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. 2021 Feb 22;2(2):CD013306.
doi: 10.1002/14651858.CD013306.pub2.

Cholinesterase inhibitors for vascular dementia and other vascular cognitive impairments: a network meta-analysis

Ceri E Battle #  1 , Azmil H Abdul-Rahim #  2 , Susan D Shenkin  3 , Jonathan Hewitt  4 , Terry J Quinn  5
Affiliations

Cholinesterase inhibitors for vascular dementia and other vascular cognitive impairments: a network meta-analysis

Ceri E Battle et al. Cochrane Database Syst Rev. .

Abstract

Background: Vascular cognitive impairment (VCI) describes a broad spectrum of cognitive impairments caused by cerebrovascular disease, ranging from mild cognitive impairment to dementia. There are currently no pharmacological treatments recommended for improving either cognition or function in people with VCI. Three cholinesterase inhibitors (donepezil, galantamine, and rivastigmine) are licenced for the treatment of dementia due to Alzheimer's disease. They are thought to work by compensating for reduced cholinergic neurotransmission, which is also a feature of VCI. Through pairwise comparisons with placebo and a network meta-analysis, we sought to determine whether these medications are effective in VCI and whether there are differences between them with regard to efficacy or adverse events.

Objectives: (1) To assess the efficacy and safety of cholinesterase inhibitors in the treatment of adults with vascular dementia and other VCI. (2) To compare the effects of different cholinesterase inhibitors on cognition and adverse events, using network meta-analysis.

Search methods: We searched ALOIS, the Cochrane Dementia and Cognitive Improvement Group's register, MEDLINE (OvidSP), Embase (OvidSP), PsycINFO (OvidSP), CINAHL (EBSCOhost), Web of Science Core Collection (ISI Web of Science), LILACS (BIREME), ClinicalTrials.gov, and the World Health Organization International Clinical Trials Registry Platform on 19 August 2020.

Selection criteria: We included randomised controlled trials in which donepezil, galantamine, or rivastigmine was compared with placebo or in which the drugs were compared with each other in adults with vascular dementia or other VCI (excluding cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL)). We included all drug doses and routes of administration.

Data collection and analysis: Two review authors independently identified eligible trials, extracted data, assessed risk of bias, and applied the GRADE approach to assess the certainty of the evidence. The primary outcomes were cognition, clinical global impression, function (performance of activities of daily living), and adverse events. Secondary outcomes were serious adverse events, incidence of development of new dementia, behavioural disturbance, carer burden, institutionalisation, quality of life and death. For the pairwise analyses, we pooled outcome data at similar time points using random-effects methods. We also performed a network meta-analysis using Bayesian methods.

Main results: We included eight trials (4373 participants) in the review. Three trials studied donepezil 5 mg or 10 mg daily (n= 2193); three trials studied rivastigmine at a maximum daily dose of 3 to 12 mg (n= 800); and two trials studied galantamine at a maximum daily dose of 16 to 24 mg (n= 1380). The trials included participants with possible or probable vascular dementia or cognitive impairment following stroke. Mean ages were between 72.2 and 73.9 years. All of the trials were at low or unclear risk of bias in all domains, and the evidence ranged from very low to high level of certainty. For cognition, the results showed that donepezil 5 mg improves cognition slightly, although the size of the effect is unlikely to be clinically important (mean difference (MD) -0.92 Alzheimer's Disease Assessment Scale-Cognitive Subscale (ADAS-Cog) points (range 0 to 70), 95% confidence interval (CI) -1.44 to -0.40; high-certainty evidence). Donepezil 10 mg (MD -2.21 ADAS-Cog points, 95% CI -3.07 to -1.35; moderate-certainty evidence) and galantamine 16 to 24 mg (MD -2.01 ADAS-Cog point, 95%CI -3.18 to -0.85; moderate-certainty evidence) probably also improve cognition, although the larger effect estimates still may not be clinically important. With low certainty, there may be little to no effect of rivastigmine 3 to 12 mg daily on cognition (MD 0.03 ADAS-Cog points, 95% CI -3.04 to 3.10; low-certainty evidence). Adverse events reported in the studies included nausea and/or vomiting, diarrhoea, dizziness, headache, and hypertension. The results showed that there was probably little to no difference between donepezil 5 mg and placebo in the number of adverse events (odds ratio (OR) 1.22, 95% CI 0.94 to 1.58; moderate-certainty evidence), but there were slightly more adverse events with donepezil 10 mg than with placebo (OR 1.95, 95% CI 1.20 to 3.15; high-certainty evidence). The effect of rivastigmine 3 to 12 mg on adverse events was very uncertain (OR 3.21, 95% CI 0.36 to 28.88; very low-certainty evidence). Galantamine 16 to 24 mg is probably associated with a slight excess of adverse events over placebo (OR 1.57, 95% CI 1.02 to 2.43; moderate-certainty evidence). In the network meta-analysis (NMA), we included cognition to represent benefit, and adverse events to represent harm. All drugs ranked above placebo for cognition and below placebo for adverse events. We found donepezil 10 mg to rank first in terms of benefit, but third in terms of harms, when considering the network estimates and quality of evidence. Galantamine was ranked second in terms of both benefit and harm. Rivastigmine had the lowest ranking of the cholinesterase inhibitors in both benefit and harm NMA estimates, but this may reflect possibly inadequate doses received by some trial participants and small trial sample sizes.

Authors' conclusions: We found moderate- to high-certainty evidence that donepezil 5 mg, donepezil 10 mg, and galantamine have a slight beneficial effect on cognition in people with VCI, although the size of the change is unlikely to be clinically important. Donepezil 10 mg and galantamine 16 to 24 mg are probably associated with more adverse events than placebo. The evidence for rivastigmine was less certain. The data suggest that donepezil 10 mg has the greatest effect on cognition, but at the cost of adverse effects. The effect is modest, but in the absence of any other treatments, people living with VCI may still wish to consider the use of these agents. Further research into rivastigmine is needed, including the use of transdermal patches.

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Conflict of interest statement

Ceri E Battle: none known

Azmil H Abdul‐Rahim: none known

Susan D Shenkin: none known

Jonathan Hewitt: none known

Terry J Quinn: none known

Figures

1
1
Study flow diagram.
2
2
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
3
3
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
4
4
Network plot: Cognition. The nodes represent an intervention. The solid lines connecting each pair of interventions represent a direct comparison, and the dotted lines an indirect comparison. The numbers on the lines represent the number of trials available for direct comparison.
5
5
Forest plot (Bayesian model) network meta‐analysis results: Cognition.
6
6
Ranking probabilities for (a) Outcome: cognition, (b) Outcome: adverse events. The horizontal axis shows the possible ranks, and the vertical axis the ranking probabilities. Each line connects the estimated probabilities of being at a particular rank for every intervention.
7
7
Network plot: Adverse events. The nodes represent an intervention. The solid lines connecting each pair of interventions represent a direct comparison, and the dotted lines an indirect comparison. The numbers on the lines represent the number of trials available for direct comparison.
8
8
Forest plot (Bayesian model) network meta‐analysis results: Adverse events.
1.1
1.1. Analysis
Comparison 1: Cognition, Outcome 1: Donepezil 5 mg ADAS‐Cog (OC or LOCF)
1.2
1.2. Analysis
Comparison 1: Cognition, Outcome 2: Donepezil 10 mg ADAS‐Cog (OC)
1.3
1.3. Analysis
Comparison 1: Cognition, Outcome 3: Rivastigmine ADAS‐Cog (LOCF)
1.4
1.4. Analysis
Comparison 1: Cognition, Outcome 4: Galantamine ADAS‐Cog (OC or LOCF)
1.5
1.5. Analysis
Comparison 1: Cognition, Outcome 5: Donepezil 5 mg ADAS‐Cog (LOCF)
1.6
1.6. Analysis
Comparison 1: Cognition, Outcome 6: Donepezil 10 mg ADAS‐Cog (LOCF)
1.7
1.7. Analysis
Comparison 1: Cognition, Outcome 7: Galantamine ADAS‐Cog (LOCF)
2.1
2.1. Analysis
Comparison 2: Clinical global impression, Outcome 1: Donepezil 5 mg CIBIC‐Plus (Improvement) (OC or LOCF)
2.2
2.2. Analysis
Comparison 2: Clinical global impression, Outcome 2: Donepezil 10 mg CIBIC‐Plus (Improvement) (OC or LOCF)
2.3
2.3. Analysis
Comparison 2: Clinical global impression, Outcome 3: Galantamine CIBIC‐Plus (Improvement) (LOCF)
2.4
2.4. Analysis
Comparison 2: Clinical global impression, Outcome 4: Donepezil 5 mg CIBIC‐Plus (Improvement) (LOCF)
2.5
2.5. Analysis
Comparison 2: Clinical global impression, Outcome 5: Donepezil 10 mg CIBIC‐Plus (Improvement) (LOCF)
3.1
3.1. Analysis
Comparison 3: Functional performance in activities of daily living, Outcome 1: Donepezil 5 mg ADFACS (LOCF)
3.2
3.2. Analysis
Comparison 3: Functional performance in activities of daily living, Outcome 2: Donepezil 10 mg ADFACS (LOCF)
3.3
3.3. Analysis
Comparison 3: Functional performance in activities of daily living, Outcome 3: Rivastigmine ADCS‐ADL & IADL (LOCF)
3.4
3.4. Analysis
Comparison 3: Functional performance in activities of daily living, Outcome 4: Galantamine ADCS‐ADL & DAD (OC or LOCF)
3.5
3.5. Analysis
Comparison 3: Functional performance in activities of daily living, Outcome 5: Galantamine ADCS‐ADL & DAD (LOCF)
4.1
4.1. Analysis
Comparison 4: Adverse events, Outcome 1: Donepezil 5 mg (LOCF)
4.2
4.2. Analysis
Comparison 4: Adverse events, Outcome 2: Donepezil 10 mg (LOCF)
4.3
4.3. Analysis
Comparison 4: Adverse events, Outcome 3: Rivastigmine (LOCF)
4.4
4.4. Analysis
Comparison 4: Adverse events, Outcome 4: Galantamine (LOCF)
5.1
5.1. Analysis
Comparison 5: Serious adverse events, Outcome 1: Donepezil 5 mg (LOCF)
5.2
5.2. Analysis
Comparison 5: Serious adverse events, Outcome 2: Donepezil 10 mg (LOCF)
5.3
5.3. Analysis
Comparison 5: Serious adverse events, Outcome 3: Rivastigmine (LOCF)
5.4
5.4. Analysis
Comparison 5: Serious adverse events, Outcome 4: Galantamine (LOCF)
6.1
6.1. Analysis
Comparison 6: Behavioural disturbance, Outcome 1: Rivastigmine NPI (LOCF)
6.2
6.2. Analysis
Comparison 6: Behavioural disturbance, Outcome 2: Galantamine NPI (OC or LOCF)
6.3
6.3. Analysis
Comparison 6: Behavioural disturbance, Outcome 3: Galantamine NPI (LOCF)
7.1
7.1. Analysis
Comparison 7: Death (LOCF), Outcome 1: Donepezil 5 mg
7.2
7.2. Analysis
Comparison 7: Death (LOCF), Outcome 2: Donepezil 10 mg
7.3
7.3. Analysis
Comparison 7: Death (LOCF), Outcome 3: Rivastigmine
7.4
7.4. Analysis
Comparison 7: Death (LOCF), Outcome 4: Galantamine
8.1
8.1. Analysis
Comparison 8: Sensitivity analyses: comparison of OC and LOCF analyses, Outcome 1: Donepezil 5 mg. Outcome: Cognition (ADAS‐Cog)
8.2
8.2. Analysis
Comparison 8: Sensitivity analyses: comparison of OC and LOCF analyses, Outcome 2: Donepezil 10 mg. Outcome: Cognition (ADAS‐Cog)
8.3
8.3. Analysis
Comparison 8: Sensitivity analyses: comparison of OC and LOCF analyses, Outcome 3: Galantamine. Outcome: Cognition (ADAS‐Cog)
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Update of

  • doi: 10.1002/14651858.CD013306

References

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