By John Schieszer, Medical Tribune News Service.
VANCOUVER, BRITISH COLUMBIA -- Some Alzheimer's disease experts
now say the best approach to combating the disease is to hit hard
and hit early.
They are advocating ``a cocktail'' approach, using a combination
of three or four different types of medication for patients in the
early stages of the disease or even for patients with just mild
cognitive impairment who don't meet the criteria for Alzheimer's
disease (AD).
``This is the trend,'' said Dr. George Grossberg, who is a
professor of psychiatry at St. Louis University School of Medicine.
``All physicians are able to do this. The problem is that there is
an educational gap. So it is our role as geriatric psychiatrists to
educate the primary care physicians so more of them are doing
this.''
Currently, he said many primary care physicians are not taking
this approach in the management of their patients who have
mild-to-moderate AD. But Grossberg hopes that will start to change.
Speaking at the Ninth International Congress of the
International Psychogeriatric Association (IPA) here on Aug. 17,
Grossberg explained that this approach involves daily treatment
with a cholinesterase inhibitor (a class of drugs used to treat
Alzheimer's disease), vitamin E, and a nonsteroidal
anti-inflammatory drug (NSAID), such as ibuprofen, or a COX-2
inhibitor, such as Celebrex or Vioxx; both NSAIDs and COX-2
inhibitors are widely used to treat the pain and inflammation of
arthritis. In women, the addition of estrogen replacement therapy
is also recommended.
``Starting early and staying on these drugs long-term if you
have the disease, at least in my estimation, is definitely the way
to go, until something else comes along. There is no doubt about
it,'' said Grossberg.
He compared this new approach to treating AD to the combination
therapy used with good results in the treatment of HIV/AIDS. Once a
diagnosis is made, patients are immediately put on a daily regimen
of medications and then they are closely monitored. Doses and types
of medications are tailored to each individual patient.
There are now three marketed cholinesterase inhibitors (tacrine,
donepezil and rivastigmine) and two others (galantamine and
metrifonate) that are expected to receive FDA approval over the
next 12 to 24 months. There are also new types of designer
estrogens or SERMS (selective estrogen receptor modulators). All of
these medications offer dozens of different treatment strategies.
``As with AIDS, neither of these two cocktail approaches can
halt disease progression absolutely but may moderate progression.
They improve quality of life and may buy people more quality
time,'' said Grossberg. ``That is where we are now.''
Currently, there are SERMS going into clinical trials that are
more selective for improving brain function. Grossberg said for
now, though, it is important that physicians begin hormone
replacement therapy in women who have mild-to-moderate AD. Both men
and women with AD they should begin ``a cocktail'' approach that
includes a cholinesterase inhibitor.
``For now the important thing is to make sure that
post-menopausal women are on some form of hormone replacement
therapy. It can be conjugated estrogen alone, or if they don't
tolerate that, combining it with conjugated estrogen with
progesterone. There are a number of different combinations
available,'' said Grossberg.
Some primary care physicians say this proposed regimen for AD
patients makes sense and although not proven may be well worth the
cost and trouble. Dr. David Parks, who is in a private practice
with a large number of geriatric patients, said for some of his
patients it will be an approach they are anxious to try.
``While all the data certainly are not in, multiple drug therapy
for Alzheimer's disease is an intriguing concept,'' said Parks, who
is also clinical instructor of medicine at Washington University
School of Medicine. ``This one of the most frustrating areas of
medicine for both patient and physician and any treatment that may
help, even if based only on theory, is welcome. We have to make
attempts at treating this debilitating disease.''
