Rivastigmine ER

Class
Anti-dementia agents
Subclass
Acetylcholinesterase inhibitors
Substance name
Rivastigmine ER
Brand names
Exelon®
Common formulations
Patch
See also
Rivastigmine tartrate (Exelon®)
Dosage and administration
Adults patients
Alzheimer's disease • Mild-to-moderate
•
Start at: 4.6 mg TD daily for 4 weeks
•
Maintenance: 9.5-13.3 mg TD daily
•
Maximum: 13.3 mg per day
Titrate after at least 4 weeks based on severity and tolerance. Restart treatment at 4.6 mg if interrupted for > 3 days.
Dementia in patients with Parkinson's disease • Mild-to-moderate
•
Start at: 4.6 mg TD daily for 4 weeks
•
Maintenance: 9.5-13.3 mg TD daily
•
Maximum: 13.3 mg per day
Titrate after at least 4 weeks based on severity and tolerance. Restart treatment at 4.6 mg if interrupted for > 3 days.
Other off-label uses
•
Treatment of isolated REM sleep behavior disorder in patients with Parkinson's disease
•
Treatment of isolated REM sleep behavior disorder in patients with MCI
Indications for use
Labeled indications
Adults
•
Treatment of Alzheimer's disease (mild-to-moderate)
•
Treatment of dementia in patients with Parkinson's disease (mild-to-moderate)
Off-label indications
Adults
•
Treatment of isolated REM sleep behavior disorder in patients with Parkinson's disease
•
Treatment of isolated REM sleep behavior disorder in patients with MCI
Safety risks
Contraindications
Hypersensitivity to rivastigmine or its components or other carbamate derivatives
History of application-site reaction with rivastigmine transdermal patch
Warnings and precautions
Bradycardia
•
Use caution in patients with sick sinus syndrome or other supraventricular cardiac conduction conditions.
Bronchospasm
•
Use caution in patients with asthma or COPD.
Cognitive difficulties
•
Use extreme caution in patients performing activities requiring mental alertness, such as driving or operating machinery.
Exacerbation of parkinsonism
•
Use caution in patients with Parkinson's disease.
Exacerbation of skeletal muscle relaxation
•
Use caution in patients receiving succinylcholine during anesthesia.
Nausea, vomiting, loss of appetite, weight loss
•
Maintain a high level of suspicion, as rivastigmine has been associated with an increased risk for these adverse events.
Peptic ulcer disease, gastrointestinal bleeding
•
Use caution in patients with a history of or at risk of peptic ulcer disease.
Seizure
•
Maintain a high level of suspicion, as cholinergic agents, although not reported specifically with rivastigmine, have been associated with an increased risk of seizures.
Urinary retention
•
Maintain a high level of suspicion, as cholinergic agents, although not reported specifically with rivastigmine, have been associated with an increased risk of urinary obstruction.
Specific populations
Renal impairment
eGFR 0-90 mL/min/1.73 m²
•
Use acceptable. No dose adjustment required.
Renal replacement therapy
Any modality
•
No guidance available.
Hepatic impairment
Child-Pugh A (mild)
•
Reduce dose. Patients may be able to only tolerate lower doses.
Child-Pugh B (moderate)
•
Reduce dose. Patients may be able to only tolerate lower doses.
Child-Pugh C (severe)
•
No guidance available.
Pregnancy and breastfeeding
Pregnancy
All trimesters • Australia Category: B2
•
Use only if benefits outweigh potential risks.
Breastfeeding
Use only if benefits outweigh potential risks.
Unknown amount excreted in breastmilk.
Unknown drug levels in breastfed infants.
Adverse reactions
Very common > 10%
•
Agitation, falls, nausea, weight loss, skin erythema
Common 1-10%
•
Dehydration, abdominal pain, anxiety, depression, diarrhea, dizziness, headache, insomnia, loss of appetite, pruritus, skin rash, asthenia, vomiting, tremor, urinary tract infections
Unknown frequency
•
↓ serum sodium, seizure, parkinsonism, bradycardia, bronchospasm, cognitive impairment, pneumonia, allergic contact dermatitis, peptic ulcer disease
Interactions
Drug(s)
Check Interactions
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