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Executive summary

Alzheimer's disease (AD) is the most commonly occurring form of dementia, accounting for approximately 62% of instances of dementia. AD is predominantly a disease of later life, with 5% of the UK population over 65 years affected. In England and Wales, among people aged 65–69 years, the incidence is estimated to be 7.4 [95% confidence interval (CI) 3.6 to 16.1] per 1000 person-years, rising to 84.9 (95% CI 63.0 to 107.8) per 1000 person-years at 85 years old and above. These rates predict 180,000 new cases of dementia per year and, if 62% of these have AD (see above), then there are approximately 111,600 new cases in England and Wales per year.

Health Technology Assessment programme

Director, Professor Tom Walley, CBE, Director, NIHR HTA programme, Professor of Clinical Pharmacology, University of Liverpool

Discussion

The remit for this report has been to update the evidence used to inform the last NICE guidance on donepezil, galantamine, rivastigmine and memantine for the treatment of AD, particularly as laid out in the report by SHTAC. In general, they considered evidence up to 2004, and this is the start date that we have used for this report.

Background

The aim of this assessment is to review and update, as necessary, the National Institute for Health and Clinical Excellence (NICE) guidance to the NHS in England and Wales (issued November 2006, amended September 2007 and August 2009) on the clinical effectiveness and cost-effectiveness of donepezil, galantamine and rivastigmine for mild-to-moderate Alzheimer's disease (AD), and memantine for moderate-to-severe AD.

Assessment of cost-effectiveness

The aim of this chapter is to assess the cost-effectiveness of donepezil, rivastigmine, galantamine and memantine for AD, updating the last guidance, NICE TA111, which considered evidence up to July 2004. The economic analysis comprises a systematic review of the literature on cost-effectiveness, a review of the manufacturer's submissions to NICE on cost-effectiveness and this Technology Assessment Group's independent economic model.

Assessment of industry submissions to NICE

Four manufacturer submissions were potentially available for this multiple TA (MTA). However, Novartis did not submit an economic evaluation and Shire provided only a critique of aspects of the previous SHTAC model that they felt remained unaddressed. The remaining two manufacturers both submitted economic evaluations based on decision models, and they are both critiqued in this chapter. A critique of their clinical effectiveness evidence reviews can be found in Chapter 3 (see Manufacturers' reviews of clinical effectiveness).

The Peninsula Technology Assessment Group cost–utility assessment

The aim of this assessment is to review, and update as necessary, NICE guidance to the NHS in England and Wales on the clinical effectiveness and cost-effectiveness of donepezil, galantamine, rivastigmine, for mild-to-moderate AD, and memantine, for moderate-to-severe AD, which was issued in November 2006, and amended in September 2007 and August 2009.

Assessment of clinical effectiveness

The purpose of the systematic review of clinical effectiveness is to record the studies found by Loveman and colleagues in 2004 and to update their findings with the results of subsequent trials.

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