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Rivastigmine Patch for GI Intolerance — MRCPsych Paper B MCQ

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ModerateOld Age PsychiatryRivastigmine Patch for GI IntoleranceMRCPsych Paper B

A 76-year-old woman with mild Alzheimer’s disease has experienced symptomatic benefit from galantamine. Despite taking it with food and reducing the dose, she has persistent nausea, reduced appetite and clinically significant weight loss. Other causes have been excluded, and the symptoms improve when galantamine is withheld. She and her family wish to continue acetylcholinesterase-inhibitor treatment if feasible. Which is the most appropriate next pharmacological option?

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Correct answer: A — Stop galantamine and, after the adverse effects settle, initiate a low-dose rivastigmine transdermal patch

Explanation lettering: B = shown as A · D = shown as B · E = shown as D · A = shown as E

B is correct. NICE permits selection of an alternative acetylcholinesterase inhibitor when the adverse-event profile makes the current drug unsuitable. Galantamine can cause nausea, reduced appetite and weight loss; because these have persisted despite dose reduction and are clinically significant, it should be stopped. Rivastigmine can then be initiated as a 4.6 mg/24-hour transdermal patch and titrated according to tolerability. Transdermal administration produces smoother plasma exposure than oral rivastigmine and may improve gastrointestinal tolerability, although nausea and weight loss can still occur; weight, pulse and skin reactions should therefore be monitored. Permanent withdrawal of all cognitive treatment is unnecessary when another acetylcholinesterase inhibitor remains feasible. Increasing galantamine may worsen dose-related cholinergic effects, while long-term antiemetic treatment does not adequately address the causative medicine. Memantine monotherapy is not the NICE-recommended alternative for mild Alzheimer’s disease.

Reference: NICE. Dementia: assessment, management and support for people living with dementia and their carers (NG97), recommendations 1.5.2 and 1.5.6. 2018. https://www.nice.org.uk/guidance/ng97/chapter/Recommendations