The final draft technology appraisal recommends that donepezil (Aricept), galantamine (Reminyl) and rivastigmine (Exelon) only be used in newly diagnosed patients who have moderately severe Alzheimer's disease (GP, 2 June 2006).
Professor Clive Ballard, director of research at the Alzheimer's Society, warned that the move would create an ethical dilemma for GPs expected to diagnose and keep a register of patients with mild Alzheimer's, while denying them effective treatment.
'GPs will have to deal with the day-to-day issue of telling patients they have to decline before they can have the treatment,' he said.
Recent research has shown that cognitive stimulation therapy is cost-effective for improving cognition for dementia patients.
But Professor Ballard said that this therapy was not a replacement for pharmacotherapy.
He added that the restriction on prescribing could even discourage patients with early Alzheimer's disease from presenting early, potentially damaging the GP-patient relationship.
He called on the royal colleges to advise their members about the treatment of patients with mild dementia.
'We need to debate the issue of NICE guidance versus best-practice guidelines,' he said.
But North London GP Dr Steve Iliffe, member of the NICE dementia clinical guideline group, claimed that the guidance could double the number of Alzheimer's patients receiving cholinesterase inhibitors.
The 2001 guidance recommended that treatment with the drugs could only be continued if the patient's condition improved in three months. This time limit will not apply under the new guideline.
He said: 'There will be no alternative treatment for mild Alzheimer's disease, but more people with moderate severity will be treated.'
But Dr Iliffe conceded that the decision to deny the drugs to patients with mild dementia was made on the basis of cost.
'We have to be realistic. There are small gains to be had at a very high cost,' he explained.
Br J Psych 2006; 188: 574-80
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