Concerns about cholinesterase inhibitor recommendations
MichaelValenzuela, Professor of Regenerative Neuroscience, University of Sydney
PerminderSachdev, Professor of Neuropsychiatry, University of New South Wales
HenryBrodaty, Professor of Ageing and Mental Health, University of New South Wales
Submitted January 18, 2018
We have some concerns about the recommendations on cholinesterase inhibitors in the recent guidelines on mild cognitive impairment (MCI). [1] Evidence in the guidelines, and in systematic reviews, [2-4] clearly show that cholinesterase inhibitors have no reliable benefit on cognition and do not reduce progression to dementia. At the same time, patients are exposed to risk: “side effects... are common, including gastrointestinal symptoms and cardiac concerns.” [1] It is, therefore, curious that the message to practitioners is equivocal. They “may choose” not to use these medicines (recommendation B3a), or choose to actively prescribe them after, “first discuss[ing] with the patient the fact this is... not currently backed by empirical evidence” (recommendation B3b). [1] This is the first instance we recall of a learned academy legitimizing prescription of a class of drugs recognized to be ineffective. Given the guidelines’ potential for influence, we are deeply concerned that patients--who often are ill-equipped to make judgments of this kind--may be unnecessarily exposed to harm, and health care systems to needless cost. More generally, we are anxious to avoid a precedent for evidence being viewed as "optional" in clinical decision-making. We call upon the AAN and authors to retract recommendation B3b and rewrite B3a to plainly recommend against use of cholinesterase inhibitors in MCI.
1. Petersen RC, Lopez O, Armstrong MJ, et al. Practice guideline update summary: Mild cognitive impairment: Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology. Neurology 2018;90:126-135.
2. Russ TC, Morling JR. Cholinesterase inhibitors for mild cognitive impairment. Cochrane Database Syst Rev 2012:CD009132.
3. Cooper C, Li R, Lyketsos C, Livingston G. Treatment for mild cognitive impairment: systematic review. Br J Psychiatry 2013;203:255-264.
4. Fink HA, Jutkowitz E, McCarten JR, et al. Pharmacologic Interventions to Prevent Cognitive Decline, Mild Cognitive Impairment, and Clinical Alzheimer-Type Dementia: A Systematic Review. Ann Intern Med 2018;168:39-51.
We have some concerns about the recommendations on cholinesterase inhibitors in the recent guidelines on mild cognitive impairment (MCI). [1] Evidence in the guidelines, and in systematic reviews, [2-4] clearly show that cholinesterase inhibitors have no reliable benefit on cognition and do not reduce progression to dementia. At the same time, patients are exposed to risk: “side effects... are common, including gastrointestinal symptoms and cardiac concerns.” [1] It is, therefore, curious that the message to practitioners is equivocal. They “may choose” not to use these medicines (recommendation B3a), or choose to actively prescribe them after, “first discuss[ing] with the patient the fact this is... not currently backed by empirical evidence” (recommendation B3b). [1] This is the first instance we recall of a learned academy legitimizing prescription of a class of drugs recognized to be ineffective. Given the guidelines’ potential for influence, we are deeply concerned that patients--who often are ill-equipped to make judgments of this kind--may be unnecessarily exposed to harm, and health care systems to needless cost. More generally, we are anxious to avoid a precedent for evidence being viewed as "optional" in clinical decision-making. We call upon the AAN and authors to retract recommendation B3b and rewrite B3a to plainly recommend against use of cholinesterase inhibitors in MCI.
1. Petersen RC, Lopez O, Armstrong MJ, et al. Practice guideline update summary: Mild cognitive impairment: Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology. Neurology 2018;90:126-135.
2. Russ TC, Morling JR. Cholinesterase inhibitors for mild cognitive impairment. Cochrane Database Syst Rev 2012:CD009132.
3. Cooper C, Li R, Lyketsos C, Livingston G. Treatment for mild cognitive impairment: systematic review. Br J Psychiatry 2013;203:255-264.
4. Fink HA, Jutkowitz E, McCarten JR, et al. Pharmacologic Interventions to Prevent Cognitive Decline, Mild Cognitive Impairment, and Clinical Alzheimer-Type Dementia: A Systematic Review. Ann Intern Med 2018;168:39-51.
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