Home' Australian Pharmacist : Australian Pharmacist September 2012 Contents 712 Australian Pharmacist September 2012 I ©Pharmaceutical Society of Australia Ltd.
In one case, an 87-year old male with
dementia treated with rivastigmine 9.5
mg/24 hour patch developed nausea,
vomiting and renal failure, resulting in
death.19 The symptoms occurred after six
rivastigmine patches had concomitantly
been erroneously applied by health
care personnel on two consecutive
days. The terminal cause of death was
considered to be renal failure as a result
of dehydration through vomiting. The
medication error was thought to have
occurred at least partly due to ambiguous
package labelling. It is important to instruct
patients and caregivers on the proper use
of the rivastigmine transdermal patch
What advice would we provide to Mrs
Based on the information available, it
appears that Mr Fielding has cognitive
impairment of Parkinson’s disease. As their
GP has indicated, Mr Fielding could well be
developing Parkinson’s disease dementia
– the transition to a diagnosis of dementia
depending on the presence of cognitive
impairment becoming of sufficient severity
such that it interferes with Mr Fielding’s
day-to-day functioning. The recent
Cochrane review concluded that there
was insufficient evidence to support the
use of cholinesterase inhibitors in patients
with cognitive impairment in Parkinson’s
With further progression of Mr Fielding’s
cognitive impairment, a trial of transdermal
rivastigmine might be warranted at a
cost of approximately $150 per month.
It might modestly improve cognitive
function and behaviour, but could worsen
tremor. If the clinical improvement after six
months is very small or the side effects are
bothersome, then the medication should
be tapered and discontinued.6 Transdermal
rivastigmine will not slow the progress
of the underlying dementia, but could
offer moderate improvements in memory,
attention and behaviour. The amount of
improvement varies, and Mrs Fielding
should expect her husband’s condition to
decline again, but from a potentially higher
Table 1. Correct application of the
rivastigmine transdermal patch22,23
Apply patches daily to clean, dry and
hairless skin on the upper or lower
back, upper arm or chest, in a position
that will not be rubbed by tight
The patch should be replaced by a new
one after 24 hours, and the previous
day’s patch must be removed before
application of a new patch, as the old
patch continues to deliver rivastigmine
after 24 hours.
Application to the same skin location
within 14 days should be avoided to
minimise skin irritation.
The patch should not be applied to skin
that is red, irritated or damaged.
The patch should not be cut into pieces.
Symptoms of rivastigmine overdose
include nausea, vomiting, diarrhoea
and hallucinations; bradycardia and/
or syncope, associated with malaise or
falls, may also occur.
In case of suspected overdose, all
rivastigmine patches should be
removed immediately and no further
patch should be applied for the next 24
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