March 7, 2005
by staff reporter

Psychiatrists are opposing plans to end the prescribing of some drugs to treat Alzheimer's disease.

Donepezil, rivastigmine, galantamine, and memantine should no longer be prescribed on the NHS to treat Alzheimer's, says new draft guidance from the National Institute for Clinical Excellence (NICE).

NICE, the NHS prescribing watchdog for England and Wales, has retracted previous guidance issued in 2001 and which said that these drugs should be prescribed for Alzheimer's disease - after reviewing latest evidence on efficacy and cost effectiveness.

But The Royal College of Psychiatrists says it "strongly disagrees' with NICE's decision that the drugs are not cost-effective.

Professor Susan Benbow, chair of the royal college's old age psychiatry faculty said: "Whilst these drugs do not provide a cure, or affect the underlying disease process, they can bring substantial benefit to many patients.

"On average, drugs for Alzheimer's disease delay the decline associated with the illness by six-nine months.

"This is a degree of benefit which clinicians, patients and carers value.

"The prescription of these drugs has been strongly supported by consumer groups such as the Alzheimer's Society. In our opinion, this degree of improvement in a devastating and progressive illness for which no other treatments are available is well worth the modest costs of the drugs."

Comments on the proposals, released last week, are being accepted until 21 March, and final guidance is expected to come into force in July this year.

The NICE assessment group says that, although donepezil, rivastigmine, and galantamine (collectively known as anticholinesterase inhibitors) have proved gains in cognitive and global scales compared with placebo in people with mild to moderate Alzheimer's disease, there is "limited and largely inconclusive" evidence on outcomes that are important to patients and carers, such as quality of life and time to admission to a nursing home.

NICE considered a range of published and unpublished trials, as well as submissions from drug manufacturers and professional and support organisations, when developing its draft guidelines.

However, it said that many of the randomised controlled trials it reviewed were of "mixed" quality.

The group also suspected "selection bias, measurement bias and attrition bias in a number of the reviewed studies."

Its own cost effectiveness calculations put the group of drugs beyond the means of the NHS, it said.

When it adjusted costs to take account of the benefits attributed to these drugs NICE estimated that donepezil, rivastigmine, and galantamine had a "cost per quality adjusted life year gained" of £48 000, £32 000, and £38 000 respectively; the corresponding cost for memantine was between £37 000 and £53 000.

If its proposed recommendations are adopted the NHS would make a saving of £15m in the first year, £45m in the second, and more than £60m in the third.

However, Prof Benbow said the economic models used to justify the withdrawal of the drugs were flawed.

"They rely on using QALY's, (quality adjusted life years), which make a variety of unknown and untested assumptions about how quality of life relates to dementia severity," she said.

Within the fortnight NICE has also issued for a second consultation its clinical guidelines for depression in children, and has issued its guidelines for obsessive compulsive disorder for a first consultation.

NICE

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