Craig I. Coleman, PharmD, and Victoria L. Baczek, PharmD Candidate
JY is a 75-year-old man who was diagnosed with mild Alzheimer’s disease (AD) 1 week ago with a Mini Mental Status Exam (MMSE) score of 19. His wife, PY, comes to the pharmacy with her husband’s prescription for donepezil (Aricept), but she believes the doctor made a mistake. She recalls seeing an advertisement for a medication named memantine (Namenda) for use in the treatment of AD. PY asks the pharmacist why the doctor wrote a prescription for donepezil and not memantine.
How should the pharmacist respond to PY?
Answer: Case One
The treatment of AD is based on a patient’s stage of cognitive decline. Various mental status examinations, such as the MMSE, are used in practice to diagnose and monitor a patient’s disease course. The MMSE is an 11-item test with a maximum score of 30 that quantifies a patient’s orientation, registration, attention, calculation, recall, and language. Mild cognitive decline is classified by an MMSE score of >18, moderate cognitive decline as a score of 10 to 18, and severe cognitive decline as a score of <10.
Medications used to treat the cognitive symptoms of AD include the cholinesterase inhibitors donepezil, rivastigmine (Exelon), and galantamine (Razadyne), and the N-methyl-D-aspartate receptor antagonist memantine. Donepezil is FDA-approved to treat all stages of AD, rivastigmine and galantamine are approved to treat mild to moderate stages, and memantine is approved to treat moderate to severe stages. Current treatment guidelines recommend that cholinesterase inhibitors be offered to patients with mild to moderate AD.
The pharmacist should reassure PY that donepezil is an appropriate medication considering her husband’s MMSE score, the drug’s approved indication, and AD treatment guidelines.
Concomitant Obsessive-Compulsive and Major Depressive Disorders
FA is a 19-year-old woman who was just diagnosed with both obsessive-compulsive disorder (OCD) and major depressive disorder (MDD). Her psychiatrist prescribed her the selective-serotonin reuptake inhibitor (SSRI) fluoxetine (Prozac) 20 mg once daily in the morning. She is also actively undergoing cognitive behavior therapy (CBT). FA comes to the pharmacy to pick up her prescription and asks if she really needs to take the fluoxetine prescribed to her.
How should the pharmacist counsel FA?
Answer: Case Two
According to current treatment guidelines, both serotonin reuptake inhibitors (SRIs) and CBT are reasonable first line therapies for the treatment of OCD. Combination therapy with both an SRI and CBT is recommended when patients have an unsatisfactory response to monotherapy, a cooccurring psychiatric condition for which SRIs are effective (such as FA’s MDD), or a desire to limit the duration of drug therapy. To date, 5 SRIs have been approved by the FDA for the treatment of OCD, including clomipramine (Anafranil), fluoxetine, fluvoxamine (Luvox), paroxetine (Paxil), and sertraline (Zoloft). Because SSRIs have fewer troublesome side effects than clomipramine, they are preferred for the initial pharmacologic treatment of OCD. Furthermore, guidelines suggest that all SSRIs indicated for OCD treatment appear equally effective; thus, prescription of fluoxetine 20 mg (the appropriate starting dose for both the treatment of OCD and MDD) along with CBT appears appropriate.
FA should also be counseled that she may not experience improvement in her OCD and/or MDD until 4 to 6 weeks after starting the medication, and that some patients experience little improvement until 10 to 12 weeks of treatment.
Dr. Coleman is an associate professor of pharmacy practice and director of the pharmacoeconomics and outcomes studies group at the University of Connecticut School of Pharmacy. Ms. Baczek is a PharmD candidate at the University of Connecticut School of Pharmacy.