Donepezil is a centrally active cholinesterase inhibitor that has been used to treat dementia in patients with Alzheimer disease. It may improve the ability to think and remember in these patients, and has also been studied in patients with cancer for fatigue and cognitive impairment.
Day, J., Zienius, K., Gehring, K., Grosshans, D., Taphoorn, M., Grant, R., . . . Brown, P.D. (2014). Interventions for preventing and ameliorating cognitive deficits in adults treated with cranial irradiation. Cochrane Database of Systematic Reviews, 12, CD011335.
PHASE OF CARE: Multiple phases of care
Three cognitive interventions aimed at preventing cognitive decline during radiation therapy were reported. Two were pharmacologic. One tested memantine versus a placebo and found significant improvement in overall cognitive function, and one tested methylphenidate versus a placebo but failed to detect any significant differences between groups. The third study was nonpharmacologic and investigated the use of a rehabilitation program to prevent cognitive decline but did not statistically compare differences between groups. Three cognitive interventions aimed at ameliorating cognitive decline were reported. All three were pharmacologic studies. Two studies compared methylphenidate versus modafinil and one study examined donepezil versus a placebo. Both methylphenidate and modafinil interventions resulted in improved cognitive function. Combination therapy resulted in greater adverse events. Donepezil was found to improve the domain of memory after radiotherapy.
The authors reported that there was evidence for the use of memantine for preventing cognitive decline in patients receiving radiotherapy for brain metastasis. Likewise, there was supporting evidence for the use of donepezil in improving memory after radiotherapy for primary or metastatic brain tumors. There was limited evidence for cognitive behavioral or training interventions in preventing cognitive decline.
Patients who receive cranial radiation therapy for primary brain tumors or metastatic lesions are at risk for declining cognitive function. The use of memantine during radiation therapy may aid in preventing cognitive decline. Those who develop cognitive decline after the completion of radiation therapy, even years afterwards, may benefit from donepezil administration. Additional exploration of interventions that may prevent or ameliorate cognitive decline related to cranial radiation therapy is warranted.
Jatoi, A., Kahanic, S.P., Frytak, S., Schaefer, P., Foote, R.L., Sloan, J., & Petersen, R.C. (2005). Donepezil and vitamin E for preventing cognitive dysfunction in small cell lung cancer patients: Preliminary results and suggestions for future study designs. Supportive Care in Cancer, 13(1), 66–69.
The study was conducted to test oral donepezil and oral vitamin E in patients with small-cell lung cancer after completion of all cancer therapy and prophylactic cranial irradiation.
A randomization procedure was conducted after participant stratification in the following ways.
The treatment group received 5 mg/day of oral donepezil, which increased to 10 mg/day after one month of therapy if tolerated well. Treatment group participants also received 1000 IU/day of oral vitamin E. The control group was given an identical oral placebo. Assessments were performed at study enrollment, one month, and every three months until cancer recurrence or treatment failure.
The study took place at the North Central Cancer Treatment Group and the Mayo Clinic.
The study was a double-blind, placebo-controlled trial.
There were no notable differences in cognitive stability, adverse events, or quality of life between treatment arms. Only one patient, who received donepezil and vitamin E, manifested a three-point drop in cognitive scores as measured by the MMSE. There was a slight trend of increased gastrointestinal side effects among patients treated with donepezil and vitamin E.
The median time spent in the study was 42 or 69 days for the treatment or control group, respectively.
Due to low enrollment and retention, the effect of oral doses of vitamin E and donepezil on cognitive function could not be determined.
Lawrence, J.A., Balcueva, E.P., Groteluschen, D.L., Samuel, T.A., Lesser, G.J., Naughton, M.J., . . . Rapp, S.R. (2016). A study of donepezil in female breast cancer survivors with self-reported cognitive dysfunction 1 to 5 years following adjuvant chemotherapy. Journal of Cancer Survivorship, 10, 176–184.
To evaluate the feasibility of taking daily donepezil, an acetylcholinesterase inhibitor, to improve cognitive function in women who report cognitive impairment one to five years after completing adjuvant chemotherapy for breast cancer
This study evaluated the feasibility of a randomized, controlled trial of 24 weeks of donepezil (5 mg/day for 6 weeks, then 10 mg/day for 18 weeks) versus placebo. Potential participants were prescreened for moderate-to-severe self-reported cognitive impairment, and those enrolled were stratified by menopausal status and time since chemotherapy. Self-reported cognitive function, co-occurring symptoms, and quality of life were measured before the trial, halfway through the trial (i.e., 12 weeks), and at the completion of the trial (i.e., 24 weeks). Neuropsychological testing was conducted at baseline and 24 weeks.
Double-blind, randomized, controlled trial of donepezil versus placebo with repeated measures
Donepezil may have some benefit for patients related to changes in cognitive function. Further research is needed to provide strong evidence.
This study primarily showed that future large studies of donepezil in women with breast cancer are feasible. The findings suggest that donepezil may improve memory in breast cancer survivors who report moderate-to-severe cognitive problems. Executive function may improve for some women. Anxiety and insomnia are potential side effects.
Rapp, S.R., Case, L.D., Peiffer, A., Naughton, M.M., Chan, M.D., Stieber, V.W., . . . Shaw, E.G. (2015). Donepezil for irradiated brain tumor survivors: A phase III randomized placebo-controlled clinical trial. Journal of Clinical Oncology, 33, 1653–1659.
To evaluate the effects of 24 weeks of donepezil versus placebo on objectively measured cognitive function starting at least six months after whole- or partial-brain irradiation
This clinical trial tested donepezil at 5 mg daily for six weeks followed by 10 mg daily for 18 weeks compared to a placebo. Study outcome measurements were collected before randomization, and 12 and 24 weeks after randomization.
PHASE OF CARE: Late effects and survivorship
Randomized, double-blinded, placebo-controlled trial
Self-reported adherence to the dose was approximately 92%, which did not differ between groups. The donepezil group reported more diarrhea (25%, p = 0.005) than the control. At baseline, both groups had poorer verbal memory, motor speed and dexterity, attention, and executive function compared to population norms. There was no improvement in overall cognitive function with 24 weeks of donepezil, but improvements were found for individual measures of memory (p = 0.007, 0.027) and motor speed and dexterity (p = 0.016). Donepezil showed greater improvement in overall cognitive function for patients with poorer cognitive function at baseline (p = 0.01).
For patients who received whole or partial brain irradiation, 24 weeks of donepezil improved memory and motor and speed dexterity. Greater improvements in multiple cognitive domains, including significant improvement in overall cognitive function, were found for patients with poorer cognitive function at baseline.
For patients who receive partial- or whole-brain irradiation for primary brain tumors or brain metastases, donepezil may improve memory and motor speed and dexterity. Patients with poorer cognitive function may have greater benefit, including improvement in overall cognitive function. Educate patients about the risk for diarrhea and appropriate management.
Shaw, E.G., Rosdhal, R., D’Agostino, R.B., Lovato, J. Naughton, M.J., Robbins, M.E., & Rapp, S.R. (2006). Phase II study of donepezil in irradiated brain tumor patients: Effect on cognitive function, mood, and quality of life. Journal of Clinical Oncology, 24(9), 1415–1420.
The study was conducted to determine whether donepezil improved cognitive functioning, mood, and quality of life in patients who had irradiated brain tumors.
All participants received 5 mg/day of donepezil for 6 weeks, then 10 mg/day of donepezil for 18 weeks, followed by a washout period of 6 weeks where no treatment was administered.
This was a prospective, open-label, phase II study.
Significant improvement was noted between the pre-treatment baseline and week 24 on measures of attention/concentration, verbal memory, figural memory, and a trend for verbal fluency (all p < 0.05). Confused mood was also improved from baseline to 24 weeks (p = 0.03). Health-related quality of life improved from baseline to 24 weeks in brain-specific concerns (p = 0.003), emotional functioning (p = 0.04), and social functioning (p = 0.02), with a trend for improvement in total health-related quality of life (p = 0.07).
Ten of 21 participants, or 48% of those who completed the study through the 30-week assessment, chose to go back on donepezil. A total of 63 toxicities ranging from grade 1 to grade 3 were reported.
Mood, health-related quality of life, and cognitive functioning (attention/concentration, verbal memory, and figural memory) were significantly improved following a 24-week course of donepezil.