Efficacy of Rivastigmine for Cognitive Symptoms in Parkinson Disease With Dementia

Department of Neurology, Mayo Clinic, Scottsdale, Arizona 85259, USA.
The Neurologist (Impact Factor: 1.16). 08/2009; 15(4):234-7. DOI: 10.1097/NRL.0b013e3181a968df
Source: PubMed


Impairment of multiple neurotransmitter networks, including acetylcholine, may contribute to the cognitive impairment in patients with Parkinson disease with dementia (PDD). Therefore, cholinesterase inhibitors might improve cognitive function in PDD. On the other hand, enhancing cholinergic function could plausibly worsen features of parkinsonism.
To determine if oral cholinesterase inhibitors improve measures of cognitive outcome and are tolerated by people with PDD.
We addressed the question through the development of a critically appraised topic. Participants included consultant and resident neurologists, clinical epidemiologists, a medical librarian, and behavioral neurology and movement disorder specialists. Participants began with a structured clinical question, devised search strategies, compiled the best evidence, performed a critical appraisal, summarized the evidence, provided commentary, and declared bottom-line conclusions.
A randomized controlled trial (n = 541) showed that, compared with placebo, rivastigmine (mean, 8.6 mg/d) significantly improved scores on 2 coprimary cognitive outcome scales in PDD, including the Alzheimer disease Cooperative Study-Clinician's Global Impression of Change. When dichotomized to evaluate clinically significant benefit (moderate or marked improvement), this outcome was not significant (risk difference = 5.3%; 95% confidence interval (CI) = -1.6 to 12.1). The number needed to treat (NNT) to avoid clinically significant worsening of cognition was 10 (95% CI = 6-28). The NNT for the combined outcome of either achieving clinically significant benefit or avoiding significant worsening was 7. The numbers needed to harm for cholinergic side effects were 9 (95% CI = 5-24) for parkinsonian symptoms and 11 (95% CI = 6-32) for rivastigmine discontinuation due to any side effect.
Rivastigmine therapy for PDD is associated with significant tradeoffs in efficacy and adverse effects. Carefully monitored trials of rivastigmine may provide meaningful benefits for a minority of PDD patients.

11 Reads
  • Source
    • "PD-D patients treated with Rivastigmine displayed improved outcomes in the Alzheimer Disease Assessment Scale-Cognitive subscale, though some patients experienced increased frequency of nausea, vomiting, and tremor [59]. A Cochrane review based on this trial concluded that Rivastigmine resulted in a clinically meaningful benefit in approximately 15% of cases, with improvements in cognition and activities of daily living [60], though there are significant trade-offs between efficacy and adverse effects [61]. A more recent Cochrane review supports the use of cholinesterase inhibitors in patients with PD-D, with a positive impact on global assessment, cognitive function, behavioural disturbance, and activities of daily living; however, the evidence on the use of cholinesterase inhibitors in PD-MCI patients is limited [62]. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Mild Cognitive Impairment in Parkinson's Disease (PD-MCI) is common and may be associated with accelerated progression to dementia. Considering the importance of this emerging entity, new diagnostic criteria have recently been proposed. Early recognition and accurate classification of PD-MCI could offer opportunities for novel therapeutic interventions. This review discusses current definitions for PD-MCI, the screening tools used, the pattern of cognitive deficits observed, and the predictors of cognitive decline and transition to Parkinson's Disease Dementia. Emerging biomarkers, which may aid diagnosis, are also explored and the role of novel treatment options is considered.
    Neurology Research International 07/2013; 2013(8):576091. DOI:10.1155/2013/576091
  • Source
    • "Rivastigmine, an inhibitor of acetylcholinesterase, Fig. (10), is as of today the only drug approved for use in the treatment of cognitive deficits in PD patients [202] [203]. Other cholinesterase inhibitors, as donepezil and galantamine, have also been evaluated, but the results obtained are not convincing [198]. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Parkinson's disease is a neurodegenerative pathology which affects the dopaminergic neurons in the mesencephalon, leading to a progressive and relentless motor disability and to non-motor symptoms of different severity. The aim of this review is to summarize the features of drugs currently used in the pharmacotherapy of Parkinson's disease, with a look at their beneficial effects and limitations. Drugs acting on dopamine transmission, as L-DOPA, direct dopaminergic agonists, inhibitors for either the MAO or COMT enzymes and drugs acting on neurotransmitters other than dopamine (e.g. acetylcholine, glutamate) will be covered. Investigational drugs currently under examination for their therapeutic potential in Parkinson's disease and recent patents which may be relevant to the field will be also discussed.
    11/2010; 5(3):221-38. DOI:10.2174/157488910793362421
  • Source

    Allergy 11/2009; 65(7):925-6. DOI:10.1111/j.1398-9995.2009.02258.x · 6.03 Impact Factor
Show more