From the Guidelines
Memantine and rivastigmine should be discontinued in dementia patients who have been on the medication for over 12 months if there has been a clinically meaningful worsening of dementia, no clinically meaningful benefit was observed, the individual has severe or end-stage dementia, development of intolerable side effects, or poor medication adherence. This recommendation is based on the most recent and highest quality study, the 5th Canadian Consensus Conference on the Diagnosis and Treatment of Dementia 1.
When considering discontinuation, several factors should be taken into account, including:
- Clinically meaningful worsening of dementia, as reflected in changes in cognition, functioning, or global assessment over the past 6 months
- No clinically meaningful benefit observed at any time during treatment
- Severe or end-stage dementia, characterized by dependence in most basic activities of daily living, inability to respond to environment, or limited life expectancy
- Development of intolerable side effects, such as severe nausea, vomiting, weight loss, anorexia, falls, confusion, dizziness, or falls
- Poor medication adherence that precludes safe ongoing use of the medication or inability to assess the effectiveness of the medication
Discontinuation of memantine and rivastigmine should be done gradually, with a dose reduction by 50% every 4 weeks until the initial starting dose is obtained, and then discontinued after 4 weeks of treatment on the recommended starting dose 1. It is essential to involve the patient's family or caregivers in the decision-making process, discussing goals of care and weighing potential benefits against side effects and quality of life. The primary goal is to prioritize the patient's quality of life, morbidity, and mortality, and to discontinue medications when they are no longer providing a significant benefit.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Weaning Memantine and Rivastigmine in Dementia
- The decision to wean memantine and rivastigmine in dementia patients should be based on individual patient needs and response to treatment 2, 3, 4.
- There is no specific guideline on when to wean these medications, but it is generally recommended to reassess the patient's condition and adjust the treatment plan as needed 2.
- Memantine has been shown to have a small clinical benefit in patients with moderate-to-severe Alzheimer's disease, but its effectiveness in mild Alzheimer's disease is uncertain 2.
- Rivastigmine, on the other hand, has been shown to be effective in improving cognitive function in patients with mild-to-moderate Alzheimer's disease 5, 3.
- The combination of memantine and rivastigmine may be considered for patients with moderate-to-severe Alzheimer's disease, but the evidence for this combination is limited 4.
- When weaning memantine and rivastigmine, it is essential to monitor the patient's condition closely and adjust the treatment plan as needed to minimize the risk of adverse events 2, 3, 4.
Factors to Consider When Weaning
- Disease severity: Patients with moderate-to-severe Alzheimer's disease may require ongoing treatment with memantine and rivastigmine, while those with mild disease may be able to taper off these medications 2, 3.
- Response to treatment: Patients who have shown significant improvement on memantine and rivastigmine may be able to continue treatment, while those who have not responded may be considered for alternative treatments 2, 3, 4.
- Adverse events: Patients who experience significant adverse events on memantine and rivastigmine may need to be weaned off these medications to minimize the risk of further adverse events 2, 3, 4.
- Combination therapy: Patients on combination therapy with memantine and rivastigmine may need to be weaned off one or both medications if they experience adverse events or if their disease severity changes 4.