Cholinesterase Inhibitors
Cholinesterase inhibitors include drugs such as donepezil, rivastigmine, and galantamine. Their role is primarily as symptom management for the cognitive effects of Alzheimer’s disease, and in some settings they are also used in related dementias such as Lewy body dementia.
Biological Rationale
These drugs work by reducing breakdown of acetylcholine, a neurotransmitter important for memory and thinking. In Alzheimer’s disease, signaling involving acetylcholine declines, so boosting acetylcholine can modestly support cognition and day-to-day function for some patients.
Evidence Strength
Moderate for symptomatic benefit.
These drugs are well established and commonly prescribed, but the expected benefit is usually modest rather than transformative. They may help maintain function or reduce symptom burden for a time, but they are not considered disease-modifying.
Limitations
They do not stop progression, and side effects such as nausea, vomiting, weight loss, dizziness, or bradycardia (low heart rate) can limit use. Their benefits vary from person to person, and they do not address core upstream pathology such as amyloid, tau, or neuroinflammation.
Sources
- Hansen, R. A., Gartlehner, G., Webb, A. P., et al. (2008). Efficacy and safety of donepezil, galantamine, and rivastigmine for the treatment of Alzheimer’s disease: a systematic review and meta-analysis.
- Singh, R., & Sadiq, N. M. (2023). Cholinesterase Inhibitors.
- Rolinski, M., Fox, C., Maidment, I., & McShane, R. (2012). Cholinesterase inhibitors for dementia with Lewy bodies, Parkinson’s disease dementia and cognitive impairment in Parkinson’s disease.
- Birks, J. S., & Harvey, R. J. (2018). Donepezil for dementia due to Alzheimer’s disease.