Dual AChEI and BuChEI inhibitor — dementia Pregnancy: Not applicable.

Rivastigmine

Brand names: Exelon

Adult dose

Dose: Oral: 1.5 mg twice daily, increasing by 1.5 mg BD every 2 weeks to max 6 mg BD; Patch: 4.6 mg/24h initially

Route: Oral or transdermal patch

Frequency: Twice daily (oral); once daily (patch — apply to upper back/shoulder/chest)

Max: 12 mg/day oral; 13.3 mg/24h patch

Alzheimer's and Parkinson's disease dementia: oral start 1.5 mg BD (with food). Increase every 2 weeks by 1.5 mg BD. Patch: 4.6 mg/24h for 4 weeks, then 9.5 mg/24h, then 13.3 mg/24h. Patch has fewer GI side effects than oral.

Paediatric dose

Route: Not applicable

Frequency: Not licensed in children

Max: Not applicable

Not licensed in children.

Dose adjustments

Renal

No dose adjustment required for mild-moderate impairment.

Hepatic

Titrate cautiously in hepatic impairment.

Clinical pearls

First-choice AChEI for Parkinson's disease dementia (evidence strongest in this indication)
Transdermal patch provides smoother plasma levels — fewer GI side effects
Rotate patch site daily — apply to upper back, upper arm, or chest
Never use more than one patch at a time
Remove old patch before applying new (risk of overdose)

Contraindications

Hypersensitivity to rivastigmine
History of application site reactions with patch that generalised

Side effects

GI toxicity (nausea, vomiting, diarrhoea — oral > patch)
Weight loss (anorexia)
Dizziness and headache
Application site reactions (patch)
Bradycardia
Nightmares

Interactions

Anticholinergics — antagonistic
Succinylcholine — prolonged neuromuscular blockade

Monitoring

MMSE/MoCA
Weight
GI tolerance
HR

Reference: BNFc; BNF; NICE TA217; NICE NG97. Verify against your local formulary and the latest BNF before prescribing.

Curated clinical cross-links plus same-class fallbacks.

Calculators

Pathways