Drug Interactions between Aricept ODT and Enlon-Plus

GENERALLY AVOID: Anticholinergic agents and other agents with significant anticholinergic activity (e.g., clozapine, class IA antiarrhythmics especially disopyramide) may antagonize the effects of cholinergic skeletal muscle stimulants (e.g., ambenonium, edrophonium, guanidine, neostigmine, pyridostigmine). Although this interaction may be desirable in some situations, such as when atropine is used to treat excessive muscarinic side effects and cholinergic crisis induced by anticholinesterase overdose, unintentional or indiscriminate use of anticholinergic agents in the treatment of myasthenia gravis may exacerbate symptoms. In addition, such use may mask the less serious, gastrointestinal signs of cholinergic overdose and lead to inadvertent induction of cholinergic crisis, which can produce respiratory paralysis and death.

MANAGEMENT: Agents with potent anticholinergic activity should preferably be avoided in patients receiving cholinergic skeletal muscle stimulants. If concurrent use is necessary, patients treated for myasthenia gravis should be monitored for potential exacerbation of symptoms. Caution is advised not only because anticholinergic agents may mask the signs of a cholinergic overdose, but also because increasing muscle weakness associated with disease aggravation may be difficult to distinguish from that due to cholinergic crisis.

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GENERALLY AVOID: Acetylcholinesterase inhibitors (e.g., donepezil, galantamine, physostigmine, rivastigmine, tacrine) may antagonize the effects of anticholinergic agents and other agents that rely partially on their anticholinergic activity for therapeutic effects (e.g., some antiparkinsonian and antiemetic/antivertigo agents; class IA antiarrhythmics). By inhibiting the metabolism of acetylcholine, more of the neurotransmitter may be available to compete at muscarinic receptors, the site of action of anticholinergic agents. Conversely, anticholinergic agents may negate the already small pharmacologic benefits of acetylcholinesterase inhibitors in the treatment of dementia. These agents may also adversely affect elderly patients in general. Clinically significant mental status changes associated with anticholinergic agents can range from mild cognitive impairment to delirium, and patients with Alzheimer's disease and other dementia are especially sensitive.

MANAGEMENT: Anticholinergic agents should generally be avoided in patients with Alzheimer's disease or other cognitive impairment, regardless of whether they are receiving an acetylcholinesterase inhibitor. For patients requiring treatment to counteract adverse effects of acetylcholinesterase inhibitor therapy (e.g., gastrointestinal intolerance, urinary problems), an agent without anticholinergic properties should be used whenever possible. Otherwise, a dosage reduction, slower titration, or even discontinuation of the acetylcholinesterase inhibitor should be considered. For patients who are already receiving an acetylcholinesterase inhibitor with anticholinergic agents, every attempt should be made to discontinue the latter or substitute them with less anticholinergic alternatives. Caution is required, however, since anticholinergic withdrawal may occur. Seizures have been reported following abrupt discontinuation of anticholinergics during acetylcholinesterase inhibitor therapy.

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MONITOR: A synergistic effect may be expected when acetylcholinesterase inhibitors are administered concurrently with other cholinesterase inhibitors or cholinergic agonists.

MANAGEMENT: Monitoring for excessive cholinergic effects and seizure activity is recommended. Patients should be advised to notify their physician if they experience nausea, vomiting, diarrhea, abdominal pain, increased salivation, cold sweats, slow or irregular heartbeat, muscle weakness or cramps, dizziness, headache, seizures, or respiratory distress.

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