Rivastigmine

How it works

It reversibly inhibits both acetylcholinesterase and butyrylcholinesterase, increasing synaptic acetylcholine to support cholinergic neurotransmission.

Prescribing in practice

• Cholinergic adverse effects, particularly nausea, vomiting and weight loss, can be marked, and severe gastrointestinal reactions warrant interruption with re-titration after any treatment gap.
• The transdermal patch should be applied to clean, dry, hairless intact skin with rotation of sites, and only one patch worn at a time to avoid overdose from accidental layering.
• Use cautiously in patients with bradycardia, conduction disturbance, peptic ulcer disease or asthma owing to its cholinergic actions.

Monitoring

Monitor weight, gastrointestinal tolerance, heart rate and cognitive response, and review the appropriateness of continued treatment periodically.

Counselling the patient

• Take oral doses with food to reduce nausea, and report persistent vomiting or significant weight loss.
• For the patch, remove the old one before applying a new one and never use more than a single patch.
• Report fainting, slow heartbeat or severe abdominal pain.

Evidence & guidelines

NICE recommends cholinesterase inhibitors including rivastigmine for mild-to-moderate Alzheimer's disease, with additional evidence supporting use in Parkinson's disease dementia.