The clinical and cost-effectiveness of donepezil, rivastigmine, galantamine and memantine for Alzheimer s diseaseSouthampton Health Technology Assessments Centre, Wessex Institute for Health Research and Development, University of Southampton, UKAlzheimer s disease (AD) is the most common cause of dementia and is characterised by an insidious onset and slow deterioration in cognition, functional ability (e.g. activities of daily living) and behaviour and mood. AD prevalence rises with increasing age and the estimated prevalence of AD for a standard primary care trust with a population of 200,000 is approximately 1100. Current service involves a wide range of agencies. In 2001, the National Institute for Health and Clinical Excellence (NICE) recommended that cholinesterase inhibitors (donepezil, rivastigmine, galantamine) should be offered to patients with mild to moderate AD under a number of conditions. Patients with more severe AD may benefit from memantine but there is currently no guidance on its use.Nine published economic evaluations of donepezil and the industry submission were included, together with two published abstracts. The literature is dominated by industry-sponsored cost-effectiveness studies and the studies identified report varied methodology and results. There are concerns over the dominant use of mini-mental state examination (MMSE) to consider disease progression, costs and outcomes in the published cost-effectiveness studies, as it has limitations for defining disease severity and also in the modelling of disease progression in AD. From a UK perspective, of three UK studies, two report donepezil as not cost-effective, whereas a third study reports an additional cost ( 1996) of between 1200 and 7000 per year in a non-severe AD health state (concerns over these estimates are raised, suggesting that they may underestimate the true cost-effectiveness of donepezil).
