Donepezil hydrochloride

How it works

It reversibly inhibits acetylcholinesterase, increasing synaptic acetylcholine availability and partially compensating for the cholinergic deficit characteristic of Alzheimer's disease.

Prescribing in practice

• Cholinergic effects can provoke bradycardia, heart block and syncope, so use caution in patients with sick sinus syndrome, conduction abnormalities or on rate-limiting drugs, and review susceptibility before starting.
• Once-daily dosing is usually taken in the evening, and the dose is titrated upward after an initial period at the lower strength to improve tolerability.
• Caution in peptic ulcer disease, asthma or chronic obstructive pulmonary disease, urinary outflow obstruction and in patients at risk of seizures.

Monitoring

Monitor cognitive and functional response, weight, heart rate and gastrointestinal tolerability, with cardiac assessment if syncope or significant bradycardia occurs.

Counselling the patient

• Take the dose in the evening and report fainting, slow heartbeat, black stools or persistent nausea.
• Benefit is symptomatic and the medicine does not cure or halt the underlying disease.
• Tell other clinicians you take this drug before any anaesthetic or new heart medication.

Evidence & guidelines

NICE guidance on dementia recommends acetylcholinesterase inhibitors including donepezil as options for managing mild to moderate Alzheimer's disease.