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Baryakova TH, Pogostin BH, Langer R, McHugh KJ. Overcoming barriers to patient adherence: the case for developing innovative drug delivery systems. Nat Rev Drug Discov 2023; 22:387-409. [PMID: 36973491 PMCID: PMC10041531 DOI: 10.1038/s41573-023-00670-0] [Citation(s) in RCA: 42] [Impact Index Per Article: 42.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/17/2023] [Indexed: 03/29/2023]
Abstract
Poor medication adherence is a pervasive issue with considerable health and socioeconomic consequences. Although the underlying reasons are generally understood, traditional intervention strategies rooted in patient-centric education and empowerment have proved to be prohibitively complex and/or ineffective. Formulating a pharmaceutical in a drug delivery system (DDS) is a promising alternative that can directly mitigate many common impediments to adherence, including frequent dosing, adverse effects and a delayed onset of action. Existing DDSs have already positively influenced patient acceptability and improved rates of adherence across various disease and intervention types. The next generation of systems have the potential to instate an even more radical paradigm shift by, for example, permitting oral delivery of biomacromolecules, allowing for autonomous dose regulation and enabling several doses to be mimicked with a single administration. Their success, however, is contingent on their ability to address the problems that have made DDSs unsuccessful in the past.
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Affiliation(s)
| | | | - Robert Langer
- David H. Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Kevin J McHugh
- Department of Bioengineering, Rice University, Houston, TX, USA.
- Department of Chemistry, Rice University, Houston, TX, USA.
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Polymeric Microneedles for Transdermal Delivery of Rivastigmine: Design and Application in Skin Mimetic Model. Pharmaceutics 2022; 14:pharmaceutics14040752. [PMID: 35456586 PMCID: PMC9028500 DOI: 10.3390/pharmaceutics14040752] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 03/22/2022] [Accepted: 03/25/2022] [Indexed: 12/20/2022] Open
Abstract
In the last years, microneedles (MNs) have been considered a valuable, painless, and minimally invasive approach for controlled transdermal drug delivery (TDD). Rivastigmine (RV), a drug administered to patients suffering from dementia, is currently delivered by oral or transdermal routes; however, both present limitations, mainly gastrointestinal adverse symptoms or local skin irritation and drug losses, respectively, for each route. Given this, the objective of the present work was to develop and evaluate the potential of polymeric MNs for RV transdermal delivery in a controlled manner. Polymeric MNs with two needle heights and different compositions were developed with calcein as a fluorescent model molecule. Morphology and mechanical characterisation were accessed. Skin permeation experiments showed the ability of the devices to deliver calcein and confirmed that the arrays were able to efficiently pierce the skin. To obtain a new TDD anti-dementia therapeutic solution, RV was loaded in 800 µm polymeric MNs of alginate and alginate/k-carrageenan MNs. In the presence of RV, the MN’s morphology was maintained; however, the presence of RV influenced the compression force. Skin permeation studies revealed that RV-loaded MNs allowed a more efficient controlled release of the drug than the commercial patch. In vivo, skin irritation tests in rabbits revealed that the developed MNs were innocuous upon removal, in contrast with the evidence found for Exelon®, the commercial patch, which caused slight mechanical damage to the skin. The herein-produced MNs demonstrated a more controlled release of the drug, being the more suitable option for the transdermal delivery of RV.
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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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Badcock JC, Larøi F, Kamp K, Kelsall-Foreman I, Bucks RS, Weinborn M, Begemann M, Taylor JP, Collerton D, O’Brien JT, El Haj M, Ffytche D, Sommer IE. Hallucinations in Older Adults: A Practical Review. Schizophr Bull 2020; 46:1382-1395. [PMID: 32638012 PMCID: PMC7707075 DOI: 10.1093/schbul/sbaa073] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Older adults experience hallucinations in a variety of social, physical, and mental health contexts. Not everyone is open about these experiences, as hallucinations are surrounded with stigma. Hence, hallucinatory experiences in older individuals are often under-recognized. They are also commonly misunderstood by service providers, suggesting that there is significant scope for improvement in the training and practice of professionals working with this age group. The aim of the present article is to increase knowledge about hallucinations in older adults and provide a practical resource for the health and aged-care workforce. Specifically, we provide a concise narrative review and critique of (1) workforce competency and training issues, (2) assessment tools, and (3) current treatments and management guidelines. We conclude with a brief summary including suggestions for service and training providers and future research.
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Affiliation(s)
- Johanna C Badcock
- School of Psychological Science, University of Western Australia, Perth, Australia
- Perth Voices Clinic, Murdoch, Australia
- To whom correspondence should be addressed; School of Psychological Science, The University of Western Australia, 35 Stirling Highway, Perth, 6009; tel: 0423123665, fax: 61864881006, e-mail:
| | - Frank Larøi
- Department of Biological and Medical Psychology, University of Bergen, Bergen, Norway
- Psychology and Neuroscience of Cognition Research Unit, University of Liege, Liege, Belgium
- Norwegian Centre of Excellence for Mental Disorders Research, University of Oslo, Oslo, Norway
| | - Karina Kamp
- Department of Psychology and Behavioural Science, Aarhus University, Aarhus C, Denmark
| | | | - Romola S Bucks
- School of Psychological Science, University of Western Australia, Perth, Australia
| | - Michael Weinborn
- School of Psychological Science, University of Western Australia, Perth, Australia
| | - Marieke Begemann
- Department of Biomedical Sciences of Cells and Systems, University Medical Center, Rijks Universiteit Groningen (RUG), Groningen, The Netherlands
| | - John-Paul Taylor
- Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK
| | - Daniel Collerton
- Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK
| | - John T O’Brien
- Department of Psychiatry, University of Cambridge, Cambridge, UK
| | - Mohamad El Haj
- Laboratoire de Psychologie des Pays de la Loire (LPPL-EA 4638), Nantes Université, Univ Angers, Nantes, France
| | - Dominic Ffytche
- Department of Old Age Psychiatry, Institute of Psychiatry, Psychology and Neuroscience, King’s College, London, UK
| | - Iris E Sommer
- Rijks Universiteit Groningen (RUG), Department of Biomedical Sciences of Cells and Systems, University Medical Center Groningen, The Netherlands
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Blesa R, Toriyama K, Ueda K, Knox S, Grossberg G. Strategies for Continued Successful Treatment in Patients with Alzheimer's Disease: An Overview of Switching Between Pharmacological Agents. Curr Alzheimer Res 2019; 15:964-974. [PMID: 29895249 PMCID: PMC6142408 DOI: 10.2174/1567205015666180613112040] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Revised: 05/11/2018] [Accepted: 06/07/2018] [Indexed: 02/07/2023]
Abstract
Introduction: Alzheimer’s disease (AD) is the most common cause of dementia, characterized by a progressive decline in cognition and function. Current treatment options for AD include the cholines-terase inhibitors (ChEIs) donepezil, galantamine, and rivastigmine, as well as the N-methyl-D-aspartate receptor antagonist memantine. Treatment guidelines recommend the use of ChEIs as the standard of care first-line therapy. Several randomized clinical studies have demonstrated the benefits of ChEIs on cogni-tion, global function, behavior and activities of daily living. However, patients may fail to achieve sus-tained clinical benefits from ChEIs due to lack/loss of efficacy and/or safety, tolerability issues, and poor adherence to the treatment. The purpose of this review is to explore the strategies for continued successful treatment in patients with AD. Methods: Literature search was performed for articles published in PubMed and MEDLINE, using pre-specified search terms. Articles were critically evaluated for inclusion based on their titles, abstracts, and full text of the publication. Results and Conclusion: The findings of this review indicate that dose up-titration and switching between ChEIs may help to improve response to ChEI treatment and also address issues such as lack/loss of effica-cy or safety/tolerability in patients with AD. However, well-designed studies are needed to provide robust evidence.
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Affiliation(s)
- Rafael Blesa
- Memory Unit, Department of Neurology, IIB Sant Pau, Hospital de la Santa Creu i Sant Pau, Universitat Autonoma de Barcelona, Barcelona, Spain
| | | | | | - Sean Knox
- Novartis Pharma AG, Basel, Switzerland
| | - George Grossberg
- Department of Psychiatry & Behavioral Neuroscience, Saint Louis University School of Medicine, St. Louis, MO, United States
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Affiliation(s)
- Silvia Duong
- Herzl Family Medicine Centre (Duong), Jewish General Hospital, Montreal, Quebec
| | - Tejal Patel
- Herzl Family Medicine Centre (Duong), Jewish General Hospital, Montreal, Quebec
| | - Feng Chang
- Herzl Family Medicine Centre (Duong), Jewish General Hospital, Montreal, Quebec
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Zhang ZX, Hong Z, Wang YP, He L, Wang N, Zhao ZX, Zhao G, Shang L, Weisskopf M, Callegari F, Strohmaier C. Rivastigmine Patch in Chinese Patients with Probable Alzheimer's disease: A 24-week, Randomized, Double-Blind Parallel-Group Study Comparing Rivastigmine Patch (9.5 mg/24 h) with Capsule (6 mg Twice Daily). CNS Neurosci Ther 2016; 22:488-96. [PMID: 27012596 DOI: 10.1111/cns.12521] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Revised: 01/08/2016] [Accepted: 01/08/2016] [Indexed: 02/05/2023] Open
Abstract
AIMS To compare the once-daily rivastigmine patch 9.5 mg/24 h (10 cm(2) ) versus twice-daily capsule (12 mg/day) in Chinese patients with probable Alzheimer's disease (AD) (mini-mental state examination [MMSE] scores of 10-20). METHODS The primary objective was to demonstrate the noninferiority of patch to capsule in Alzheimer's Disease Assessment Scale-Cognitive subscale (ADAS-Cog) change from baseline to 24 week. Secondary endpoints included cognition (MMSE), overall clinical response (Alzheimer's Disease Cooperative Study-Clinical Global Impression of Change [ADCS-CGIC]), activities of daily living (Alzheimer's Disease Cooperative Study-Activities of Daily Living [ADCS-ADL]), behavior (Neuropsychiatric Inventory [NPI-12]), and safety. RESULTS Similar cognitive improvement was observed in both patch (n = 248) and capsule (n = 253) groups. Statistical noninferiority for ADAS-Cog was not established (least-square means difference, 0.1; 95% confidence interval, -1.2; 1.5). Considering all efficacy parameters into account, both treatments showed similar performance at Week 24. Treatment-related adverse events (AEs) were lower for patch (39.7%) compared with capsule (49.8%). Application site pruritus was reported in 10.9% of patients receiving patch; most cases were mild. Gastrointestinal AEs including nausea, vomiting, and diarrhea occurred less frequently in the patch group (15.8% vs. 28.7%). CONCLUSION Rivastigmine patch 9.5 mg/24 h is effective and well tolerated in Chinese patients with probable AD.
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Affiliation(s)
| | - Zhen Hong
- Huashan Hospital Affiliated to Fudan University, Shanghai, China
| | - Yan-Ping Wang
- No 2 Hospital affiliated to Guangzhou Medical University, Guangzhou City, China
| | - Li He
- Department of Neurology, West China Hospital of Sichuan University, Chengdu, China
| | - Ning Wang
- Department of Neurology, First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | | | | | - Lan Shang
- Huilongguan Hospital, Beijing, China
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Gauthier S, Robillard A, Cohen S, Black S, Sampalis J, Colizza D, de Takacsy F, Schecter R. Real-life effectiveness and tolerability of the rivastigmine transdermal patch in patients with mild-to-moderate Alzheimer's disease: the EMBRACE study. Curr Med Res Opin 2013; 29:989-1000. [PMID: 23647369 DOI: 10.1185/03007995.2013.802230] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To assess the real-life effectiveness and tolerability of the rivastigmine transdermal patch in patients with mild-to-moderate Alzheimer's disease (AD) in Canada. RESEARCH DESIGN AND METHODS Eighteen-month observational, prospective, multi-center, open-label study conducted on AD patients with Standardized Mini-Mental State Examination (SMMSE) score of 10-26 and Global Deterioration Scale (GDS) score of 4-6. Patients were treated with the rivastigmine transdermal patch (Exelon patch*) 5 cm² (4.6 mg/24 hours) or 10 cm² (9.5 mg/24 hours), once daily. MAIN OUTCOME MEASURES Primary outcome was change in SMMSE from baseline to 18 months. Secondary outcomes included change in SMMSE at 6 and 12 months and change in GDS, Assessment of Patient Ability (APA-C), Overall Patient Assessment Rating (OPAR), caregiver-reported compliance and treatment satisfaction at 6, 12, and 18 months. RESULTS Among the 1204 patients enrolled, 969 were included in the ITT analysis. Mean (SD) age was 80.2 (8.00) years, disease duration was 0.6 (1.26) years, 62.0% of patients were women, 80.4% were living in the community, and 69.3% were treatment naïve. Mean (SD) baseline SMMSE and GDS scores were 21.8 (3.98) and 4.2 (0.61), respectively. Over 18 months of treatment there were no clinically significant changes in SMMSE and GDS. The majority of patients showed improvement or no change in GDS, APA-C and OPAR over 18 months. The proportion with reported improvement in GDS, APA-C and OPAR was higher than the proportion that deteriorated. Compliance improved from baseline to 18 months and for 88.2% of patients caregivers preferred the transdermal patch to oral medications. CONCLUSIONS The rivastigmine transdermal patch is effective in maintaining cognitive function over 18 months of treatment in patients with mild-to-moderate AD. The safety profile was comparable to the data in the Canadian product monograph. Lack of a comparator group is a potential limitation of the study.
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Affiliation(s)
- Serge Gauthier
- McGill Centre for Studies of Aging, Douglas Hospital, Montreal, Quebec, Canada.
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Di Stefano A, Iannitelli A, Laserra S, Sozio P. Drug delivery strategies for Alzheimer's disease treatment. Expert Opin Drug Deliv 2011; 8:581-603. [PMID: 21391862 DOI: 10.1517/17425247.2011.561311] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Current Alzheimer's disease (AD) therapy is based on the administration of the drugs donepezil, galantamine, rivastigmine and memantine. Until disease-modifying therapies become available, further research is needed to develop new drug delivery strategies to ensure ease of administration and treatment persistence. AREAS COVERED In addition to the conventional oral formulations, a variety of drug delivery strategies applied to the treatment of AD are reviewed in this paper, with a focus on strategies leading to simplified dosage regimens and to providing new pharmacological tools. Alternatives include extended release, orally disintegrating or sublingual formulations, intranasal or short- and long-acting intramuscular or transdermal forms, and nanotechnology-based delivery systems. EXPERT OPINION The advent of new research on molecular mechanisms of AD pathogenesis has outlined new strategies for therapeutic intervention; these include the stimulation of α-secretase cleavage, the inhibition of γ-secretase activity, the use of non-steroidal anti-inflammatory drugs, neuroprotection based on antioxidant therapy, the use of estrogens, NO synthetase inhibitors, and natural agents such as polyphenols. Unfortunately, these compounds might not help patients with end stage AD, but might hopefully slow or stop the disease process in its early stage. Nanotechnologies may prove to be a promising contribution in future AD drug delivery strategies, in particular drug carrier nano- or microsystems, which can limit the side effects of anti-Alzheimer drugs.
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Affiliation(s)
- Antonio Di Stefano
- G d'Annunzio University, School of Pharmacy, Department of Drug Sciences, Via dei Vestini 31, 66100 Chieti, Italy.
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