Response

I thank Dr Lexchin for his interest in my paper published in the January issue of Canadian Family Physician.1 He had some concerns about my conclusions’ not reflecting the evidence published in the recent literature on memantine.

First, my conclusion that memantine is “effective” should be interpreted in the clinical context of its use. This medication has been mostly studied in moderate to severe stages of Alzheimer disease (AD), where the natural history is inevitable deterioration of cognitive and functional capacities and behaviour. Therapeutic expectations need to be adapted accordingly. Most clinicians would agree that mild improvement, stabilization, and slower deterioration are all acceptable objectives at this stage of AD. Considering these objectives, published clinical trials with memantine do support its clinical superiority (alone or in combination with cholinesterase inhibitors) over placebo in the moderate to severe stages of AD.

Second, memantine’s pharmacoeconomic profile has not yet been adequately assessed, as clearly stated in my paper. The paper by Reisberg et al2 showed a decrease in the time spent by caregivers supervising patients in the memantine group compared with the placebo group. How this translates in terms of cost savings and delay of institutionalization is unclear. Obviously, this issue is the most important consideration for funding organizations and is regularly evoked to justify not covering the medication.

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