OBJECT DRUGS

Cholinesterase Inhibitors:

• Donepezil (Aricept, etc.)
• Galantamine (Razadyne, etc.)
• Rivastigmine (Exelon)

PRECIPITANT DRUGS

Antidepressants, Tricyclic:

• Amitriptyline (Elavil)
• Amoxapine (Asendin)
• Clomipramine (Anafranil)
• Desipramine (Norpramin)
• Doxepin (Sinequan, etc.)
• Imipramine (Tofranil, etc.)
• Nortriptyline (Aventyl, etc.)
• Protriptyline (Vivactil)
• Trimipramine (Surmontil)

Comment:

The cholinesterase inhibitors used to treat Alzheimer's dementia are cholinergic, while tricyclic antidepressants are anticholinergic. Thus, one would expect that these antidepressants would inhibit the efficacy of cholinesterase inhibitors. The clinical evidence suggests that this may occur. Note that some tricyclic antidepressants such as amitriptyline and clomipramine may have stronger anticholinergic effects than others such as desipramine and amoxapine.

Class 3: Assess Risk & Take Action if Necessary

• Consider Alternative: Consider using an antidepressant with little or no anticholinergic effects such as bupropion (Wellbutrin), mirtazapine (Remeron), trazodone (Desyrel), selective serotonin reuptake inhibitors (SSRIs) as a class, and serotonin-norepinephrine reuptake inhibitors (SNRIs) as a class.
• Monitor: If the combination is used, monitor for evidence of reduced efficacy of the cholinesterase inhibitor.