Letters to the Editor  |   October 2006
Author Affiliations
  • Jay M. Ellis, DO
    Neuroscience Research of the Berkshires Pittsfield, Mass
Article Information
Geriatric Medicine / Neuromusculoskeletal Disorders
Letters to the Editor   |   October 2006
The Journal of the American Osteopathic Association, October 2006, Vol. 106, 590. doi:
The Journal of the American Osteopathic Association, October 2006, Vol. 106, 590. doi:
The purpose of my March 2005 review article (J Am Osteopath Assoc. 2005; 105:145–158) was to make it clear that, among the acetylcholinesterase inhibitors, there is no single “best” agent for the treatment of patients with Alzheimer disease. In my own practice, I use all three agents to treat patients for this condition. 
In my article, I diligently avoided recommending any agent preferentially. In fact, to avoid the appearance of favoritism toward any of the agents mentioned, I intentionally rotated the sequence of the names when all three agents were presented together. This personal preference of mine diverges from traditional editorial practice, which places lists of agents in alphabetical order by default when no specific treatment recommendations are being made as a result of differences in efficacy or tolerability, for example. My preference required specific instructions to my manuscript editor at The Journal (R.J. Fiala, MA, oral communication, March 2005). 
Finally, it is the responsibility of biomedical researchers to discover and report treatment differences among pharmaceutical agents, as I did. Drs Shah and Krueger took exception to what they perceived as an implied recommendation of rivastigmine tartrate in my statement about a positive difference in overall ADAS-Cog [the Alzheimer's Disease Assessment Scale -Cognitive Subscale] scores between that agent and placebo. However, my statement accurately reflected the data available at the time of publication1,2 and in no way indicates (or implies) that this difference should be the basis for recommending rivastigmine tartrate over donepezil hydrochloride or galantamine hydrobromide. 
Drs Shah and Krueger accurately report that head-to-head studies for acetylcholinesterase inhibitors were lacking at the time of publication. These data are now available, however. As anticipated, each acetylcholinesterase inhibitor was efficacious. Subsequent researchers have joined me in stating that physicians cannot easily predict which treatment option would be best for any given patient. 
Corey-Bloom J, Anand R, Veach J. A randomized trial evaluating the efficacy and safety of ENA 713 (rivastigmine tartrate), a new acetylcholinesterase inhibitor, in patients with mild to moderately severe Alzheimer's disease. Int Geriatr Psychopharmacol. 1998;2:55 –65.
Rosler M, Anand R, Cicin-Sain A, Gauthier S, Agid Y, Dal-Bianco P, et al. Efficacy and safety of rivastigmine in patients with Alzheimer's disease: international randomised controlled trial [published correction appears in BMJ. 2001;322:1456]. BMJ. 1999;318:633–638. Available at: Accessed September 26, 2006.