rivastigmine: clinical use

Prescribing considerations

• Initiation and supervision should involve a clinician experienced in diagnosing and treating Alzheimer’s dementia, with reliable caregiver support for patch administration and monitoring.
• Assess cardiac conduction disease, QT-risk factors, ulcer history, urinary obstruction, seizures, asthma or obstructive pulmonary disease, low body weight and hepatic impairment.
• Medication errors commonly involve failure to remove an old patch or simultaneous use of multiple patches; provide explicit application training.
• Use particular caution after treatment interruption and if switching formulation; follow the relevant current product information rather than assuming oral and patch quantities are equivalent.

Contraindications and cautions

• Hypersensitivity to rivastigmine, another carbamate derivative or a product excipient.
• Previous patch-site reaction suggestive of allergic contact dermatitis to rivastigmine.

Monitoring

• Regularly reassess cognitive, functional and overall clinical benefit.
• Monitor weight, appetite, gastrointestinal tolerance and hydration.
• Review pulse, syncope and falls; consider ECG monitoring where conduction or QT risk exists.
• Inspect and ask about application-site reactions, especially spreading erythema, oedema, papules or vesicles.
• Monitor for tremor or other new or worsening extrapyramidal symptoms.

Clinical pharmacology

Rivastigmine is a carbamate acetylcholinesterase and butyrylcholinesterase inhibitor. It forms a temporarily inactivating complex with these enzymes. Transdermal absorption is gradual and produces less peak-to-trough fluctuation than oral administration; patch release quantities cannot be directly equated with oral milligram quantities.

Formulation and product differences

• The selected patch is licensed for Alzheimer’s dementia and delivers rivastigmine through intact skin.
• Transdermal exposure is smoother than oral exposure and may have a different tolerability profile, but local skin reactions are specific to patches.
• Patches must not be cut, exposed to prolonged external heat or layered with another patch.
• Oral-to-patch switching requires formulation-specific prescribing instructions and clinical oversight.

Transdermal patch

Route: Transdermal

Strengths: 4.6 mg/24 hours, 9.5 mg/24 hours, 13.3 mg/24 hours