Makindo Medical Notes

💡 Note: Clinical trials suggest that cholinesterase inhibitors may provide modest benefits in mild-to-moderate Alzheimer’s disease, dementia with Lewy bodies, vascular dementia, or mixed dementia. They can help with cognition, function, and behaviour but are not disease-modifying.

📖 About

Always check the BNF link here before prescribing.

• 💊 Rivastigmine is an acetylcholinesterase inhibitor (ChEI).
• 🧠 Increases central acetylcholine levels → enhances cholinergic neurotransmission.
• Used primarily in dementia syndromes.

⚙️ Mode of Action

• Inhibits acetylcholinesterase and butyrylcholinesterase enzymes.
• Reduces breakdown of acetylcholine → improves cholinergic signalling in the cortex and hippocampus.

📋 Indications

• 🧓 Alzheimer’s dementia (mild to moderate severity).
• 🧩 Parkinson’s disease dementia (preferred agent due to lower EPS risk).
• 💭 Sometimes used in Lewy body dementia (off-label, specialist advice).

💊 Dose

• PO: 1.5 mg BD → titrate every 2–4 weeks up to 3–6 mg BD (max tolerated dose).
• Transdermal patch: 4.6 mg/24 h → may increase to 9.5 mg/24 h (improves GI tolerability).
• Always start low and titrate slowly to reduce GI side effects.

🔄 Interactions

• See BNF for full list.
• ⚠️ Additive bradycardia with β-blockers, digoxin, or amiodarone.
• ⚠️ May worsen bronchospasm in asthma/COPD patients on β₂-agonists.

⛔ Contraindications / Cautions

• ❤️ Heart block, sick sinus syndrome, bradycardia.
• 🫁 Asthma or COPD → risk of bronchospasm.
• 🧠 History of seizures → may lower seizure threshold.
• 🚻 Bladder outflow obstruction.
• Monitor weight in frail/elderly patients.

⚠️ Side Effects

• 💧 Cholinergic symptoms – “DUMBELS” mnemonic: Diarrhoea, Urination, Miosis, Bronchospasm, Emesis (vomiting), Lacrimation/salivation, Sweating.
• ❤️ Bradycardia, hypotension, syncope, ↑ falls risk.
• 🧠 Headache, dizziness, insomnia, fatigue.
• 🍽️ GI: nausea, vomiting, anorexia, weight loss.
• 💪 Muscle cramps.

📝 Clinical Pearls

• Start at the lowest dose and titrate every 2–4 weeks based on tolerance.
• Transdermal patch often better tolerated than oral forms (fewer GI side effects).
• Monitor weight, blood pressure, and pulse regularly.
• Falls risk is increased → counsel carers and patients.
• Stop if no meaningful benefit after 6 months or if side effects outweigh gains.

📚 References

• Cochrane Review – Rivastigmine in Alzheimer’s Disease
• BNF: Rivastigmine