Acetylcholinesterace Inhibitors – Clinical Pearls, Common Mistakes

The acetylcholinesterace inhibitors are used almost exclusively for dementia.  Here’s a few clinical pearls and common mistakes that I’ve seen with them.

  1. GI symptoms – Diarrhea, nausea, and vomiting are common adverse effects.  Be on the lookout for these symptoms and corresponding medications that may treat these symptoms (Lomotil, loperamide, Zofran, PPI’s, etc.).
  2. With the GI symptoms also comes the possibility of weight loss.  Acetylcholinesterace inhibitors are one of the most common medication causes of weight loss in the elderly.  Megace, Remeron and Marinol are common medication additions that I’ve seen that should prompt you to look at a patients medication regimen.
  3. Occasionally these medications can contribute to insomnia.  Anecdotally, switching the dosing to the morning may potentially help with this, but doesn’t always work.
  4. I most commonly see Aricept (donepezil) used in this class.  There is a patch formulation of rivastigmine, but obviously with that comes significant expense.
  5. Acetylcholinesterace inhibitors will not reverse or cure dementia.  This is a common misconception with patients/caregivers who anticipate that their loved one’s cognition will improve.
  6. Assessing for anticholinergics is very important prior to initiating dementia medications. Anticholinergics (especially non-selective) directly oppose the action of acetylcholinesterace inhibitors and can contribute to drug induced dementia.

What else would you add to this list?

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  1. grant cleveland, pharmd

    I would add bradycardia to your list. Side effects in general more pronounced at the higher doses Aricept 20mg or 23mg.

  2. Daniel

    I like to encourage patients to take donepezil at bedtime, not so much due to drowsiness, but primarily to avoid nausea by sleeping through it. (I learned this neat pearl from RxPrep when preparing for boards a few years ago).


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Written By Eric Christianson

May 11, 2016

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