There are several options for printing:

• Click "Print this page" on the left to print the whole section
• Download a handy PILL (Patient Information Leaflet), a two-page summary of the main questions and answers from here. This can then be printed.
• Download a BILL (Basic Information Leaflet), a one-page larger print basic summary of the really main questions and answers from here. This can then be printed.

There are many other Patient Information Leaflets (PILs) across the world for patients and carers. There are also official information leaflets (often called a Data Sheet, Package Insert, or Summary of Product Characteristics). They are not on our site, so we can't take any responsibility for them but you can click here for links to other sites and leaflets

^{Updated 1.12}

• Hide this answer

Alzheimer’s Disease is an illness where the main symptoms are loss of memory, lack of social functioning and personality changes. Anticholinesterases (e.g. donepezil, galantamine and rivastigmine) help to treat the symptoms of mild or moderate Alzheimer's Disease. They do not help as much if the symptoms have become more severe. Studies have shown that around 60-80% of sufferers have either slightly improved or stabilised (or not got worse) over six months.

^10.10

• Hide this answer

The starting dose for donepezil is 5mg each day, best taken in the evening. After a month this can be increased to 10mg a day, usually the top dose. A slightly slower dose increase may be needed in people with liver damage. It has not been studied in children.

^{Updated 10.11}

• Hide this answer

To help you choose, click on the links for the main options (self-help and help from others), the main medicines, and a handy chart comparing the main medicines for:

• Dementia - main options, main medicines and handy chart

^{Updated 10.11}

• Hide this answer

The brain has chemical messengers, which help pass messages from one brain cell to another. One of these chemical messengers is called acetylcholine. It is involved in the areas of the brain which control learning and memory (e.g. recall and laying down). In Alzheimer’s Disease, there are many changes within the brain, but the main effect is of reduced acetylcholine activity. If you have less acetylcholine, you have less memory ability, reduced learning etc

Acetylcholine is broken down in the brain by an enzyme called acetylcholine esterase. Donepezil blocks this enzyme and stops it breaking acetylcholine down. This increases the amount of acetylcholine and makes it last longer. This in turn helps stabilise or improve memory, learning and functioning

Anticholinesterases do not cure the condition but in some people it may improve the symptoms for a while. They probably do not slow the underlying decline.

^3.11

• Hide this answer

Take your medication as directed on the medicine label. Try to take it at a regular time each day, in the evening, just before going to bed. Rivastigmine (Reminyl) capsules are usually taken twice a day, morning and evening. The patches should be applied every day, although it doesn't really matter when during the day.

^3.11

• Hide this answer

Tablets and capsules:
Tablets or capsules should be swallowed with at least half a glass of water whilst sitting or standing. This is to make sure that they reach the stomach and do not stick in the throat. The capsules should not be chewed or crushed.
Melt-in-the-mouth tablets:
"Aricept Evess" are melt-in-the-mouth tablets. The tablet should be placed on the tongue and allowed to dissolve before swallowing. They can be taken with or without water.
Patches:
"Exelon transdermal patches" should be applied once a day to clean, dry, hairless, intact healthy skin on the upper or lower back, upper arm or chest. This should be in a place that will not be rubbed by tight clothing. It is best to avoid putting the patch on the thigh or to the abdomen (body, trunk) because less of the active drug rivastigmine is absorbed so there is less effect. Do not put the patch on skin that is red, irritated or cut. Leave 14 days before putting another patch on the same piece of skin to reduce the risk of skin rashes or irritation. The transdermal patch should be replaced by a new one after 24 hours. Only one transdermal patch should be worn at a time. There is a separate PILL or leaflet for rivastigmine patches above.
Liquids:
Use the dropper given to you with the bottle.

^{Updated 10.11}

• Hide this answer

Anticholinesterases take about four weeks to show their full effects at the starting dose for dementia or Alzheimer's Disease (click the link for more information). After four weeks, your doctor may increase your dose.

^{Updated 10.11}

• Hide this answer

This should be discussed with your doctor as different people respond differently. Click the link for more advice on an anticholinesterase for dementia or Alzheimer's Disease.

^{Updated 10.11}

• Hide this answer

The anticholinesterases are not addictive. There is no evidence of withdrawal symptoms, although often people with Alzheimer's Disease get worse when they stop an anticholinesterase, because the effect is lost and they go down towards the level they would have been if they'd never had the medicine.

For a drug to be addictive or produce dependence, then it must have a number of characteristics:

• should produce craving for the drug when the last dose "wears off"

• there should be a "reward" (e.g. a good feeling) from taking the drug

• should produce tolerance ie you need more drug to get the same effect

• should produce withdrawal symptoms specific to that drug.

These characteristics come from the World Health Organisation. The anticholinesterases have none of these and so are not addictive. Any discontinuation effects are probably more of an "adjustment" reaction from sudden removal of a drug rather than "withdrawal".

Click here to read a bit more about this, where you can find our thoughts on this knotty problem.

^9.10

• Hide this answer

Start again as soon as you remember unless it is almost time for your next dose. Do not try to catch up by taking two or more doses at once as you may get more side-effects. If you miss several doses start again when you remember. Tell your doctor about this next time you meet. Missing the occasional dose (e.g. once a week) isn't usually a big problem.

If you have problems with your doses (as very many people do) ask you pharmacist, doctor or nurse about this. There are some special packs, boxes and devices that can be used to help you. You can try leaving the pack somewhere you will see it e.g. in the bathroom, kitchen etc.

^9.10

• Hide this answer

There are no known problems with stopping an anticholinesterase suddenly e.g. before surgery.

^{Updated 10.11}

• Hide this answer

Use the table below to find out about some of the side effects you might get with an anticholinesterase:

If you are having the rivastigmine skin patch, about 1 in 25 people (4%) have to stop due to skin rash. If this happens make sure you follow the instructions carefully e.g. rotating the place where the patch is put on.

Do not be worried by this list of side effects. Some people get no side effects at all and others may get some effects that are not listed in this table. Side effects tend to be worse with higher doses. Starting with a lower dose sometimes helps. If you think you might have a side effect to your medicine, you should discuss this with your doctor, nurse of pharmacist. You should also see the manufacturer's information leaflet.

^{Updated 12.11}

• Hide this answer

Drowsiness or sleepiness is not a main side effect of anticholinesterases. If you do feel drowsy, you should not drive (see below) or operate machinery. You should be careful as it may affect your reaction times.

^{Updated 11.11}

• Hide this answer

Weight gain is not thought to be a side effect of anticholinesterases. If, however, you do start to have problems with your weight tell your doctor next time you meet as he or she can arrange for you to see a dietician for advice.

Click here for a few tips on how to help you feel less hungry and lose weight.

^5.11

• Hide this answer

Drugs can affect desire (libido), arousal (erection) and orgasmic ability. Anticholinesterase are not thought to affect any of these stages.

^9.10

• Hide this answer

You should have no problem with any foods or drinks.

^{Updated 8.11}

• Hide this answer

Whether or not it is safe to drink alcohol with any medicine will depend on:

• How much you have to drink e.g. the amount and over how long
• What you then try to do (e.g. sleep or drive)
• If you have any other conditions e.g. asthma or a chest infection (as alcohol can make it harder to breathe), epilepsy
• If you are taking any other medicines

Alcohol reaches all parts of the brain and can affect many things e.g. thinking, reactions and breathing. Alcohol can also boost the effect of GABA (the brain's main calming chemical messenger).

It is not thought that alcohol will make you more drowsy if you are also taking an anticholinesterase.   

It is not safe to drive after drinking alcohol, with or without an anticholinesterase. Some countries allow driving after a small amount of alcohol but others have a zero tolerance. The UK has the highest limit in Europe, France lower, Scandanavia even lower and zero in some Eastern European countries. It is not possible to say what blood level you might have from a drink so it is safest not to drink if you know you may have to drive. It is taken as a very serious offence in most countries. You should see National Guidelines, laws and regulations in the country in which you are driving.

^{Updated 11.11}

• Hide this answer

The anticholinesterases (donepezil, rivastigmine and galantamine) have a few interactions with other medicines:

• The effects of anticholinesterases can sometimes be increased by ketoconazole (an antifungal, due to reduced breakdown of the anticholinesterase), or some SSRIs (eg paroxetine)
• The effect of anticholinesterases can be decreased by anticholinergics (because anticholinesterases increase the effect of acetylcholine, but anticholinergics reduce the effect acetylcholine)
• Anticholinesterases can increase the effect of suxamethonium (a muscle relaxant) or beta-blockers (e.g. propranolol, atenolol; used to treat fast heart rate and high blood pressure)

This does not necessarily mean that this will happen in everyone or that some of these medicines can not be used together. It is just that you may need to follow your doctor's instructions very carefully. There are many other possible drug interactions (e.g. you can try an external on-line drug interactions checker, although this is nothing to do with our site).

^{Updated 1.12}

• Hide this answer

Cigarette smoke contains over 3000 different chemicals. Some of these chemicals can make some of the enzymes in the liver work faster (called "enzyme induction" of e.g. CYP1A2 or P4501A2). This means that any medicine those enzymes break down will be broken down quicker. So, you'll end up with less of that medicine if you smoke. And also you will have more of it in the body if you stop smoking. However, it seems that there are no extra problems if smoking with any of the anticholinesterases.

^3.11

• Hide this answer

By including this section, we're not saying it's right to take illicit or illegal drugs, because it isn't. We're just trying to answer the questions as best we can under the circumstances. With illicit drugs, the full answer is usually that we don't really know. So, we can only go on a few studies, a few reports and what we know about the drugs themselves.

Cannabis (illegal in most countries):

Smoking cannabis increases the amount of dopamine in the pleasure centres of the brain, which is where the reward or buzz comes from. However, psychosis also comes from having too much dopamine in another area of the brain. You have to remember that cannabis can increase dopamine in all areas of the brain and so can make psychosis worse. Please be careful, everything in moderation and if dope makes you worse, keep off the grass. It really won't help you in the long-term. Don't forget that if you're a toker, you're also a smoker, so see the question above. However, it seems that there are no extra problems if smoking cannabis with any of the anticholinesterases.

Cocaine (illegal in most countries)

Cocaine is of course highly addictive and has many adverse or side effects on the body and brain. It can make most mental health symptoms worse in the long-term. However, there are no reports of extra problems with the anticholinesterases and cocaine, although this doesn't mean it's safe.

Ecstasy (illegal in most countries)

Ecstasy has many effects on the brain, the main ones producing the high seem to be by boosting serotonin, noradrenaline and dopamine in the brain. While it can cause a high, the effect wears off fairly quickly. It seems that the toxic effects on the brain are cumulative i.e. the more tablets you have over your lifetime, the more chance you have of having damage to the brain e.g. long-term depression and poor memory. However, there are no reports of extra problems with the anticholinesterases and ecstasy, but again this doesn't mean it's safe.

Opiates

The opiates include many chemicals, some of which are used in medical care (e.g. codeine for diarrhoea and stopping coughs, diamorphine and morphine for pain). However, there are no extra problems reported from taking opiates (e.g. heroin, methadone, codeine) with the anticholinesterases.

^{Updated 1.12}

• Hide this answer

In the UK, Levonelle one step® is available and is usually known as 'the morning after pill'. It is taken to reduce the chances of becoming pregnant after unprotected sex or failure of a contraceptive method. In fact "Emergency Contraception" is the better term because it can be taken up to 72 hours (3 days) afterwards. It can be bought over-the-counter without a prescription from pharmacies. EllaOne® tablets (which may work up to 5 days afterwards) and a coil (Intra-uterine device) can also be used but must be prescribed by a Doctor.

If you are taking an anticholinesterase, the usual dose should work if you follow the instructions carefully.

N.B. We accept that for religious, cultural or ethical reasons some people do not approve of, or agree with, the use of the "Morning After" pill. However, we have answered the question because it is one of the most often asked of NHS Direct in UK, and they suggested we include it.

^6.11

• Hide this answer

You should have no problems with "The Pill" and any of the anticholinesterases.

^{Updated 8.11}

• Hide this answer

Several female functions such as menstrual cycle (e.g. your periods) are controlled by a hormone called prolactin. Prolactin in the body rises during and after pregnancy and this triggers the body to make breast milk. The amount of prolactin in the body is kept in control by one part of the brain uses dopamine as its chemical messenger. Some medicines (especially antipsychotics) block the effect of dopamine in the brain.

Luckily the anticholinesterases don't seem to have any effect on dopamine in this part of the brain and so should not have any effect on your periods. If your periods are irregular or late, or you start leaking milk, then you should see your doctor about this to find the cause.

^{Updated 11.11}

• Hide this answer

It is important to consider that there will be a risk to you and your child from taking a medicine during pregnancy but also a possible risk from stopping the medicine e.g. getting ill again. Unfortunately, no decision is risk-free. It will be for you to decide which is the least risk. All we can do here is to help you understand some of the issues, so you can make an informed decision. For your information, major malformations occur "spontaneously" in about 2-4% of all pregnancies, even if no drugs are taken. The main problem with medicines is termed "teratogenicity" i.e. a medicine causing a malformation in the unborn child. A medicine causing teratogenicity is called a "teratogen". Since a baby has completed it's main development between days 17 and 60 of the pregnancy (the so-called "first trimester") these first 2-16 weeks are the main concern. After that, there may be other problems e.g. some medicines may cause slower growth. The infant may also be affected after birth e.g. withdrawal effects are possible with some drugs

If possible, the best option is to plan in advance. If you think you could become pregnant, discuss this with your doctor and it may be possible to switch to medicines thought to carry least risk, and take other risk-reducing steps e.g. adjusting doses, taking vitamin supplements etc. If you have just discovered you are pregnant, don't panic, but seek advice from your GP within the next few days if possible. He or she may also want to refer you on to someone with more specialist knowledge of your medicine

Very few medicines have been shown to be completely safe in pregnancy and so no manufacturer or advisor can ever say any medicine is safe. They will usually advise not to take a medicine during pregnancy, unless the benefit is much greater than the risk. In the UK, there is the NTIS (National Teratology Information Service) who offer individual risk assessments. However, their advice should always be used to help you and your doctor decide what is the risk to you and your baby. There is a risk from taking the medicine and a risk should you stop a medicine e.g. you might become ill again and need to go back on the medication again. The advice offered here is just that i.e. advice, but may give you some idea about the possible risks and what (at the time of writing) is known through the medical press

It may be helpful to know that in the USA, the FDA (Food and Drug Administration) classifies medicines in pregnancy in five groups:
A = Studies show no risk, so harm to the unborn child appears only a remote possibility
B = Animal and human studies indicate a lack of risk but are not fully conclusive
C = Animal studies indicate a risk but there is no safety data in humans
D = a definite risk exists but the benefit may outweigh the risk in some people
X = the risk outweighs any possible benefit

Anticholinesterases are classified as "C". There is no evidence of a teratogenic effect, and animal tests show a low risk of danger but you should still seek personal advice from your GP, who may then if necessary seek further specialist advice.

^3.11

• Hide this answer

Almost every medicine passes into breast-milk. The main questions are how much and if this is likely to have an effect on your baby. But also remember that being ill (e.g. depressed, manic, psychotic) may have more harmful and lasting effects on you and your child (such as bonding and behaviour e.g. Field, 2010) than a small amount of an effective medicine. If you have been taking a medicine while you are pregnant, you should usually be able to carry on as the amount in breast-milk is much less than the baby would have got while you were pregnant. It is usually thought to be fairly safe if the baby gets less than 10% of the mum's dose. But there may be times when although a medicine gets into breast milk the benefit may be worth the risk, so you should seek personal advice on this.

If you stop any medicine suddenly, some people can get discontinuation or withdrawal symptoms (see question above). If you have been taking a medicine during pregnancy, the same can sometimes happen to the baby when born. If the drug gets into breast milk, this can reduce the effect of suddenly not having the medicine (as well as coping with being in the big wide world too).

If you want to breast-feed there are some things you can do to reduce any risk:

• Nearly all medicines can be taken once a day. So, taking your daily dose just before the baby's longest sleep (often this will be at night) will reduce the amount the baby gets from the milk.
• Any side effects in the baby will be higher if the mum is taking a higher dose. So, try to take the lowest dose possible to still get an effect.
• Try not to take any medicines you don't really need. This includes any medicines you might buy over-the-counter
• Make sure your nurse, health visitor or doctor checks your baby for any side effects e.g. being extra sleepy, having colic, feeding problems, being floppy or poor weight gain. If there are any problems you might need to switch medicines or drop your dose a bit
• Hind milk (the second half of the feed) is likely to contain slightly more of any medicine than the first half
• Avoid new medicines if possible as there is less information about them and breast-feeding.

You must be extra careful of any medicines if your baby was pre-mature, or has kidney, liver, heart or brain problems.

We don't really know about anticholinesterases. It is officially not recommended and the risk would seem to be there so we wouldn't recommend it either.

^6.11

• Hide this answer

Anticholinesterases should not affect your ability to carry out skilled tasks such as driving or operating machinery.

If you are taking any medicines, the rules about driving will depend on the country you’re driving in. Click on the links below for advice:

• Medicines and driving in the UK (England, Scotland, Northern Ireland and Wales)

• Medicines and driving in the Republic of Ireland

General advice on driving safely

If you want to drive, you should take sensible steps to reduce any risk. These could include:

• Avoid driving when you are tired or ill
• Do not drive after having any alcohol as this can make any drowsiness worse (a third of all fatal road traffic incidents involve alcohol-dependent drivers)
• Avoid driving at night, dusk or in bad weather
• Avoid motorways, dual carriageways and the rush hour
• Give yourself plenty of time. Don’t rush
• Be extra careful if you have not slept well the previous night

As some medicines can affect your driving, be extra careful:

• If starting a new medicine
• After a change in dose (especially an increase)
• If you are on a high dose or seem very sensitive to side effects
• If you are taking any medicines for other symptoms e.g. antihistamines for hay fever or allergies
• If your medicine causes you blurred vision, drowsiness, poor co-ordination, poor attention

If you are driving less than 2000 miles a year, once you consider insurance, tax, MoT, repairs, maintenance, parking and petrol, you may actually find it is cheaper to get taxis and busses, and walk the short journeys.

^{Updated 11.11}

• Hide this answer

You should not need to have a blood test to check on your anticholinesterase, although your doctor may want to check your blood for other reasons.

^3.11

• Hide this answer