Donepezil Dosing Schedule Recommendations
Donepezil should be taken once daily in the evening, just prior to retiring, with a starting dose of 5 mg that can be increased to 10 mg after 4-6 weeks if needed. 1
Standard Dosing Protocol
- Donepezil is designed for once-daily administration, not twice daily dosing 2, 1
- The recommended starting dose is 5 mg administered once per day in the evening, just prior to retiring 1
- After 4-6 weeks on the 5 mg dose, the dose can be increased to 10 mg per day if clinically indicated 1, 3
- The medication can be taken with or without food 1
Morning vs. Evening Administration
- While the FDA label recommends evening administration, the American Geriatrics Society suggests morning administration may be preferable for some patients to minimize sleep disturbances 2
- If a patient experiences sleep disturbances with evening dosing, switching to morning administration may improve sleep quality while maintaining effectiveness 2
Dose-Related Side Effects
- Gastrointestinal side effects are dose-dependent, with higher incidence at 10 mg compared to 5 mg 4, 5
- Common adverse effects include:
Special Dosing Considerations
- For patients with moderate to severe Alzheimer's disease, the maximum recommended dosage can be increased to 23 mg per day, but only after being on 10 mg daily for at least 3 months 1
- Higher doses (23 mg) have not shown greater benefits than 10 mg but do have higher rates of adverse events 6
- For patients with severe renal impairment, dose adjustment may be necessary 2
Practical Administration Tips
- Gastrointestinal side effects typically occur within the first 2 weeks of treatment and resolve within the first month for most patients 3
- The 23 mg tablet should not be split, crushed, or chewed 1
- Withdrawal rates due to adverse events ranged from 0% to 57% in treatment groups compared to 0% to 20% in placebo groups 4
- Monitoring for weight loss is important as anorexia has the highest relative risk among side effects 4, 5
Clinical Pitfalls to Avoid
- Avoid rapid dose escalation; the recommended 4-6 week period before increasing from 5 mg to 10 mg helps minimize gastrointestinal side effects 1, 3
- Unlike some other cholinesterase inhibitors, donepezil does not cause hepatotoxicity and does not require liver function monitoring 3
- Be aware that donepezil may exaggerate succinylcholine-type muscle relaxation during anesthesia due to its cholinesterase inhibition 1
- Monitor for bradycardia or heart block, especially in patients with underlying cardiac conduction abnormalities 1