Objective and Design: Dementia with Lewy bodies (DLB) is a common dementia that responds symptomatically to cholinesterase inhibitors (CIs). Unfortunately, not all patients respond to initial CI, and alternative CIs may be considered. Minimal clinical experience exists with switching among CIs. We describe an initial pilot study of donepezil switchover to galantamine, with resulting consequences.
Materials and Methods: 3 consecutive DLB patients (mean age 73 years, mean DLB duration 1.4 years, mean MMSE scores 22/30) were treated with donepezil 10-mg daily before diminution of response (mean duration 1.2 years). Switching to galantamine was undertaken without donepezil washout in 2 patients, and with a 1-week overlap between donepezil and galantamine in 1 patient. Mean pre-switch cognitive test scores were: MMSE 20/30 and NPI 45/144.
Results: Although the MMSE deteriorated only slightly, all 3 subjects developed neuropsychiatric complications following the switchover: 2 patients switched to galantamine without washout developed adverse events, including dyskinesias, restlessness, and concentration difficulties. Of these, one patient developed nighttime agitation and insomnia and required concomitant trazodone and quetiapine. The third patient (with overlap of the CIs), developed delirium and required hospitalization. Only 1 subject was eventually maintained on galantamine. Mean 3-month post-switch follow-up scores were: MMSE 20/30 and NPI 39/144.
Conclusion: Donepezil produces cognitive improvements in DLB, although benefits are not sustained over time. In preliminary observations, galantamine switchover using 2 different approaches led to development of adverse events in 3 subjects. Although the MMSE scores appeared stable, the NPI better reflected the observed clinical deterioration. While further research needs to address CI switching in DLB, clinicians should be vigilant for deterioration following the switch.
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