Examining the Case for Involuntary Weight Loss After Switching Acetylcholinesterase Inhibitors: Page 2 of 2

March 15, 2013

Considering Polypharmacy 

Stewart and colleagues’ case patient received several co-administered medications that could have contributed to his weight loss during the 17-month period when he received galantamine and during the 3-month period when he regained most of his weight after being switched back to donepezil. However, the authors reported no significant changes to any of these coadministered medications during either period, making it unlikely that these agents contributed to his weight changes. 

Another problem that is mentioned is the patient’s repeated falls, which was a major contributor to his nursing home admission. The authors do not discuss whether the falls resolved upon the patient being switched back to donepezil or after he regained his weight. Although falls are a known risk of AChEI use, he was taking several other medications that have been associated with falls, including risperidone, gabapentin, and citalopram. Therefore, a patient’s total psychoactive drug load needs to be considered when he or she experiences recurrent falls.15,16 The patient’s history of schizophrenia suggests that discontinuing risperidone was not an option. Because his gabapentin dosage was very low, his serum drug concentrations may have been too low to determine whether this agent posed any risk; however, the reason for using gabapentin and the additive effect of his psychoactive drug load on his falls need to be considered. 

Stewart and colleagues also report that the patient’s depression medication was switched from citalopram to mirtazapine to improve his appetite, but this switch was not successful and he continued to lose weight. Because weight gain was not an objective in this overweight diabetic patient, no nutritional supplements or nutritional aides were added to his 2000-calorie per day diet that also enabled him to eat snacks as desired.17 The authors did not provide information on his baseline serum albumin, vitamin B12, homocysteine, and folate levels and on his total lymphocyte count, but this information might have shed additional light on his nutritional status and enabled the authors to fully account for any changes in his condition.1 


Although it is possible that several other factors contributed to Stewart and colleagues’ case patient losing weight after being switched to galantamine, we agree with the authors that their report provides a reminder of how the risk and benefits of AChEIs need to be carefully assessed and their use individualized. We also agree that all agents in a particular medication class may not always have the same side effect profile for a given patient. 


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15. Cooper JW, Freeman MH, Cook CL, Burfield AH. Assessment of psychotropic and psychoactive drug loads and falls in nursing facility residents. Consult Pharm. 2007;22(6):483-489.

16. Cooper JW, Freeman MH, Cook CL, Burfield AH. Psychotropic and psychoactive drugs and hospitalization rates in nursing facility residents. Pharmacy Practice. 2007;5(3):140-144.

17. McRae A, Cooper JW. Use of nonaggressive short-term nutritional supplementation in a skilled nursing facility. Consult Pharm. 1998;13:174-181. 


Dr. Cooper has served in the past as a researcher, advisor, and/or speaker for donepezil, galantamine, citalopram, memantine, escitalopram, mirtazapine, risperidone, and gabapentin. He has no current activities, interests, or ownership of any kind in any of these products. Dr. Burfield reports no relevant financial relationships. 


Address correspondence to:

Allison H. Burfield, RN, MSN, PhD 

University of North Carolina at Charlotte

College of Health and Human Services, School of Nursing

9201 University City Blvd

Charlotte, NC 28223-0001