Alzheimer disease
Progressive neurodegenerative disease with amyloid plaque and neurofibrillary tangle accumulation leading to dementia. Standard therapy includes cholinesterase inhibitors and memantine; anti-amyloid monoclonal antibodies (lecanemab, donanemab) are emerging.
ICD-10 G3010 drugs
Also known as: AD
Drugs used for this condition
- ADonepezilFirst line · Selective reversible acetylcholinesterase inhibitorFirst-line for mild-to-severe Alzheimer's disease (NICE NG97, 2018). Starting dose 5 mg once daily at bedtime; uptitrate to 10 mg after 4–6 weeks. For severe disease a 23 mg dose is available in the US, while the EU continues 10 mg. The 2018 Cochrane meta-analysis showed cognitive improvement (ADAS-Cog) by 2.9 points and functional gains. The effect is symptomatic and does not modify progression.
- AGalantamineFirst line · Acetylcholinesterase inhibitor with allosteric nicotinic modulationFirst-line for mild-to-moderate Alzheimer's disease per NICE 2018, AAN 2024, and SEN 2024 alongside donepezil and rivastigmine. Starting dose 8 mg once daily (extended-release) titrated to 24 mg over 4–8 weeks. Efficacy comparable to other AChE inhibitors. Some patients tolerate it better thanks to nicotinic modulation.
- AMemantineSecond line · Non-competitive NMDA receptor antagonistFor moderate-to-severe Alzheimer's disease; at the mild-to-moderate stage the first line is cholinesterase inhibitors (donepezil, rivastigmine, galantamine), while memantine is added at the moderate-to-severe stage or when they are not tolerated, often combined with donepezil (NICE NG97, 2018). Dose titrated from 5 mg once daily to 20 mg (5 mg per week). The effect is modest – it slows cognitive decline by about 6 months and improves daily functioning, without modifying the underlying disease.
- ARivastigmineFirst line · Acetyl- and butyrylcholinesterase inhibitorFirst-line for mild-to-moderate Alzheimer's disease per NICE 2018, AAN 2024, and SEN 2024 alongside donepezil and galantamine. Transdermal patch 4.6 mg/24 h titrated to 9.5 mg/24 h is preferred due to less nausea and vomiting than the oral form. Efficacy is comparable to donepezil.
Marketing claims without evidence base
The drug is promoted for these uses outside international guidelines. Each entry below is analyzed against AEMPS, FDA, EMA, Cochrane and major RCTs.
- DAcetyl-L-carnitineNot recommended · Acetylated ester of L-carnitine; supplement with claimed neurotropic effectAcetyl-L-carnitine is marketed as a nootropic that slows dementia and improves memory in Alzheimer disease. The Cochrane review (Hudson & Tabet 2003, updated 2014) analysed 16 RCTs with 1204 patients: differences from placebo on clinical scales (MMSE, ADAS-cog) are minimal and do not reach clinical significance. The product is not in NICE, AAN or Spanish SEN guidelines for Alzheimer disease. Standard therapy – cholinesterase inhibitors (donepezil, rivastigmine, galantamine) and memantine – is not replaced by acetyl-L-carnitine.
- DBacopa monnieri (brahmi)Not recommended · Plant nootropic adaptogen from Ayurvedic medicine, supplement. Not registered as medicine in EU or AEMPSBacopa monnieri (brahmi) is a herb from the Ayurvedic tradition, and its extract is sold as a supplement for memory and Alzheimer's disease. In Alzheimer-type dementia, bacopa has not shown convincing benefit, and there is no solid evidence for this use. What helps in Alzheimer's disease are cholinesterase inhibitors and memantine chosen by a doctor, together with care and family support. Do not take bacopa instead of prescribed treatment, since that can mean missing therapy with proven benefit.
- DHuperzine A (Huperzia serrata)Not recommended · Alkaloid of Chinese club moss (Huperzia serrata, Lycopodium serratum), a selective reversible acetylcholinesterase inhibitor. Registered as a prescription medicine Shuangyiping for Alzheimer disease in China. No marketing authorisation in the EU or USA; sold as a dietary supplementHuperzine A is registered in China as the medicine Shuangyiping for Alzheimer disease; no FDA or EMA marketing authorisation in the EU or USA. The Yang 2013 systematic review (Int J Geriatr Psychiatry) pooled 20 RCTs from China totalling 1823 patients with mild-to-moderate Alzheimer and recorded moderate MMSE and ADL improvement at 0.2–0.4 mg/day. Authors rated evidence quality as low due to geographic concentration in one country, small samples, lack of independent Western replication and insufficient bias control. NICE dementia 2018 (NG97) for Alzheimer disease lists donepezil, rivastigmine and galantamine first-line at MMSE 10–26 and memantine in severe dementia; huperzine A is not in guidelines. AEMPS has not registered the product. If huperzine A was recommended for confirmed Alzheimer instead of approved cholinesterase inhibitors and memantine, consider seeking a second opinion from a dementia-specialist neurologist.
- DLion's mane (Hericium erinaceus)Not recommended · Medicinal mushroom, supplement. AEMPS does not register as medicineLion's mane (Hericium erinaceus) is an edible mushroom whose extract is sold as a memory supplement and marketed to slow Alzheimer's disease. It has not shown convincing benefit for this use – there's no solid evidence that it affects the course of the disease. For Alzheimer's, the treatments with proven effect come from other drug classes (cholinesterase inhibitors, memantine) alongside care and support, with the regimen chosen by a neurologist. The mushroom is harmless in this role, but don't take it instead of prescribed therapy – that risks missing out on treatment with proven benefit.
- FCholine alfoscerateNot recommended · Other nervous system drugs. ParasympathomimeticsAlpha-GPC is sometimes recommended in Alzheimer disease as «natural enhancement of cholinergic therapy». The Italian ASCOMALVA RCT (n≈210) tested alpha-GPC 1200 mg/day as an add-on to donepezil 10 mg/day vs donepezil + placebo in mild-to-moderate Alzheimer. Published results showed a heterogeneous effect on MMSE and ADAS-Cog, but the design is criticised for a single-centre sample and lack of independent replication. NICE 2018 (NG97) for Alzheimer disease lists cholinesterase inhibitors (donepezil, rivastigmine, galantamine) first-line at MMSE 10–26 and memantine in severe dementia; alpha-GPC is not in guidelines. AEMPS has not registered the product; FDA has not granted a marketing authorisation. If alpha-GPC was recommended for confirmed Alzheimer disease instead of donepezil, rivastigmine or galantamine, consider seeking a second opinion from a dementia-specialist neurologist.
- FMethylthioninium chloride (methylene blue)Not recommended · Antidotes (V03AB17). The drug has one FDA-approved indication – methaemoglobinaemia. Biohacker use is off-label.The methylene blue derivative LMTX (hydromethylthionine mesylate, TauRx) was studied in phase 3 RCTs for Alzheimer's disease and frontotemporal dementia (TRx-237-005, TRx-237-015, TRx-237-007). ADAS-Cog and ADCS-ADL endpoints were not met. AAN and Alzheimer's Association guidelines do not list methylene blue or its derivatives.
How to read tiers A–F
Evidence tiers belong to the drug-indication pair, not to the drug as a whole: the same substance can be A for one condition and F for another.
- AStrong evidence – first or second line in international guidelines
- BRecommended in selected cases
- CStudy data contradict each other
- DBenefit not proven, no documented harm
- FDocumented harm, or risk without benefit