no newly approved medicines to treat AD. Under pharmacological treatment, the personal characteristic and the intra-individual therapeutic evaluations to examine various cognitive domains, behavioral and psychological problems, and global function should be considered when choosing any of AChEIs. The use of optimal dosage referring to the expected clinical outcomes and currently reported deficits from patient with AD has become an important issue in clinical treatment. Establishing and maintaining a strong therapeutic alliance to physician, patient, and caregiver is crucial and central to the comprehensive care in AD.
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Affiliation(s)
- Yuan-Han Yang
- Department of Neurology, Kaohsiung Municipal Ta-Tung Hospital, Taiwan, China
- Department of Neurology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan, China
- Neuroscience Research Center, Kaohsiung Medical University, Kaohsiung City, Taiwan, China
| | - Rajka Liscic
- Department of Neurology, Johannes Kepler University Linz, Austria
| | - Jacqueline Dominguez
- Institute for Neurosciences, St. Luke’s Medical Center, Quezon City, Philippines
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16
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Alzheimer's Disease Therapeutic Approaches. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2020; 1195:105-116. [PMID: 32468465 DOI: 10.1007/978-3-030-32633-3_15] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Alzheimer's disease (AD) was first described and diagnosed by Dr. Alois Alzheimer in 1906 (Hippius and Neundorfer, Dialogues Clin Neurosc 5:101-108, 2003). According to World Health Organization (WHO), AD is the most common cause of dementia, accounting for as many as 60-70% of senile dementia cases and affecting 47.5 million people worldwide (data from 2015) (Dementia Fact Sheet No 362. http://who.int/mediacentre/factsheets/fs362/en/ ). The median survival time after the onset of dementia ranges from 3.3 to 11.7 years (Todd et al. Int J Geriatr Psychiatry 28:1109-1124, 2013). AD is characterized as a severe, chronic, incurable, and progressive neurodegenerative disorder, associated with memory loss and cognition impairment accompanied by abnormal behavior and personality changes (Godyn et al. Pharmacol Rep 68:127-138, 2016). AD is characterized by neuronal death, which usually correlates with the appearance of key neuropathological changes, including acetylcholine deficiency, glutamate excitotoxicity, extracellular deposition of β-amyloid (Aβ plaques), intracellular neurofibrillary tangles by hyperphosphorylated tau protein deposits, neuroinflammation, and widespread neuronal loss (Godyn et al. Pharmacol Rep 68:127-138, 2016; Graham et al. Annu Rev. Med 68:413-430, 2017). The discovery of the degeneration of cholinergic neurons and the reduction of acetylcholine levels in postmortem studies of patients resulted in the use of drugs that leads to the increase of acetylcholine levels in brain (Dubois et al. Lacet Neurol 13:614-629, 2014). At present there is no preventative or curative treatment that interferes with the development of the disease. However, in recent years progress was made in the development of cholinergic drugs which have a positive effect on disease progression. Nowadays, specific drugs that can inhibit the enzyme that degrades acetylcholine are used. The development of new effective drugs involves a difficult and time-consuming process, accompanied by a very high failure rate. In the absence of effective therapies, the estimated number of people with dementia will reach 115 to 131, five million by 2050 (Dubois et al. Lacet Neurol 13:614-629, 2014; Cummings et al. Alzheimers Res Ther 6:37, 2014). Novel therapies and new targets required for developing more effective drugs for the treatment of AD patients are urgently needed.
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Chauhan MK, Sharma PK. Optimization and characterization of rivastigmine nanolipid carrier loaded transdermal patches for the treatment of dementia. Chem Phys Lipids 2019; 224:104794. [DOI: 10.1016/j.chemphyslip.2019.104794] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Revised: 05/02/2019] [Accepted: 07/25/2019] [Indexed: 10/26/2022]
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18
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Singhal M, Merino V, Rosini M, Cavalli A, Kalia YN. Controlled Iontophoretic Delivery in Vitro and in Vivo of ARN14140-A Multitarget Compound for Alzheimer's Disease. Mol Pharm 2019; 16:3460-3468. [PMID: 31241959 DOI: 10.1021/acs.molpharmaceut.9b00252] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
ARN14140 is a galantamine-memantine conjugate that acts upon both cholinergic and glutamatergic pathways for better management of Alzheimer's disease. Poor oral bioavailability and pharmacokinetics meant that earlier preclinical in vivo studies employed intracerebroventricular injection to administer ARN14140 directly to the brain. The aim of the present study was to evaluate the feasibility of using constant current transdermal iontophoresis for the noninvasive systemic delivery of ARN14140 and to quantify the amounts present in the blood and the brain. Preliminary experiments in vitro were performed using porcine skin and validated with human skin. Cumulative ARN14140 permeation across the skin increased linearly with current density and concentration. Delivery efficiency (i.e., fraction of the amount applied that is delivered) reached an exceptional 76.9%. Statistically equivalent delivery was observed after iontophoresis across human and porcine skin. In vivo studies in male Wistar rats showed that iontophoretic transport of ARN14140 could be controlled using the current density (426.7 ± 42 and 1118.3 ± 73 nmol/cm2 at 0.15 and 0.5 mA/cm2 for 6 h) and demonstrated that transdermal iontophoresis was able to deliver ARN14140 noninvasively to the brain. This is the first report quantifying drug levels in the blood and the brain following transdermal iontophoresis.
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Affiliation(s)
- Mayank Singhal
- School of Pharmaceutical Sciences , University of Geneva and University of Lausanne , Geneva , Switzerland
| | - Virginia Merino
- Instituto Interuniversitario de Investigación de Reconocimiento Molecular y Desarrollo Tecnológico (IDM) Universitat Politecnica de València , Universitat de València , Valencia , Spain.,Departamento de Farmacia y Tecnología Farmacéutica y Parasitología, Facultad de Farmacia , Universitat de València , Valencia , Spain
| | - Michela Rosini
- Department of Pharmacy and Biotechnology , University of Bologna , Bologna , Italy
| | - Andrea Cavalli
- Department of Pharmacy and Biotechnology , University of Bologna , Bologna , Italy.,Drug Discovery and Development , Istituto Italiano di Tecnologia , Genova , Italy
| | - Yogeshvar N Kalia
- School of Pharmaceutical Sciences , University of Geneva and University of Lausanne , Geneva , Switzerland
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19
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Awad A, Fgaier H, Mustafa I, Elkamel A, Elnashaie S. Pharmacokinetic/Pharmacodynamic modeling and simulation of the effect of medications on β-amyloid aggregates and cholinergic neurocycle. Comput Chem Eng 2019. [DOI: 10.1016/j.compchemeng.2019.04.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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20
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Richter N, Beckers N, Onur OA, Dietlein M, Tittgemeyer M, Kracht L, Neumaier B, Fink GR, Kukolja J. Effect of cholinergic treatment depends on cholinergic integrity in early Alzheimer's disease. Brain 2019; 141:903-915. [PMID: 29309600 DOI: 10.1093/brain/awx356] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Accepted: 11/08/2017] [Indexed: 02/04/2023] Open
Abstract
In early Alzheimer's disease, which initially presents with progressive loss of short-term memory, neurodegeneration especially affects cholinergic neurons of the basal forebrain. Pharmacotherapy of Alzheimer's disease therefore often targets the cholinergic system. In contrast, cholinergic pharmacotherapy of mild cognitive impairment is debated since its efficacy to date remains controversial. We here investigated the relationship between cholinergic treatment effects and the integrity of the cholinergic system in mild cognitive impairment due to Alzheimer's disease. Fourteen patients with high likelihood of mild cognitive impairment due to Alzheimer's disease and 16 age-matched cognitively normal adults performed an episodic memory task during functional magnetic resonance imaging under three conditions: (i) without pharmacotherapy; (ii) with placebo; and (iii) with a single dose of rivastigmine (3 mg). Cortical acetylcholinesterase activity was measured using PET with the tracer 11C-N-methyl-4-piperidyl acetate (MP4A). Cortical acetylcholinesterase activity was significantly decreased in patients relative to controls, especially in the lateral temporal lobes. Without pharmacotherapy, mild cognitive impairment was associated with less memory-related neural activation in the fusiform gyrus and impaired deactivation in the posterior cingulate cortex, relative to controls. These differences were attenuated under cholinergic stimulation with rivastigmine: patients showed increased neural activation in the right fusiform gyrus but enhanced deactivation of the posterior cingulate cortex under rivastigmine, compared to placebo. Conversely, controls showed reduced activation of the fusiform gyrus and reduced deactivation of the posterior cingulate under rivastigmine, compared to placebo. In both groups, the change in neural activation in response to rivastigmine was negatively associated with local acetylcholinesterase activity. At the behavioural level, an analysis of covariance revealed a significant group × treatment interaction in episodic memory performance when accounting for hippocampal grey matter atrophy and function. Our results indicate that rivastigmine differentially affects memory-related neural activity in patients with mild cognitive impairment and cognitively normal, age-matched adults, depending on acetylcholinesterase activity as a marker for the integrity of the cortical cholinergic system. Furthermore, hippocampal integrity showed an independent association with the response of memory performance to acetylcholinesterase inhibition.
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Affiliation(s)
- Nils Richter
- Department of Neurology, University Hospital Cologne, 50937 Cologne, Germany.,Cognitive Neuroscience, Institute of Neuroscience and Medicine (INM-3), Research Center Jülich, 52425 Jülich, Germany.,Max-Planck-Institute for Metabolism Research, 50937 Cologne, Germany
| | - Nora Beckers
- Department of Neurology, University Hospital Cologne, 50937 Cologne, Germany
| | - Oezguer A Onur
- Department of Neurology, University Hospital Cologne, 50937 Cologne, Germany.,Cognitive Neuroscience, Institute of Neuroscience and Medicine (INM-3), Research Center Jülich, 52425 Jülich, Germany
| | - Markus Dietlein
- Department of Nuclear Medicine, University Hospital Cologne, 50937 Cologne, Germany
| | - Marc Tittgemeyer
- Max-Planck-Institute for Metabolism Research, 50937 Cologne, Germany
| | - Lutz Kracht
- Max-Planck-Institute for Metabolism Research, 50937 Cologne, Germany.,Department of Nuclear Medicine, University Hospital Cologne, 50937 Cologne, Germany
| | - Bernd Neumaier
- Nuclear Chemistry, Institute of Neuroscience and Medicine (INM-5), Research Center Jülich, 52425 Jülich, Germany.,Institute for Radiochemistry and Experimental Molecular Imaging, University Hospital Cologne, 50937 Cologne, Germany
| | - Gereon R Fink
- Department of Neurology, University Hospital Cologne, 50937 Cologne, Germany.,Cognitive Neuroscience, Institute of Neuroscience and Medicine (INM-3), Research Center Jülich, 52425 Jülich, Germany
| | - Juraj Kukolja
- Department of Neurology, University Hospital Cologne, 50937 Cologne, Germany.,Cognitive Neuroscience, Institute of Neuroscience and Medicine (INM-3), Research Center Jülich, 52425 Jülich, Germany
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21
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22
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Tsuno N, Mori T, Ishikawa I, Bando N, Park H, Matsumoto Y, Mori I, Tanaka M, Hirano T, Nakamura Y. Efficacy of rivastigmine transdermal therapy on low food intake in patients with Alzheimer's disease: The Attitude Towards Food Consumption in Alzheimer's Disease Patients Revive with Rivastigmine Effects study. Geriatr Gerontol Int 2019; 19:571-576. [PMID: 30864298 PMCID: PMC6850597 DOI: 10.1111/ggi.13644] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 01/24/2019] [Accepted: 02/03/2019] [Indexed: 12/27/2022]
Abstract
Aim Most patients with Alzheimer's disease (AD) experience poor food intake and/or loss of appetite, which accelerates cognitive impairment. Several reports have shown that rivastigmine improves appetite in AD patients. The present study investigated the efficacy of a rivastigmine transdermal patch for the treatment of low food intake in AD patients. Methods AD patients, recruited through the Attitude Towards Food Consumption in Alzheimer's Disease Patients Revive with Rivastigmine Effects study, were recognized as experiencing either a loss of appetite or poor food intake. A rivastigmine transdermal patch was administered to study participants for 16 weeks. Patients’ food intake, bodyweight, Mini‐Mental State Examination scores and any adverse events were recorded. Results A total of 38 patients with AD (age 86.2 ± 5.4 years) were examined. Their mean Mini‐Mental State Examination score was 10.1 ± 7.0 at baseline. A significant increase in food intake amount (54.9 ± 98.0 g, P < 0.01) and food intake ratio (9.3% ± 17.6%, P < 0.01) was observed by week 1, improvements that were maintained throughout the study duration. A multiple linear regression analysis showed that no independent variables were significantly associated with changes in food intake amount or ratio. Patients in the higher Mini‐Mental State Examination subgroup showed a trend change in food intake amount, although this did not reach statistical significance (P = 0.07). Conclusions The present study suggests that a rivastigmine transdermal patch might improve poor food intake or loss of appetite in patients with AD. Geriatr Gerontol Int 2019; 19: 571–576.
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Affiliation(s)
- Norifumi Tsuno
- Department of Neuropsychiatry, Faculty of Medicine, Kagawa University, Miki-cho, Japan
| | - Takahiro Mori
- Department of Neuropsychiatry, Faculty of Medicine, Kagawa University, Miki-cho, Japan
| | - Ichiro Ishikawa
- Department of Neuropsychiatry, Faculty of Medicine, Kagawa University, Miki-cho, Japan
| | - Nobuyasu Bando
- Department of Mental Health, Kaisei General Hospital, Sakaide, Japan
| | | | - Yoshito Matsumoto
- Nishitakamatsu Neurosurgery and Internal Medicine Clinic, Takamatsu, Japan
| | - Itsuko Mori
- Medical Juridical Person Eisei Hospital, Nakatado, Japan
| | | | | | - Yu Nakamura
- Department of Neuropsychiatry, Faculty of Medicine, Kagawa University, Miki-cho, Japan
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Grossberg GT, Tong G, Burke AD, Tariot PN. Present Algorithms and Future Treatments for Alzheimer's Disease. J Alzheimers Dis 2019; 67:1157-1171. [PMID: 30741683 PMCID: PMC6484274 DOI: 10.3233/jad-180903] [Citation(s) in RCA: 61] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/21/2018] [Indexed: 12/13/2022]
Abstract
An estimated 47 million people live with Alzheimer's disease (AD) and other forms of dementia worldwide. Although no disease-modifying treatments are currently available for AD, earlier diagnosis and proper management of the disease could have considerable impact on patient and caregiver quality of life and functioning. Drugs currently approved for AD treat the cognitive, behavioral, and functional symptoms of the disease and consist of three cholinesterase inhibitors (ChEIs) and the N-methyl-D-aspartate receptor antagonist memantine. Treatment of patients with mild to moderate AD is generally initiated with a ChEI. Patients who show progression of symptoms while on ChEI monotherapy may be switched to another ChEI and/or memantine can be added to the treatment regimen. In recent years, putative disease-modifying therapies have emerged that aim to slow the progression of AD instead of only addressing its symptoms. However, many therapies have failed in clinical trials in patients with established AD, suggesting that, once developed, disease-modifying agents may need to be deployed earlier in the course of illness. The goal of this narrative literature review is to discuss present treatment algorithms and potential future therapies in AD.
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Abstract
The overall physiologic changes associated with aging lead to changes in both pharmacokinetic and pharmacodynamic actions of many medications. This, in turn, leads to changes in the impact that a wide variety of medications have on older adults when compared to younger, healthy individuals. These pharmacokinetic and pharmacodynamic variations can cause either lesser or greater than expected responses to medication. Knowledge of the physiologic changes that are expected to occur in the elderly can help to identify medications that may require dose adjustments or that should be avoided, due to increased risk in this population. As a general principle, medications should be started at lower doses in the elderly with slow titration schedules to reduce the risk of adverse effects.
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Affiliation(s)
- Jacob Tillmann
- Pharmacy Service, Department of Veterans Affairs Medical Center, Gainesville, FL, United States.
| | - Ashley Reich
- Pharmacy Service, Department of Veterans Affairs Medical Center, Lake City, FL, United States
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Khan MS, Roberts MS. Challenges and innovations of drug delivery in older age. Adv Drug Deliv Rev 2018; 135:3-38. [PMID: 30217519 DOI: 10.1016/j.addr.2018.09.003] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2018] [Revised: 08/31/2018] [Accepted: 09/07/2018] [Indexed: 12/12/2022]
Abstract
Both drug delivery performance and various age-related physical, mental and physiological changes can affect drug effectiveness and safety in elderly patients. The many drug delivery systems developed over the years include recent novel transdermal, nasal, pulmonary and orally disintegrating tablets that provide consistent, precise, timely and more targeted drug delivery. Certain drug delivery systems may be associated with suboptimal outcomes in the elderly because of the nature of drug present, a lack of appreciation of the impact of age-related changes in drug absorption, distribution and clearance, the limited availability of pharmacokinetic, safety and clinical data. Polypharmacy, patient morbidity and poor adherence can also contribute to sub-optimal drug delivery systems outcomes in the elderly. The development of drug delivery systems for the elderly is a poorly realised opportunity, with each system having specific advantages and limitations. A key challenge is to provide the innovation that best meets the specific physiological, psychological and multiple drug requirements of individual elderly patients.
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Cawello W, Braun M, Andreas JO. Drug Delivery and Transport into the Central Circulation: An Example of Zero-Order In vivo Absorption of Rotigotine from a Transdermal Patch Formulation. Eur J Drug Metab Pharmacokinet 2018; 43:475-481. [DOI: 10.1007/s13318-018-0460-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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Khoury R, Rajamanickam J, Grossberg GT. An update on the safety of current therapies for Alzheimer's disease: focus on rivastigmine. Ther Adv Drug Saf 2018; 9:171-178. [PMID: 29492246 DOI: 10.1177/2042098617750555] [Citation(s) in RCA: 76] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2017] [Accepted: 12/06/2017] [Indexed: 01/05/2023] Open
Abstract
Alzheimer's disease (AD) is the most common cause of major neurocognitive disorders worldwide. Despite all research efforts, therapeutic options for AD are still limited to two drug classes: cholinesterase inhibitors (ChEIs) and the NMDA-receptor antagonist memantine. Donepezil, rivastigmine and galantamine are the three ChEIs FDA-approved as first-line treatment for AD. Although they share the same mode of action, they differ in terms of their pharmacologic characteristics and route of administration, which can impact their safety and tolerability profile. Rivastigmine, available in both oral and transdermal patch formulations, is a slowly reversible dual inhibitor of acetyl and butyryl cholinesterase, selective for the G1 isoform of acetylcholinesterase, without hepatic metabolism by the CYP-450 system. Despite its unique features, it has been associated with a higher incidence of adverse events in comparison to other ChEIs. The oral form, approved for the treatment of mild to moderate AD, is associated with a higher incidence of gastrointestinal side effects. The transdermal patch formulation approved for use across all stages of AD has been shown to have a better tolerability profile in comparison to both the oral form and even other ChEIs. One important tolerability concern is adverse dermatologic reactions, which are mostly benign, and can be either preventable or manageable. One important safety concern is the risk of treatment overdose by administering multiple patches at the same time, potentially leading to fatal outcomes. This can be prevented by educating patients and caregivers about the proper use of the patch. The goal for the future would be to optimize the patch formulation to increase both efficacy and safety.
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Affiliation(s)
- Rita Khoury
- Division of Geriatric Psychiatry, St. Louis University School of Medicine, 1438 S Grand Blvd, St. Louis, MO 63104, USA
| | - Jayashree Rajamanickam
- Division of Geriatric Psychiatry, St. Louis University School of Medicine, St. Louis, MO, USA
| | - George T Grossberg
- Division of Geriatric Psychiatry, St. Louis University School of Medicine, St. Louis, MO, USA
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Quantitative estimation of cholinesterase-specific drug metabolism of carbamate inhibitors provided by the analysis of the area under the inhibition-time curve. J Pharm Biomed Anal 2017; 144:167-174. [PMID: 28468728 DOI: 10.1016/j.jpba.2017.04.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Revised: 03/30/2017] [Accepted: 04/09/2017] [Indexed: 12/25/2022]
Abstract
Several molecules containing carbamate groups are metabolized by cholinesterases. This metabolism includes a time-dependent catalytic step which temporary inhibits the enzymes. In this paper we demonstrate that the analysis of the area under the inhibition versus time curve (AUIC) can be used to obtain a quantitative estimation of the amount of carbamate metabolized by the enzyme. (R)-bambuterol monocarbamate and plasma butyrylcholinesterase were used as model carbamate-cholinesterase system. The inhibition of different concentrations of the enzyme was monitored for 5h upon incubation with different concentrations of carbamate and the resulting AUICs were analyzed. The amount of carbamate metabolized could be estimated with <15% accuracy (RE%) and ≤23% precision (RSD%). Since the knowledge of the inhibition kinetics is not required for the analysis, this approach could be used to determine the amount of drug metabolized by cholinesterases in a selected compartment in which the cholinesterase is confined (e.g. in vitro solutions, tissues or body fluids), either in vitro or in vivo.
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Lefèvre G, Callegari F, Gsteiger S, Xiong Y. Effects of Renal Impairment on Steady-State Plasma Concentrations of Rivastigmine: A Population Pharmacokinetic Analysis of Capsule and Patch Formulations in Patients with Alzheimer's Disease. Drugs Aging 2017; 33:725-736. [PMID: 27681702 PMCID: PMC5075013 DOI: 10.1007/s40266-016-0405-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Introduction The glomerular filtration rate (GFR), a measure of renal function, decreases by approximately 10 mL/min every 10 years after the age of 40 years, which could lead to the accumulation of drugs and/or renal toxicity. Pharmacokinetic studies of drugs excreted both renally and non-renally are desirable in patients with impaired renal function, defined by parameters including estimated GFR (eGFR) and creatinine clearance (CLCR). Objective We describe here a population pharmacokinetic analysis of the possible effects of renal impairment on steady-state plasma concentrations of rivastigmine and its metabolite NAP226-90 after rivastigmine patch (5 cm2 [4.6 mg/24 h], 10 cm2 [9.5 mg/24 h], 15 cm2 [13.3 mg/24 h], and 20 cm2 [17.4 mg/24 h]) and capsule (1.5, 3, 4.5, and 6 mg/12 h) treatment in patients with Alzheimer’s disease. Methods The data used to conduct the current pharmacokinetic analysis were obtained from the pivotal phase III, 24-week, multicenter, randomized, double-blind, placebo- and active-controlled, parallel-group study (IDEAL). One blood sample was collected from each patient at steady-state to measure plasma concentrations of rivastigmine and NAP226-90 using a liquid chromatography–tandem mass spectrometry (LC–MS/MS) method. The steady-state plasma concentrations of rivastigmine and NAP226-90 were plotted against CLCR and eGFR data, and boxplots were constructed after stratification by renal function. Results The two groups (mild/no renal impairment vs. moderate/severe/end-stage renal impairment) showed comparable demographic covariates for all patch sizes and capsule doses. No correlation was observed between CLCR or eGFR and plasma concentrations of rivastigmine or NAP226-90. Boxplots of concentrations of rivastigmine or NAP226-90 for each dose largely overlapped for patch and capsule. Additionally, model-based estimates of plasma concentrations adjusted for body weight yielded similar results. Conclusion The results of this study show that renal function does not affect rivastigmine or NAP226-90 steady-state plasma concentrations, and no dose adjustment in patients with renal impairment is required. ClinicalTrials.gov NCT00099242.
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Affiliation(s)
- Gilbert Lefèvre
- WSJ-386.12.48.10, Novartis Institutes for Biomedical Research, Translational Medicine, Clinical PK/PD, 4002, Basel, Switzerland.
| | | | | | - Yuan Xiong
- Novartis Pharmaceuticals Corporation, One Health Plaza, East Hanover, NJ, USA
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Mohammad D, Chan P, Bradley J, Lanctôt K, Herrmann N. Acetylcholinesterase inhibitors for treating dementia symptoms - a safety evaluation. Expert Opin Drug Saf 2017; 16:1009-1019. [PMID: 28678552 DOI: 10.1080/14740338.2017.1351540] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
INTRODUCTION The prevalence of Alzheimer's disease (AD) continues to rise, while treatment options for cognitive impairment are limited. Acetylcholinesterase inhibitors (AChEIs) aim to provide symptomatic benefit for cognitive decline, however these drugs are not without adverse events (AEs). The safety profile of each drug must be taken carefully into consideration before being prescribed, as new dosages and formulations have recently been approved. Areas covered: Donepezil, galantamine and rivastigmine are the three AChEIs approved for the treatment of varying stages of AD. Numerous clinical trials and post-marketing studies have evaluated the safety of these medications. This article will review the safety, efficacy and tolerability of these drugs in treating AD. Topics including pharmacovigilance databases, concomitant drug interactions, prescribing cascades, and treatment discontinuation are also covered. Expert opinion: AChEI use in those with mild, moderate or severe AD provide modest improvements in cognition, function and behavior. The pharmacological treatment of AD using AChEIs is associated with generally mild AEs. Differences in drug formulations should be taken into account when determining the most appropriate route of administration for each individual. Furthermore, discontinuation of AChEIs must be carefully monitored as it may be associated with worsening cognitive impairment.
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Affiliation(s)
- Dana Mohammad
- a Department of Pharmacology and Toxicology , University of Toronto , Toronto , ON , Canada.,b Neuropsychopharmacology Research Group, Hurvitz Brain Sciences Program , Sunnybrook Research Institute , Toronto , ON , Canada
| | - Parco Chan
- a Department of Pharmacology and Toxicology , University of Toronto , Toronto , ON , Canada.,b Neuropsychopharmacology Research Group, Hurvitz Brain Sciences Program , Sunnybrook Research Institute , Toronto , ON , Canada
| | - Janelle Bradley
- b Neuropsychopharmacology Research Group, Hurvitz Brain Sciences Program , Sunnybrook Research Institute , Toronto , ON , Canada
| | - Krista Lanctôt
- a Department of Pharmacology and Toxicology , University of Toronto , Toronto , ON , Canada.,b Neuropsychopharmacology Research Group, Hurvitz Brain Sciences Program , Sunnybrook Research Institute , Toronto , ON , Canada.,c Department of Psychiatry , University of Toronto , Toronto , ON , Canada
| | - Nathan Herrmann
- b Neuropsychopharmacology Research Group, Hurvitz Brain Sciences Program , Sunnybrook Research Institute , Toronto , ON , Canada.,c Department of Psychiatry , University of Toronto , Toronto , ON , Canada
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Suzuki Y, Kamijo Y, Yoshizawa T, Fujita Y, Usui K, Kishino T. Acute cholinergic syndrome in a patient with mild Alzheimer's type dementia who had applied a large number of rivastigmine transdermal patches on her body. Clin Toxicol (Phila) 2017; 55:1008-1010. [PMID: 28594244 DOI: 10.1080/15563650.2017.1329536] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
CASE PRESENTATION A 91-year-old woman was transferred to our Emergency Medical Center and Poison Center with somnolence, hypertension (186/61 mm Hg), and repeated vomiting. Three hours later, 10 transdermal patches, each containing 18 mg of rivastigmine (9.5 mg/24 h), were found on her lower back and both thighs, when miosis, facial and trunk sweating, enhanced bowel sound, hypertension, and sinus tachycardia were noted. She was diagnosed with acute cholinergic syndrome due to rivastigmine poisoning. Her hypertension and sinus tachycardia peaked 8 and 5 h after all the patches were removed, respectively. Her symptoms subsided spontaneously after 17 h. DISCUSSION In the present case, our patient was presented with acute cholinergic syndrome due to carbamate intoxication after massive transdermal exposure to rivastigmine. Toxicological analysis revealed a remarkably high estimated serum rivastigmine concentration (150.6 ng/ml) and notably low serum butyrylcholinesterase activity (35 IU/l) on admission, with a markedly prolonged calculated elimination half-life of 6.5 h. CONCLUSIONS Emergency physicians should consider acetylcholinesterase inhibitor exposure (e.g., rivastigmine) when patients are present with acute cholinergic syndrome.
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Affiliation(s)
- Yoshiki Suzuki
- a Emergency Medical Center and Poison Center , Saitama Medical University Hospital , Saitama , Japan.,b Department of Pharmacy , Saitama Medical University Hospital , Saitama , Japan
| | - Yoshito Kamijo
- a Emergency Medical Center and Poison Center , Saitama Medical University Hospital , Saitama , Japan
| | - Tomohiro Yoshizawa
- a Emergency Medical Center and Poison Center , Saitama Medical University Hospital , Saitama , Japan.,b Department of Pharmacy , Saitama Medical University Hospital , Saitama , Japan
| | - Yuji Fujita
- c Department of Emergency, Disaster and General Medicine , Iwate Medical University School of Medicine , Iwate , Japan
| | - Kiyotaka Usui
- d Department of Forensic Medicine , Tohoku University Graduate School of Medicine , Miyagi , Japan
| | - Tohru Kishino
- b Department of Pharmacy , Saitama Medical University Hospital , Saitama , Japan
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Factors affecting therapeutic response to Rivastigmine in Alzheimer's disease patients in Taiwan. Kaohsiung J Med Sci 2017; 33:277-283. [PMID: 28601231 DOI: 10.1016/j.kjms.2017.04.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Revised: 04/06/2017] [Accepted: 04/14/2017] [Indexed: 12/27/2022] Open
Abstract
Rivastigmine has been widely used in mild-to-moderate Alzheimer's disease (AD), but the therapeutic response rate varies from 20 to 60%. A dose-dependent effect has been suggested, but the plasma concentration of rivastigmine and its metabolite, NAP 226-90, were not measured in previous studies. The influencing factors of therapeutic response are complicated and discordant in various studies among different ethnic groups. Hence, we analyzed the therapeutic responses of rivastigmine, measured by neuropsychological assessments, among 63 clinically diagnosed AD patients taking a daily dosage of 6-9 mg in relation to their plasma concentration of rivastigmine and NAP 226-90, apolipoprotein E (APOE) genotype and demographic characteristics. Our reports revealed that 41.3% of recruited AD patients had improvement in cognition, measured by Mini-Mental Status Examination (MMSE), and 63.5% in global status, by Clinical Dementia Rating Scale Sum of Boxes (CDR-SB) score. In cognition, the clinically improving group had a significantly higher rivastigmine concentration [p = 0.049, odds ratio (OR) = 1.029, 95%CI = 1.000-1.058], lower initial MMSE score (p = 0.010, OR = 0.708, 95%CI = 0.546-0.920), and lower initial CDR-SB score (p = 0.003, OR = 0.552, 95%CI = 0.372-0.817). The patients with APOE ε4 allele had worsening cognition (p = 0.037, OR = 3.870, 95%CI = 1.082-13.840). In global status, only higher education (p = 0.043, OR = 1.222, 95%CI = 1.007-1.484) was significantly associated with clinical improvement. In conclusion, high concentrations of rivastigmine may benefit cognitive function of AD patients, especially in APOE ε4 (-) carriers.
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Fisher A, Carney G, Bassett K, Dormuth CR. Tolerability of Cholinesterase Inhibitors: A Population-Based Study of Persistence, Adherence, and Switching. Drugs Aging 2017; 34:221-231. [DOI: 10.1007/s40266-017-0438-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Abstract
Alzheimer's disease (AD) is a progressive neurodegenerative disease, characterized by the loss of memory, multiple cognitive impairments and changes in the personality and behavior. Several decades of intense research have revealed that multiple cellular changes are involved in disease process, including synaptic damage, mitochondrial abnormalities and inflammatory responses, in addition to formation and accumulation of amyloid-β (Aβ) and phosphorylated tau. Although tremendous progress has been made in understanding the impact of neurotransmitters in the progression and pathogenesis of AD, we still do not have a drug molecule associated with neurotransmitter(s) that can delay disease process in elderly individuals and/or restore cognitive functions in AD patients. The purpose of our article is to assess the latest developments in neurotransmitters research using cell and mouse models of AD. We also updated the current status of clinical trials using neurotransmitters' agonists/antagonists in AD.
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Affiliation(s)
- Ramesh Kandimalla
- Garrison Institute on Aging Department, Texas Tech University Health Sciences Center, Lubbock, TX, USA
- Pharmacology & Neuroscience Department, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - P. Hemachandra Reddy
- Garrison Institute on Aging Department, Texas Tech University Health Sciences Center, Lubbock, TX, USA
- Pharmacology & Neuroscience Department, Texas Tech University Health Sciences Center, Lubbock, TX, USA
- Cell Biology & Biochemistry Department, Texas Tech University Health Sciences Center, Lubbock, TX, USA
- Neurology Department, Texas Tech University Health Sciences Center, Lubbock, TX, USA
- Garrison Institute on Aging, South West Campus, Texas Tech University Health Sciences Center, Lubbock, TX, USA
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Morgan TM, Soh B. Absolute bioavailability and safety of a novel rivastigmine nasal spray in healthy elderly individuals. Br J Clin Pharmacol 2016; 83:510-516. [PMID: 27639640 DOI: 10.1111/bcp.13133] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Revised: 09/06/2016] [Accepted: 09/12/2016] [Indexed: 11/30/2022] Open
Abstract
AIMS To test the feasibility of a novel rivastigmine nasal spray as prospective treatment for dementia. METHODS A single dose, crossover absolute bioavailability and safety study was conducted with rivastigmine intravenous solution (1 mg) and nasal spray (3.126 mg) in eight healthy elderly individuals, aged 58-75 years. RESULTS Absolute bioavailability (F) of the nasal spray was significant at 0.62 (0.15) for F > 0 (P < 0.001, n = 8). The systemic dose absorbed was 2.0 (0.6) mg, time to maximum plasma concentration was 1.1 (0.5) h and maximum plasma concentration was 6.9 (2.0) ng ml-1 . The NAP226-90 to rivastigmine AUC0-∞ ratio was 0.78 (0.19). The single dose safety was good with two of five mild adverse events related to the nasal spray. Nasal and throat irritation were perceived as mild and transient, and both had resolved at 20 min post-nasal dose. An estimated dose of two or three sprays twice-daily with nasal spray would deliver comparable rivastigmine exposure and efficacy as a 6-9.7 mg day-1 oral dose and a 10 cm2 transdermal patch, respectively. CONCLUSIONS The rivastigmine nasal spray had superior absolute bioavailability compared to historical values for oral capsule and transdermal patch determined by other researchers. It had rapid onset of action, low NAP226-90 to rivastigmine exposure ratio and a favourable safety and tolerability profile. The ability to achieve adjustable, individual, twice-daily dosing during waking hours has good potential to minimise undesirable cholinergic burden and sleep disturbances whilst delivering an effective dose for the treatment of dementia associated with Alzheimer's and Parkinson's disease.
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Affiliation(s)
- Timothy M Morgan
- Executive Director, Lachesis Biosciences Pty Ltd, Warrnambool, Victoria, 3280, Australia
| | - Bob Soh
- Principal Investigator, Nucleus Network Ltd, Melbourne, Victoria, 3004, Australia
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Simon A, Amaro MI, Healy AM, Cabral LM, de Sousa VP. Comparative evaluation of rivastigmine permeation from a transdermal system in the Franz cell using synthetic membranes and pig ear skin with in vivo-in vitro correlation. Int J Pharm 2016; 512:234-241. [PMID: 27568498 DOI: 10.1016/j.ijpharm.2016.08.052] [Citation(s) in RCA: 100] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Revised: 08/18/2016] [Accepted: 08/24/2016] [Indexed: 10/21/2022]
Abstract
In the present study, in vitro permeation experiments in a Franz diffusion cell were performed using different synthetic polymeric membranes and pig ear skin to evaluate a rivastigmine (RV) transdermal drug delivery system. In vitro-in vivo correlations (IVIVC) were examined to determine the best model membrane. In vitro permeation studies across different synthetic membranes and skin were performed for the Exelon(®) Patch (which contains RV), and the results were compared. Deconvolution of bioavailability data using the Wagner-Nelson method enabled the fraction of RV absorbed to be determined and a point-to-point IVIVC to be established. The synthetic membrane, Strat-M™, showed a RV permeation profile similar to that obtained with pig ear skin (R(2)=0.920). Studies with Strat-M™ resulted in a good and linear IVIVC (R(2)=0.991) when compared with other synthetic membranes that showed R(2) values less than 0.90. The R(2) for pig ear skin was 0.982. Strat-M™ membrane was the only synthetic membrane that adequately simulated skin barrier performance and therefore it can be considered to be a suitable alternative to human or animal skin in evaluating transdermal drug transport, potentially reducing the number of studies requiring human or animal samples.
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Affiliation(s)
- Alice Simon
- Department of Drugs and Pharmaceutics, Faculty of Pharmacy, Federal University of Rio de Janeiro, Av. Carlos Chagas Filho, 373, CCS, Bss, sl15, Rio de Janeiro, RJ, 21941-902, Brazil
| | - Maria Inês Amaro
- School of Pharmacy and Pharmaceutical Sciences, Trinity College Dublin, Dublin 2, Ireland
| | - Anne Marie Healy
- School of Pharmacy and Pharmaceutical Sciences, Trinity College Dublin, Dublin 2, Ireland
| | - Lucio Mendes Cabral
- Department of Drugs and Pharmaceutics, Faculty of Pharmacy, Federal University of Rio de Janeiro, Av. Carlos Chagas Filho, 373, CCS, Bss, sl15, Rio de Janeiro, RJ, 21941-902, Brazil
| | - Valeria Pereira de Sousa
- Department of Drugs and Pharmaceutics, Faculty of Pharmacy, Federal University of Rio de Janeiro, Av. Carlos Chagas Filho, 373, CCS, Bss, sl15, Rio de Janeiro, RJ, 21941-902, Brazil.
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Deardorff WJ, Grossberg GT. Pharmacotherapeutic strategies in the treatment of severe Alzheimer's disease. Expert Opin Pharmacother 2016; 17:1789-800. [PMID: 27450461 DOI: 10.1080/14656566.2016.1215431] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
INTRODUCTION Alzheimer's disease (AD) is a slowly progressive neurodegenerative disease. Patients with severe AD often require assistance with daily functioning and have a substantially higher probability of admission to nursing homes compared to the general population. AREAS COVERED Medications approved by the US Food and Drug Administration for the treatment of severe AD include the cholinesterase inhibitors (ChEIs), donepezil (10 and 23 mg/day) and rivastigmine (transdermal patch, 13.3 mg/24 hours), and the N-methyl-D-aspartate receptor antagonist memantine (immediate- and extended-release formulations). This article will review the efficacy, safety, and tolerability data of these agents in the treatment of severe AD. Issues related to combination therapy, neuropsychiatric symptoms, and treatment discontinuation are also discussed. EXPERT OPINION AD therapeutics provide benefits on measures of cognition, functioning, behavior, and global status even in the severe stages of AD. Combination therapy with memantine and ChEIs may provide additive benefits compared with ChEI monotherapy. Decisions regarding discontinuation of these medications should be made on a case-by-case basis, with some evidence suggesting that discontinuation may worsen cognition and functional impairment. It is recommended that patients entering the terminal stages of AD discontinue all medications not necessary for comfort.
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Affiliation(s)
| | - George T Grossberg
- a Department of Psychiatry , St. Louis University School of Medicine , St Louis , MO , USA
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Transdermal Rivastigmine Delivery for Alzheimer Disease: Amenability of Exposure Predictions of Rivastigmine and Metabolite, NAP226-90, by Linear Regression Model Using Limited Samples. Clin Neuropharmacol 2016; 39:169-77. [DOI: 10.1097/wnf.0000000000000154] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Nozaki S, Yamaguchi M, Lefèvre G. Pharmacokinetic Modeling to Simulate the Concentration-Time Profiles After Dermal Application of Rivastigmine Patch. J Pharm Sci 2016; 105:2213-21. [PMID: 27212635 DOI: 10.1016/j.xphs.2016.04.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Revised: 04/09/2016] [Accepted: 04/11/2016] [Indexed: 11/19/2022]
Abstract
Rivastigmine is an inhibitor of acetylcholinesterases and butyrylcholinesterases for symptomatic treatment of Alzheimer disease and is available as oral and transdermal patch formulations. A dermal absorption pharmacokinetic (PK) model was developed to simulate the plasma concentration-time profile of rivastigmine to answer questions relative to the efficacy and safety risks after misuse of the patch (e.g., longer application than 24 h, multiple patches applied at the same time, and so forth). The model comprised 2 compartments which was a combination of mechanistic dermal absorption model and a basic 1-compartment model. The initial values for the model were determined based on the physicochemical characteristics of rivastigmine and PK parameters after intravenous administration. The model was fitted to the clinical PK profiles after single application of rivastigmine patch to obtain model parameters. The final model was validated by confirming that the simulated concentration-time curves and PK parameters (Cmax and area under the drug plasma concentration-time curve) conformed to the observed values and then was used to simulate the PK profiles of rivastigmine. This work demonstrated that the mechanistic dermal PK model fitted the clinical data well and was able to simulate the PK profile after patch misuse.
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Affiliation(s)
- Sachiko Nozaki
- Drug Metabolism & Pharmacokinetics, Translational Medicine, Novartis Pharma K.K., Tokyo, Japan.
| | - Masayuki Yamaguchi
- Drug Metabolism & Pharmacokinetics, Translational Medicine, Novartis Pharma K.K., Tokyo, Japan
| | - Gilbert Lefèvre
- Clinical PK/PD, Translational Medicine, Novartis Institutes for Biomedical Research, Basel, Switzerland
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40
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Nieto RA, Deardorff WJ, Grossberg GT. Efficacy of rivastigmine tartrate, transdermal system, in Alzheimer’s disease. Expert Opin Pharmacother 2016; 17:861-70. [DOI: 10.1517/14656566.2016.1159296] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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41
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Reich M, Kotecki N. Interactions médicamenteuses entre les psychotropes et les thérapies pharmacologiques en oncologie : quelles modalités de prescription ? PSYCHO-ONCOLOGIE 2016. [DOI: 10.1007/s11839-015-0540-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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42
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Lee SH, Kim SH, Noh YH, Choi BM, Noh GJ, Park WD, Kim EJ, Cho IH, Bae CS. Pharmacokinetics of Memantine after a Single and Multiple Dose of Oral and Patch Administration in Rats. Basic Clin Pharmacol Toxicol 2015; 118:122-7. [PMID: 26310825 DOI: 10.1111/bcpt.12479] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Accepted: 08/13/2015] [Indexed: 11/29/2022]
Abstract
Memantine is a non-competitive N-methyl-D-aspartate (NMDA) receptor antagonist used to treat Alzheimer's disease. We investigated memantine pharmacokinetics after oral, IV and patch administration in rats, and compared memantine pharmacokinetics after multiple- or single-dose oral and transdermal administration. Venous blood was collected at preset intervals in single- and multiple-dose studies. Non-compartmental pharmacokinetics was analysed for all formulations. The oral, IV and patch memantine doses were 10 mg/kg, 2 mg/kg and 8.21 ± 0.89 mg/kg, respectively. The maximum plasma concentration was lower and the half-life longer after patch administration than oral and IV administration. Memantine bioavailability was 41 and 63% for oral and patch administration, respectively. Steady state was achieved around 24 hr for oral and patch administration. The mean AUC increased after oral or patch administration from single to multiple dose. The memantine patch formulation displayed a longer duration of action and lower peak plasma concentration. However, drug exposure was similar to the oral formulation at each dose. Additionally, the memantine patch formulation displayed a smaller interindividual variability and lower accumulation than the oral formulation.
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Affiliation(s)
- Soo-Han Lee
- Department of Veterinary Internal Medicine, College of Veterinary Medicine, Konkuk University, Seoul, Korea
| | - Seung-Hyun Kim
- Department of Veterinary Surgery, College of Veterinary Medicine, Chonnam National University, Gwangju, Korea
| | - Yook-Hwan Noh
- Department of Bioengineering and Therapeutic Sciences, School of Pharmacy, University of California San Francisco, San Francisco, CA, USA
| | - Byung-Moon Choi
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Gyu-Jeong Noh
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.,Department of Clinical Pharmacology and Therapeutics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Woo-Dae Park
- Department of Veterinary Nurse and Pet Science, Seojeong College, Yangju, Korea
| | - Eun-Jung Kim
- Pharmaceutical Research Center, Handok Incorporation, Seoul, Korea
| | - Ik-Hyun Cho
- Department of Convergence Medical Science, Kyunghee University, Seoul, Korea
| | - Chun-Sik Bae
- Department of Veterinary Surgery, College of Veterinary Medicine, Chonnam National University, Gwangju, Korea
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Choi HY, Kim YH, Hong D, Kim SS, Bae KS, Lim HS. Therapeutic dosage assessment based on population pharmacokinetics of a novel single-dose transdermal donepezil patch in healthy volunteers. Eur J Clin Pharmacol 2015; 71:967-77. [DOI: 10.1007/s00228-015-1875-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Accepted: 05/18/2015] [Indexed: 10/23/2022]
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Pastore MN, Kalia YN, Horstmann M, Roberts MS. Transdermal patches: history, development and pharmacology. Br J Pharmacol 2015; 172:2179-209. [PMID: 25560046 PMCID: PMC4403087 DOI: 10.1111/bph.13059] [Citation(s) in RCA: 260] [Impact Index Per Article: 28.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2014] [Revised: 12/17/2014] [Accepted: 12/18/2014] [Indexed: 12/24/2022] Open
Abstract
Transdermal patches are now widely used as cosmetic, topical and transdermal delivery systems. These patches represent a key outcome from the growth in skin science, technology and expertise developed through trial and error, clinical observation and evidence-based studies that date back to the first existing human records. This review begins with the earliest topical therapies and traces topical delivery to the present-day transdermal patches, describing along the way the initial trials, devices and drug delivery systems that underpin current transdermal patches and their actives. This is followed by consideration of the evolution in the various patch designs and their limitations as well as requirements for actives to be used for transdermal delivery. The properties of and issues associated with the use of currently marketed products, such as variability, safety and regulatory aspects, are then described. The review concludes by examining future prospects for transdermal patches and drug delivery systems, such as the combination of active delivery systems with patches, minimally invasive microneedle patches and cutaneous solutions, including metered-dose systems.
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MESH Headings
- Administration, Cutaneous
- Animals
- Chemistry, Pharmaceutical/history
- Drug Carriers
- History, 15th Century
- History, 18th Century
- History, 19th Century
- History, 20th Century
- History, 21st Century
- History, Ancient
- Humans
- Pharmaceutical Preparations/administration & dosage
- Pharmaceutical Preparations/chemistry
- Pharmaceutical Preparations/history
- Technology, Pharmaceutical/history
- Technology, Pharmaceutical/methods
- Transdermal Patch/history
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Affiliation(s)
- Michael N Pastore
- School of Pharmacy and Medical Sciences, University of South AustraliaAdelaide, SA, Australia
| | - Yogeshvar N Kalia
- School of Pharmaceutical Sciences, University of Geneva & University of LausanneGeneva, Switzerland
| | - Michael Horstmann
- former Acino Pharma AG, now Independent Pharmacist (Transdermalpharma UG)Neuwied, Germany
| | - Michael S Roberts
- School of Pharmacy and Medical Sciences, University of South AustraliaAdelaide, SA, Australia
- Therapeutics Research Centre, School of Medicine, University of Queensland, Princess Alexandra HospitalBrisbane, Qld, Australia
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45
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Vasenina EE, Levin OS. [Characteristics of the clinical picture and treatment of moderate or severe Alzheimer's disease]. Zh Nevrol Psikhiatr Im S S Korsakova 2015. [PMID: 28635780 DOI: 10.17116/jnevro20151156217-25] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Alzheimer's disease (AD) is the most frequent cause of dementia and one of the most frequent disease in elderly patients. Pathomorphological data have demonstrated that AD is a sole cause in 40% of patients with dementia and in about 15-20% of cases with vascular comorbidity. We consider the evolution of cognitive and mental disorders in moderate and severe stages of AD and describe new approaches to treatment of late AD stages using high doses of cholinesterase inhibitors (in particular, a new form of rivastigmine transdermal system (15 cm2) releasing 13,3 mg of active substance per day), and combinations of cholinesterase inhibitors and memantine with non-pharmacological correction of behavioral disorders the clinical assessment of treatment efficacy. Attention is drawn to the formation of the adequate level of expectations in caregivers.
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Affiliation(s)
- E E Vasenina
- Russian Medical Academy of Postgraduate Education, Moscow
| | - O S Levin
- Russian Medical Academy of Postgraduate Education, Moscow
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Affiliation(s)
- Soo-Jung Hahn
- Department of Rehabilitation Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Korea
| | - Nam-Jong Paik
- Department of Rehabilitation Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Korea
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Amanatkar HR, Grossberg GT. Transdermal rivastigmine in the treatment of Alzheimer’s disease: current and future directions. Expert Rev Neurother 2014; 14:1119-25. [DOI: 10.1586/14737175.2014.955852] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Sadowsky CH, Micca JL, Grossberg GT, Velting DM. Rivastigmine from capsules to patch: therapeutic advances in the management of Alzheimer's disease and Parkinson's disease dementia. Prim Care Companion CNS Disord 2014; 16:14r01654. [PMID: 25667813 DOI: 10.4088/pcc.14r01654] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2014] [Accepted: 06/03/2014] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE To discuss the pharmacology, mechanism of action, and chemical properties of the cholinesterase inhibitor (ChEI) rivastigmine; to provide a rationale for transdermal delivery and supportive clinical data, along with practical guidance on rivastigmine patch use in Alzheimer's disease and Parkinson's disease dementia. DATA SOURCES Pivotal studies of rivastigmine capsules and patch were identified using PubMed and the rivastigmine US prescribing information. PubMed searches were performed in 2013 using rivastigmine as a keyword. STUDY SELECTION English-language articles related to rivastigmine considered of relevance to primary care physicians were included. DATA SYNTHESIS Pharmacologic differences exist between rivastigmine and ChEIs. Clinical studies demonstrate symptomatic efficacy of oral rivastigmine across all stages of Alzheimer's disease and mild-to-moderate Parkinson's disease dementia. However, gastrointestinal adverse events limit access to optimal therapeutic doses. Strategies that lower maximum plasma concentrations (Cmax) and prolong time to Cmax, ie, transdermal delivery, may improve tolerability. Clinical registration studies have demonstrated improved tolerability of rivastigmine 9.5-mg/24-h patch versus 6-mg twice-daily capsules in mild-to-moderate Alzheimer's disease, and a positive benefit-risk profile of 13.3-mg/24-h versus 9.5-mg/24-h patch in patients needing enhanced efficacy. Clinical data comparing 13.3-mg/24-h versus 4.6-mg/24-h patch in severe Alzheimer's disease demonstrated efficacy on cognition and activities of daily living. These data led to approval of rivastigmine patch in severe Alzheimer's disease. Transdermal delivery also has practical advantages, including simple, once-daily administration and a visual indicator of compliance. Potential application site reactions can be minimized and need not be a barrier to treatment. CONCLUSIONS In addition to practical advantages, rivastigmine patch may improve clinical outcomes throughout the course of Alzheimer's disease by providing access to high-dose efficacy without compromising tolerability.
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Affiliation(s)
- Carl H Sadowsky
- Division of Neurology, Nova Southeastern University, Fort Lauderdale, and Premiere Research Institute, Palm Beach Neurology, West Palm Beach, Florida (Dr Sadowsky); Private Practice, Marietta, Georgia (Dr Micca); Department of Neurology and Psychiatry, St Louis University School of Medicine, St Louis, Missouri (Dr Grossberg); and Novartis Pharmaceuticals Corporation, East Hanover, New Jersey (Dr Velting)
| | - Joseph L Micca
- Division of Neurology, Nova Southeastern University, Fort Lauderdale, and Premiere Research Institute, Palm Beach Neurology, West Palm Beach, Florida (Dr Sadowsky); Private Practice, Marietta, Georgia (Dr Micca); Department of Neurology and Psychiatry, St Louis University School of Medicine, St Louis, Missouri (Dr Grossberg); and Novartis Pharmaceuticals Corporation, East Hanover, New Jersey (Dr Velting)
| | - George T Grossberg
- Division of Neurology, Nova Southeastern University, Fort Lauderdale, and Premiere Research Institute, Palm Beach Neurology, West Palm Beach, Florida (Dr Sadowsky); Private Practice, Marietta, Georgia (Dr Micca); Department of Neurology and Psychiatry, St Louis University School of Medicine, St Louis, Missouri (Dr Grossberg); and Novartis Pharmaceuticals Corporation, East Hanover, New Jersey (Dr Velting)
| | - Drew M Velting
- Division of Neurology, Nova Southeastern University, Fort Lauderdale, and Premiere Research Institute, Palm Beach Neurology, West Palm Beach, Florida (Dr Sadowsky); Private Practice, Marietta, Georgia (Dr Micca); Department of Neurology and Psychiatry, St Louis University School of Medicine, St Louis, Missouri (Dr Grossberg); and Novartis Pharmaceuticals Corporation, East Hanover, New Jersey (Dr Velting)
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Moretti DV, Frisoni GB, Binetti G, Zanetti O. Comparison of the effects of transdermal and oral rivastigmine on cognitive function and EEG markers in patients with Alzheimer's disease. Front Aging Neurosci 2014; 6:179. [PMID: 25100996 PMCID: PMC4107674 DOI: 10.3389/fnagi.2014.00179] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2014] [Accepted: 07/04/2014] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Alzheimer's disease (AD) is the most common cause of dementia in older patients. Rivastigmine (RV, Exelon, Novartis), a reversible cholinesterase inhibitor, improves clinical manifestations of AD and may enhance ACh-modulated electroencephalogram (EEG) alpha frequency. This pilot study aimed to determine the effects of two formulations of RV [transdermal patch (RV-TDP) and oral capsules (TV-CP)] on alpha frequency, in particular the posterior dominant rhythm, and cognitive function [assessed by the Mini-Mental State Examination (MMSE)] in patients with AD. METHODS Subjects with AD were assigned to receive either RV-TDP 10 cm(2) or RV-CP 12 mg/day. All patients underwent EEG recordings at the beginning and end of the 18-month study period using P3, P4, O1, and O2 electrodes, each at high (10.5-13.0 Hz) and low (8.0-10.5 Hz) frequency. MMSE scores were determined at the start of the study (T0) and at three successive 6-month intervals (T1, T2, and T3). RESULTS RV-TDP administration (n = 10) maintained cognitive function as evidenced by stable MMSE scores from baseline to 18 months (21.07 ± 2.4-21.2 ± 3.1) compared with a decrease in MMSE score with RV-CP (n = 10) over 18 months [18.3 ± 3.6-13.6 ± 5.06 (adjusted for covariates p = 0.006)]. MMSE scores were significantly different between treatment groups from 6 months (p = 0.04). RV-TDP also increased the spectral power of alpha waves in the posterior region measured with electrode P3 in a significantly great percentage of patients than TV-CP from baseline to 18 months; 80% vs 30%, respectively [p = 0.025 (χ (2) test)]. CONCLUSIONS RV-TDP was associated with a greater proportion of patients with increased posterior region alpha wave spectral power and significantly higher cognitive function at 18 months, compared with RV-CP treatment. Our findings suggest that RV-TDP provides an effective long-term management option in patients with AD compared with oral RV-CP. This study is a pilot, open-label study with a clear explorative purpose and with a small number of patients. Further randomized, double-blind, placebo-controlled trial studies with a bigger sample size as well as healthy controls are needed to support these initial results.
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Affiliation(s)
- Davide V Moretti
- Scientific Institute for Research and Care of Alzheimer's and Psychiatric Diseases, San Giovanni Di Dio Fatebenefratelli Brescia, Italy
| | - Giovanni B Frisoni
- Scientific Institute for Research and Care of Alzheimer's and Psychiatric Diseases, San Giovanni Di Dio Fatebenefratelli Brescia, Italy
| | - Giuliano Binetti
- Scientific Institute for Research and Care of Alzheimer's and Psychiatric Diseases, San Giovanni Di Dio Fatebenefratelli Brescia, Italy
| | - Orazio Zanetti
- Scientific Institute for Research and Care of Alzheimer's and Psychiatric Diseases, San Giovanni Di Dio Fatebenefratelli Brescia, Italy
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Frampton JE. Rivastigmine Transdermal Patch 13.3 mg/24 h: A Review of Its Use in the Management of Mild to Moderate Alzheimer’s Dementia. Drugs Aging 2014; 31:639-49. [DOI: 10.1007/s40266-014-0197-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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