Sandwell and West
Birmingham Clinical
Commissioning Group
Wolverhampton City
Clinical Commissioning Group
Shared Care Agreement for
Donepezil, Galantamine, Rivastigmine and Memantine
ESCA: For the treatment of Alzheimer’s disease
SECONDARY CARE SECTION TO BE COMPLETED BY INITIATING DOCTOR
Patient’s Name:
NHS Number:
Date of Birth:
Date Treatment Started:
Name of drug:
(Add Date)
One copy of information leaflet given to patient
One copy of agreement sent to general practitioner
One copy filed in patients notes
Name of Initiating Doctor:
Consultant:
Speciality:
Fax Number:
PRIMARY CARE SECTION TO BE COMPLETED BY GENERAL PRACTITIONER
I agree*/don’t agree* to enter into a shared care arrangement for the treatment of the above patient with
this medicine (*delete as appropriate)
GP Name:
Signature:
Date:
Once signed please detach this sheet and fax to the number shown above.
BACK-UP ADVICE AND SUPPORT
Contact details
Telephone No.
01902 444140
Fax:
01902 444730
Dr Viswanathan
(Wolverhampton)
01902 442509
01902 444730
Dr Griffiths (Wolverhampton)
01902 445497
01902 444730
Dr Jenkins (Wolverhampton)
This Shared Care Agreement should be read in conjunction with the Summary of Product Characteristics (SPC) for donepezil, galantamine,
rivastigmine and memantine
Date approved: 15/09/2013
Expiry date: September 2015
Sandwell and West
Birmingham Clinical
Commissioning Group
Wolverhampton City
Clinical Commissioning Group
Shared Care Agreement for
Donepezil, Galantamine, Rivastigmine and Memantine
ESCA: For the treatment of Alzheimer’s disease
Dr Prasanna (Wolverhampton)
01902 575151
01902 444730
Memory Clinic (Wolverhampton)
01902 445794
01902 444730
Dr Lowe (Sandwell)
0121 6128203
0121 6128200
Dr Curran (Sandwell)
0121 6128202
0121 6128200
Dr Qassem (Sandwell)
0121 6128211
0121 6128200
Dr Blissett (Sandwell)
0121 6128206
0121 6128200
BCPFT Pharmacy Dept:
Mr Tim Kingscote-Davies
0121 6128609
0121 6128611
CCG Pharmacist
(Wolverhampton):
Mr David Birch
01902 575184
01902 444522
This Shared Care Agreement should be read in conjunction with the Summary of Product Characteristics (SPC) for donepezil, galantamine,
rivastigmine and memantine
Date approved: 15/09/2013
Expiry date: September 2015
Sandwell and West
Birmingham Clinical
Commissioning Group
Wolverhampton City
Clinical Commissioning Group
Shared Care Agreement for
Donepezil, Galantamine, Rivastigmine and Memantine
ESCA: For the treatment of Alzheimer’s disease
Patient’s Name:
NHS Number:
Date of Birth:
Date treatment commenced:
Name of drug, form and dosage:
AREAS OF RESPONSIBILITY FOR THE SHARING OF CARE
This shared care agreement outlines suggested ways in which the responsibilities for managing the prescribing of
donepezil, galantamine, rivastigmine and memantine for the treatment of Alzheimer’s disease can be shared between
the specialist and general practitioner (GP). GPs are invited to participate. If GPs are not confident to undertake these
roles, then they are under no obligation to do so. In such an event, the total clinical responsibility for the patient for the
diagnosed condition remains with the specialist. If a specialist asks the GP to prescribe this drug, the GP should
reply to this request as soon as practicable. Note that this ESCA does not include the use of any of these
medicines outside their licensed indications.
Sharing of care assumes communication between the specialist, GP and patient. The intention to share care should
be explained to the patient by the doctor initiating treatment. It is important that patients and carers are consulted
about treatment and are in agreement with it.
The doctor/non-medical prescriber who prescribes the medication legally assumes clinical responsibility for
the drug and the consequences of its use.
RESPONSIBILITIES and ROLES
Specialist responsibilities

Confirm diagnosis of Alzheimer’s disease using cognitive, global, functional and behavioural
assessment. Carers’ views on the patient’s condition at baseline should be sought.
 The three AChE inhibitors donepezil, galantamine and rivastigmine are recommended as options for
managing mild to moderate Alzheimer’s disease. Memantine is an option for managing Alzheimer’s
disease for people with moderate Alzheimer’s disease who are intolerant of or have a
contraindication to AChE inhibitors or severe Alzheimer’s disease.
 The least expensive drug should normally be chosen as first line, unless there are patient specific
reasons not to.
 Obtain consent and ensure provision of information on disease, treatment, benefits, side-effects and
discontinuation of medication to patient and/or carer.
 Initiate treatment in accordance with NICE guidance and provide medication until prescribing is
transferred to the GP.
 Send a letter to the GP to obtain consent to share prescribing responsibility, informing the GP of
formal assessments undertaken, results and confirmation that the patient has mild, moderate or
severe Alzheimer’s disease. Complete the Secondary Care Section of the Shared Care Agreement
and send to the GP.
 If patient already using a blister pack or dossett box for medication, ask the GP to initiate the
medication, with close supervision and guidance.
 Advise the GP of the medication and dosage to be prescribed and any dosage adjustments required.
 Liaise with the GP after each review and as necessary.
 The Community Mental Health Team (CMHT) will provide ongoing monitoring and support.
 Once stabilised, review patient’s clinical condition, carer’s views, response to treatment, drug
compliance and use cognitive, global, functional and behavioural assessment every 6 months.
Communicate these results and any dosage adjustments promptly to the GP.
 Review and consider discontinuing treatment if there is no clinically significant benefit. Treatment
should be continued only when it is considered to be having a worthwhile effect on cognitive, global,
functional or behavioural symptoms.
This Shared Care Agreement should be read in conjunction with the Summary of Product Characteristics (SPC) for donepezil, galantamine,
rivastigmine and memantine
Date approved: 15/09/2013
Expiry date: September 2015
Sandwell and West
Birmingham Clinical
Commissioning Group
Wolverhampton City
Clinical Commissioning Group
Shared Care Agreement for
Donepezil, Galantamine, Rivastigmine and Memantine
ESCA: For the treatment of Alzheimer’s disease




Ensure that backup advice is available at all times.
Advise and support patients and their carers.
Notify the GP of patient’s failure to attend appointments.
Report adverse events to the Medicines and Healthcare products Regulatory Agency (MHRA) using
the yellow card system.
General Practitioner responsibilities
1 Reply to the specialist requesting shared care.
2 Complete the Primary Care Section of the Shared Care Agreement and return to the Specialist
3 Provide repeat prescriptions following initiation by specialist, at dose advised, ensuring no interacting
drugs are prescribed. It is recommended that no more than one month’s prescription should be
issued at a time.
4 Report to and seek advice from the specialist on any aspect of patient care that is of concern to the
GP and may affect treatment.
5 Act upon results communicated by specialist.
6 Encourage patient’s ongoing engagement with secondary care services.
7 If patient’s condition deteriorates the GP should advise the specialist for earlier review.
8 Ensure all relevant staff within the practice are aware of the shared care guidelines.
Patient's role




Report to the GP or specialist if he or she does not have a clear understanding of the treatment.
Ensure regular attendance at appointments for review and monitoring.
Be aware of side effects and report any adverse effects to the specialist or GP.
Inform the GP or specialist if health problems arise.
This Shared Care Agreement should be read in conjunction with the Summary of Product Characteristics (SPC) for donepezil, galantamine,
rivastigmine and memantine
Date approved: 15/09/2013
Expiry date: September 2015
Sandwell and West
Birmingham Clinical
Commissioning Group
Wolverhampton City
Clinical Commissioning Group
Shared Care Agreement for
Donepezil, Galantamine, Rivastigmine and Memantine
ESCA: For the treatment of Alzheimer’s disease
SUPPORTING CLINICAL INFORMATION
See current edition of the British National Formulary (BNF) and Summary of Product Characteristics (SPCs) for
donepezil, galantamine, rivastigmine and memantine (http://www.emc.medicines.org.uk/) for full details of licensed
indications, dosage and administration, contraindications, cautions, side-effects and drug interactions.
DONEPEZIL:
Indications
Mild to moderate dementia in Alzheimer’s disease.
Dosage and Administration
Initially 5mg once daily at bedtime, increased if necessary after one month to maximum 10mg daily.
If standard formulation not appropriate, donepezil orodispersible tablets may be prescribed. Place on the tongue,
allow to disperse and swallow.
Contraindications
Known hypersensitivity to donepezil, piperidine derivatives, or to any excipients used in the formulation.
Cautions
Sick sinus syndrome or other supraventricular conduction abnormalities. Susceptibility to peptic ulcers. Asthma,
chronic obstructive pulmonary disease. Hepatic impairment – caution in mild to moderate impairment, no information
for severe impairment.
Side Effects
Nausea, vomiting, anorexia, diarrhoea, fatigue, insomnia, headache, dizziness, syncope, abnormal dreams,
hallucinations, agitation, aggression, muscle cramps, urinary incontinence, rash, pruritus. Less commonly gastric and
duodenal ulcers, gastro-intestinal haemorrhage, bradycardia, seizures.
Interactions
Donepezil possibly enhances the effect of suxamethonium but antagonises the effect of non-depolarising muscle
relaxants.
Donepezil has the potential to interfere with medications having anticholinergic activity.
GALANTAMINE:
Indications
Mild to moderate dementia in Alzheimer’s disease.
Dosage and Administration
Initially 4mg twice daily for 4 weeks increased to 8mg twice daily for 4 weeks. Maintenance dose 8 – 12mg twice
daily. Take with or just after food.
Galantamine MR: Initially 8mg once daily for 4 weeks increased to 16mg once daily for 4 weeks. Maintenance dose
16-24mg daily. Swallow whole with or just after food.
If standard formulations not appropriate, galantamine oral solution may be prescribed. Take with or just after food.
Contraindications
Hypersensitivity to the active substance or to any of the excipients.
Since no data are available on the use of galantamine in patients with severe hepatic (Child-Pugh score greater than
9) and severe renal (creatinine clearance less than 9 ml/min) impairment, galantamine is contraindicated in these
populations. Galantamine is contra-indicated in patients who have both significant renal and hepatic dysfunction.
Cautions
Cardiac disease (including sick sinus syndrome or other supraventricular conduction abnormalities, unstable angina,
congestive heart failure). Electrolyte disturbances. Susceptibility to peptic ulcers. Asthma, chronic obstructive
pulmonary disease, pulmonary infection. Avoid in urinary retention, gastro-intestinal obstruction and while recovering
This Shared Care Agreement should be read in conjunction with the Summary of Product Characteristics (SPC) for donepezil, galantamine,
rivastigmine and memantine
Date approved: 15/09/2013
Expiry date: September 2015
Sandwell and West
Birmingham Clinical
Commissioning Group
Wolverhampton City
Clinical Commissioning Group
Shared Care Agreement for
Donepezil, Galantamine, Rivastigmine and Memantine
ESCA: For the treatment of Alzheimer’s disease
from bladder or gastro-intestinal surgery. History of seizures. Hepatic impairment - dose adjustment required in
moderate hepatic impairment, avoid in severe impairment. Renal impairment – avoid if eGFR less than
9ml/minute/1.73m2.
Side Effects
Vomiting, nausea, abdominal pain, diarrhoea, dyspepsia, anorexia, weight loss, bradycardia, hypertension, syncope,
hallucinations, depression, dizziness, tremor, headache, drowsiness, malaise, muscle spasm, sweating. Less
commonly taste disturbances, palpitation, arrhythmias, first-degree AV block, hypotension, flushing, paraesthesia,
dehydration, muscular weakness, blurred vision, tinnitus.
Interactions
Plasma concentration of galantamine increased by erythromycin, paroxetine and ketoconazole.
Because of its mechanism of action, galantamine should not be given concomitantly with other cholinomimetics
(such as donepezil and rivastigmine).
Galantamine has the potential to antagonise the effect of anticholinergic medication.
Galantamine enhances the effect of suxamethonium.
RIVASTIGMINE:
Indications
Mild to moderate dementia in Alzheimer’s disease or in Parkinson’s disease.
Dosage and Administration
Initially 1.5mg twice daily, increased in steps of 1.5mg twice daily at intervals of at least 2 weeks according to
response and tolerance; usual range 3-6mg twice daily; maximum 6mg twice daily. If treatment interrupted for more
than several days, treatment should be retitrated from 1.5mg twice daily. Take with or just after food. Capsules must
be swallowed whole.
If standard formulation not appropriate, rivastigmine oral solution may be prescribed.
Patches – initially apply 4.6mg/24 hours patch to clean, dry, non-hairy, non-irritated skin on back, upper arm, or
chest, removing after 24 hours and siting a replacement patch on a different area (avoid using the same area for 14
days); if well tolerated increase to 9.5mg/24 hours patch daily after at least 4 weeks; if treatment interrupted for more
than several days, treatment should be retitrated from 4.6mg/24 hours patch.
When switching from oral to transdermal therapy, patients taking 3-6mg by mouth daily should initially switch to
4.6mg/24 hours patch (then titrate as above). Patients taking 9-12mg by mouth daily should switch to 9.5mg/24
hours patch. The first patch should be applied on the day following the last oral dose.
Contraindications
Hypersensitivity to the active substance rivastigmine, to other carbamate derivatives or to any of the excipients
used in the formulation. Previous history of application site reactions suggestive of allergic contact dermatitis with
rivastigmine patch.
Cautions
Gastric or duodenal ulcers (or susceptibility to ulcers). Monitor body weight. Sick sinus syndrome, conduction
abnormalities. History of asthma or chronic obstructive pulmonary disease. History of seizures. Bladder outflow
obstruction. Use with caution in hepatic and renal impairment.
Side Effects
Nausea, vomiting, diarrhoea, dyspepsia, anorexia, weight loss, increased salivation, abdominal pain, bradycardia,
dizziness, headache, drowsiness, malaise, agitation, anxiety, tremor, confusion, insomnia, extrapyramidal symptoms
(and worsening of Parkinson’s disease), sweating. Less commonly atrial fibrillation, AV block, depression, syncope.
Interactions
Rivastigmine enhances the effect of suxamethonium but antagonises the effect of non-depolarising muscle relaxants.
Rivastigmine should not be given concomitantly with other cholinomimetic substances (such as donepezil and
rivastigmine) and might interfere with the activity of anticholinergic medicinal products.
This Shared Care Agreement should be read in conjunction with the Summary of Product Characteristics (SPC) for donepezil, galantamine,
rivastigmine and memantine
Date approved: 15/09/2013
Expiry date: September 2015
Sandwell and West
Birmingham Clinical
Commissioning Group
Wolverhampton City
Clinical Commissioning Group
Shared Care Agreement for
Donepezil, Galantamine, Rivastigmine and Memantine
ESCA: For the treatment of Alzheimer’s disease
MEMANTINE:
Indications
Moderate to severe dementia in Alzheimer’s disease
Dosage and Administration
Initially 5mg once daily, increased in steps of 5mg at weekly intervals to maximum 20mg daily.
If standard formulation not appropriate, memantine oral solution may be prescribed.
Treatment initiation packs also available.
Contraindications
Hypersensitivity to the active substance or to any of the excipients.
Cautions
History of convulsions. Avoid in severe hepatic impairment – no information available. Dose adjustment required in
renal impairment. Avoid if eGFR less than 5ml/minute/1.73m 2.
Side Effects
Constipation, hypertension, dyspnoea, headache, dizziness, drowsiness. Less commonly vomiting, thrombosis, heart
failure, confusion, fatigue, hallucinations and abnormal gait.
Interactions
Increased risk of CNS toxicity when memantine given with ketamine or dextromethorphan (manufacturer advises
avoid concomitant use).
Memantine possibly enhances anticoagulant effect of warfarin.
Memantine possibly enhances effects of antimuscarincs.
Memantine possibly reduces effects of antipsychotics.
Memantine possibly enhances effects of dopaminergics and selegiline. Inreased risk of CNS toxicity when
memantine given with amantadine (manufacturer advises avoid concomitant use).
Memantine possibly modifies effects of baclofen and dantrolene.
Version Control
Version
Date of Issue
Author/s
Brief Description of Changes
1.0
September 2011
Sue Horton
Updated NICE Guidance to include memantine
2.0
August 2013
Sue Horton
Review, minor alterations, supporting information separate for individual
drugs inclusion of Sandwell Consultants, Wolverhampton CCG and
Sandwell and West Birmingham CCG.
This Shared Care Agreement should be read in conjunction with the Summary of Product Characteristics (SPC) for donepezil, galantamine,
rivastigmine and memantine
Date approved: 15/09/2013
Expiry date: September 2015