Types of dementia Reminyl is indicated for a patient with mild to moderately severe dementia of the Alzheimer type. The benefit of galantamine in patients with other types of dementia or other types of memory impairment has not been demonstrated. In 2 clinical trials of 2 years duration in individuals with so called mild cognitive impairment (milder types of memory impairment not fulfilling the criteria of Alzheimer's dementia), galantamine therapy failed to demonstrate any benefit either in slowing cognitive decline or reducing the clinical conversion to dementia. The mortality rate in the galantamine group was significantly higher than in the placebo group, 14/1026 (1.4%) patients on galantamine and 3 /1022 (0.3%) patients on placebo. The deaths were due to various causes. About half of the galantamine deaths appeared to result from various vascular causes (myocardial infarction, stroke, and sudden death). The relevance of this finding for the treatment of patients with Alzheimer's dementia is unknown. No increased mortality in the galantamine group was observed in a long term, randomized, placebo controlled study in 2045 patients with mild to moderate Alzheimer´s disease. The mortality rate in the placebo group was significantly higher than in the galantamine group. There were 56/1021 (5.5%) deaths in patients on placebo and 33/1024 (3.2%) deaths in patients on galantamine (hazard ratio and 95% confidence intervals of 0.58 [0.37 0.89]; p=0.011).A diagnosis of Alzheimer's dementia should be made according to current guidelines by an experienced physician. Therapy with galantamine should occur under the supervision of a physician and should only be initiated if a caregiver is available who will regularly monitor medicinal product intake by the patient.
Serious skin reactionsSerious skin reactions (Stevens Johnson syndrome and acute generalized exanthematous pustulosis) have been reported in patients receiving Reminyl (see section 4.8). It is recommended that patients be informed about the signs of serious skin reactions, and that use of Reminyl be discontinued at the first appearance of skin rash.
Weight monitoringPatients with Alzheimer's disease lose weight. Treatment with cholinesterase inhibitors, including galantamine, has been associated with weight loss in these patients. During therapy, patient's weight should be monitored.
Conditions requiring cautionAs with other cholinomimetics, galantamine should be given with caution in the following conditions:
Cardiac disorders Because of their pharmacological action, cholinomimetics may have vagotonic effects on heart rate (e.g. bradycardia). The potential for this action may be particularly important to patients with 'sick sinus syndrome' or other supraventricular cardiac conduction disturbances or in those who use medicinal products that significantly reduce heart rate concomitantly, such as digoxin and beta blockers or for patients with an uncorrected electrolyte disturbance (e.g. hyperkalaemia, hypokalaemia). Caution should therefore be exercised when administering galantamine to patients with cardiovascular diseases, e.g. immediate post-myocardial infarction period, new-onset atrial fibrillation, second degree heart block or greater, unstable angina pectoris, or congestive heart failure, especially NYHA group III IV.In a pooled analysis of placebo-controlled studies in patients with Alzheimer's dementia treated with galantamine an increased incidence of certain cardiovascular adverse events were observed (see section 4.8).
Gastrointestinal disorders Patients at increased risk of developing peptic ulcers, e.g. those with a history of ulcer disease or those predisposed to these conditions, including those receiving concurrent non-steroidal anti-inflammatory drugs (NSAIDS), should be monitored for symptoms. The use of galantamine is not recommended in patients with gastro-intestinal obstruction or recovering from gastro-intestinal surgery.
Nervous system disordersSeizures have been reported with galantamine (see section 4.8). Seizure activity may also be a manifestation of Alzheimer's disease. In rare cases an increase in cholinergic tone may worsen Parkinsonian symptoms. In a pooled analysis of placebo-controlled studies in patients with Alzheimer's dementia treated with galantamine cerebrovascular events were uncommonly observed (see section 4.8). This should be considered when administering galantamine to patients with cerebrovascular disease.
Respiratory, thoracic and mediastinal disordersCholinomimetics should be prescribed with care for patients with a history of severe asthma or obstructive pulmonary disease or active pulmonary infections (e.g. pneumonia).
Renal and urinary disordersThe use of galantamine is not recommended in patients with urinary outflow obstruction or recovering from bladder surgery.
Surgical and medical proceduresGalantamine, as a cholinomimetic, is likely to exaggerate succinylcholine type muscle relaxation during anaesthesia, especially in cases of pseudocholinesterase deficiency.
Excipients of Reminyl film-coated tabletsOrange yellow S aluminium lake (E110), present in the 12 mg tablet, may cause allergic reactions. Reminyl tablets contain lactose monohydrate. Patients with rare hereditary problems of galactose intolerance, the Lapp lactase deficiency or glucose-galactose malabsorption should not take this medicine.