What is the recommended treatment and dosage for mild to moderate Alzheimer's disease using Aricept (donepezil)?

Donepezil Treatment for Mild to Moderate Alzheimer's Disease

For mild to moderate Alzheimer's disease, donepezil (Aricept) should be initiated at 5 mg once daily in the evening, with a potential increase to 10 mg once daily after 4-6 weeks if well tolerated. 1

Dosing Protocol

Initial Dosing

• Start with 5 mg once daily in the evening, just prior to retiring
• Can be taken with or without food
• Administer as a single evening dose 1

Dose Titration

• Maintain 5 mg daily dose for 4-6 weeks to assess tolerability
• If well tolerated, increase to 10 mg once daily (maximum recommended dose for mild to moderate Alzheimer's disease) 1
• Rapid dose escalation can lead to increased side effects 2

Efficacy and Monitoring

Donepezil provides modest but significant benefits in:

• Cognitive function
• Global clinical function
• Activities of daily living
• Behavioral symptoms 2

Expected Benefits

• Improvement of 1.9-2.9 points on the ADAS-Cog scale at 24 weeks compared to placebo 3
• Modest improvement or stabilization rather than dramatic improvement 2
• Delay in nursing home placement with long-term use 4

Monitoring Response

• Evaluate beneficial response after 6-12 months of treatment through:
  • Physician assessment
  • Caregiver reports
  • Neuropsychological testing
  • Functional changes 2

Side Effects and Management

Common Side Effects

• Nausea, vomiting, diarrhea (most common)
• Insomnia, muscle cramps, fatigue, anorexia 2, 1

Side Effect Management

• Side effects are dose-related
• Can be reduced by taking medication with food
• Gradual dose titration helps minimize adverse effects 2

When to Consider Discontinuation

Consider discontinuation if:

• Side effects develop and don't resolve
• Adherence is poor
• Continued deterioration at pre-treatment rate after 6-12 months of treatment 2

Special Considerations

Hepatic Safety

• Unlike tacrine, donepezil has no significant hepatotoxicity
• No dose adjustment needed for patients with mild to moderate hepatic disease
• No routine liver function monitoring necessary for most patients without pre-existing liver disease 2
• For patients with pre-existing liver disease, monitor liver function tests monthly 2

Drug Interactions

• Potential to interfere with anticholinergic medications
• Synergistic effects possible with succinylcholine and similar neuromuscular blocking agents 1
• Caution advised in patients with bradycardia 4

Important Caveats

• The 23 mg tablet (used for moderate to severe Alzheimer's) should not be split, crushed, or chewed 1
• Inadequate trial duration (less than 6 months) can lead to inaccurate assessment of benefit 2
• While higher doses (15-20 mg) have been studied, they are not FDA-approved for mild to moderate Alzheimer's disease and may increase side effects 5

Donepezil provides modest cognitive and functional benefits for patients with mild to moderate Alzheimer's disease, with a favorable safety profile compared to earlier medications in its class. The standard dosing protocol with careful monitoring provides the best balance of efficacy and tolerability.