Utilization of Cholinesterase Inhibitors for Alzheimer Disease in Canada

Key Messages

• Due to upcoming Canadian market approvals of biologics for Alzheimer disease, a utilization study was conducted to assess the current utilization patterns and funding criteria for cholinesterase inhibitors (ChEIs) in selected Canadian jurisdictions from 2017 to 2020.
• Most jurisdictions list ChEIs as exception status, special authorization, or limited use drugs except Manitoba; as of 2018, Manitoba lists donepezil and galantamine as regular benefits and rivastigmine as an exception status drug. Additionally, British Columbia and New Brunswick fund galantamine and rivastigmine after a patient is deemed intolerant to donepezil.
• The following are insights from the utilization analysis.
  • Across Canada, there has been a decrease in the number of beneficiaries and claims for all ChEIs from 2017 to 2020 in all jurisdictions except Manitoba:
    • There was a 12% reduction in number of beneficiaries and a 17% reduction in the number of total claims from 2017 to 2020.
    • In Manitoba, there was an increase in the number of ChEI beneficiaries that peaked in 2018, which corresponds to the formulary changes for donepezil and galantamine during this period.
  • Across Canada, donepezil had the highest market share among all ChEIs each year from 2017 to 2020, which increased from 71.2% in 2017 to 75.8% in 2020. Galantamine had the second-highest market share each year. The market shares for both galantamine and rivastigmine decreased over time, indicating there is a preference for prescribing donepezil to patients with Alzheimer disease.
    • The greater use of donepezil may be explained by prescriber preferences or coverage criteria for ChEIs (e.g., donepezil is considered first line in British Columbia and New Brunswick).
  • The cumulative costs of all ChEIs paid for by public drug plans across Canada in 2020 was $20,659,136, a decrease of 43% from $36,325,781 in 2017, which corresponds with the decrease in the total number of ChEI beneficiaries.
    • Donepezil had the highest national total costs, followed by galantamine, then rivastigmine, which corresponds to the market share for each of these drugs. However, on a cost-per-beneficiary basis, donepezil was associated with the lowest cost estimates in each year from 2017 to 2020.