Included as part of the PRECAUTIONS section.

Medication Errors Resulting in Overdose

Medication errors with Exelon Patch have resulted in serious adverse reactions; some cases have required hospitalization, and rarely, led to death. The majority of medication errors have involved not removing the old patch when putting on a new one and the use of multiple patches at one time. Instruct patients and their caregivers on important administration instructions for Exelon Patch. [see DOSAGE AND ADMINISTRATION].

Gastrointestinal Adverse Reactions

Exelon Patch can cause gastrointestinal adverse reactions, including significant nausea, vomiting, diarrhea, anorexia/decreased appetite, and weight loss. Dehydration may result from prolonged vomiting or diarrhea and can be associated with serious outcomes. The incidence and severity of these reactions are dose-related [see ADVERSE REACTIONS]. For this reason, initiate treatment with Exelon Patch at a dose of 4.6 mg/24 hours and titrate to a dose of 9.5 mg/24 hours and then to a dose of 13.3 mg/24 hours, if appropriate [see DOSAGE AND ADMINISTRATION].

If treatment is interrupted for more than three days because of intolerance, reinitiate Exelon Patch with the 4.6 mg/24 hours dose to reduce the possibility of severe vomiting and its potentially serious sequelae. A postmarketing report described a case of severe vomiting with esophageal rupture following inappropriate reinitiation of treatment of an oral formulation of rivastigmine without retitration after 8 weeks of treatment interruption.

Inform caregivers to monitor for gastrointestinal adverse reactions and to inform the physician if they occur. It is critical to inform caregivers that if therapy has been interrupted for more than three days because of intolerance, the next dose should not be administered without contacting the physician regarding proper retitration.

Other Adverse Reactions from Increased Cholinergic Activity

Neurologic Effects

Extrapyramidal Symptoms: Like other cholinomimetics, rivastigmine may exacerbate or induce extrapyramidal symptoms. Worsening of parkinsonian symptoms, particularly tremor, has been observed in patients with dementia associated with Parkinson's disease who were treated with Exelon capsules.

Seizures: Drugs that increase cholinergic activity are believed to have some potential for causing seizures. However, seizure activity also may be a manifestation of Alzheimer's disease.

Peptic Ulcers/Gastrointestinal Bleeding

Cholinesterase inhibitors, including rivastigmine, may increase gastric acid secretion due to increased cholinergic activity. Monitor patients using Exelon Patch for symptoms of active or occult gastrointestinal bleeding, especially those at increased risk for developing ulcers, e.g., those with a history of ulcer disease or those receiving concurrent nonsteroidal anti-inflammatory drugs (NSAIDs). Clinical studies of rivastigmine have shown no significant increase, relative to placebo, in the incidence of either peptic ulcer disease or gastrointestinal bleeding.

Use with Anesthesia

Rivastigmine, as a cholinesterase inhibitor, is likely to exaggerate succinylcholine-type muscle relaxation during anesthesia.

Cardiac Conduction Effects

Because rivastigmine increases cholinergic activity, use of the Exelon Patch may have vagotonic effects on heart rate (e.g., bradycardia). The potential for this action may be particularly important in patients with sick sinus syndrome or other supraventricular cardiac conduction conditions. In clinical trials, rivastigmine was not associated with any increased incidence of cardiovascular adverse events, heart rate or blood pressure changes, or ECG abnormalities.

Genitourinary Effects

Although not observed in clinical trials of rivastigmine, drugs that increase cholinergic activity may cause urinary obstruction.

Pulmonary Effects

Like other drugs that increase cholinergic activity, Exelon Patch should be used with care in patients with a history of asthma or obstructive pulmonary disease.

Impairment in Driving or Use of Machinery

Dementia may cause gradual impairment of driving performance or compromise the ability to use machinery. The administration of rivastigmine may also result in adverse reactions that are detrimental to these functions. During treatment with the Exelon Patch, routinely evaluate the patient's ability to continue driving or operating machinery.

Patient Counseling Information

See FDA-approved patient labeling (PATIENT INFORMATION).

Importance of Correct Usage

Inform patients or caregivers of the importance of applying the correct dose on the correct part of the body. They should be instructed to rotate the application site in order to minimize skin irritation. The same site should not be used within 14 days. The previous day's patch must be removed before applying a new patch to a different skin location. Exelon Patch should be replaced every 24 hours and the time of day should be consistent. It may be helpful for this to be part of a daily routine, such as the daily bath or shower.

Instruct patients or caregivers to avoid exposure of the patch to external heat sources (excessive sunlight, saunas, solariums) for long periods of time.

Instruct patients who have missed a dose to apply a new patch immediately. They may apply the next patch at the usual time the next day. Instruct patients to not apply two patches to make up for one missed.

Inform the patient or caregiver to contact the physician for retitration instructions if treatment has been interrupted.

Discarding Used Patches

Instruct patients or caregivers to fold the patch in half after use, return the used patch to its original pouch, and discard it out of the reach and sight of children and pets. They should also be informed that drug still remains in the patch after 24-hour usage. They should be instructed to avoid eye contact and to wash their hands after handling the patch.

Gastrointestinal Adverse Reactions

Inform patients or caregivers of the potential gastrointestinal adverse reactions such as nausea, vomiting, and diarrhea, including the possibility of dehydration due to these symptoms. Explain that Exelon Patch may affect the patient's appetite and/or the patient's weight. Patients and caregivers should be instructed to look for these adverse reactions, in particular when treatment is initiated or the dose is increased. Instruct patients and caregivers to inform a physician if these adverse reactions persist.

Concomitant Use of Drugs with Cholinergic Action

Inform patients or caregivers that while wearing Exelon Patch, patients should not be taking Exelon capsules or Exelon oral solution or other drugs with cholinergic effects.

Nonclinical Toxicology

Carcinogenesis, Mutagenesis, Impairment of Fertility

Carcinogenesis

In oral carcinogenicity studies conducted at doses up to 1.1 mg base/kg/day in rats and 1.6 mg base/kg/day in mice, rivastigmine was not carcinogenic.

In a dermal carcinogenicity study conducted at doses up to 0.75 mg base/kg/day in mice, rivastigmine was not carcinogenic. The mean rivastigmine plasma exposure (AUC) at this dose was less than that in humans at the maximum recommended human dose (13.3 mg/24 hours).

Mutagenesis

Rivastigmine was clastogenic in in vitro chromosomal aberration assays in mammalian cells in the presence, but not the absence, of metabolic activation. Rivastigmine was negative in an in vitro bacterial reverse mutation (Ames) assay, an in vitro HGPRT assay, and in an in vivo mouse micronucleus test.

Impairment of Fertility

No fertility or reproduction studies of dermal rivastigmine have been conducted in animals. Rivastigmine had no effect on fertility or reproductive performance in rats at oral doses up to 1.1 mg base/kg/day.

Use In Specific Populations

Pregnancy

Pregnancy Category B

There are no adequate and well-controlled studies in pregnant women. No dermal reproduction studies in animals have been conducted. Oral reproduction studies conducted in pregnant rats and rabbits revealed no evidence of teratogenicity. Studies in rats showed slightly decreased fetal/pup weight, usually at doses causing some maternal toxicity. Because animal reproduction studies are not always predictive of human response, this drug should be used during pregnancy only if clearly needed.

Nursing Mothers

Rivastigmine and its metabolites are excreted in rat milk following oral administration of rivastigmine; levels of rivastigmine plus metabolites in rat milk are approximately two times that in maternal plasma. It is not known whether rivastigmine is excreted in human milk. Because many drugs are excreted in human milk and because of the potential for serious adverse reactions in nursing infants from Exelon Patch, a decision should be made whether to discontinue nursing or to discontinue the drug, taking into account the importance of the drug to the mother.

Pediatric Use

Safety and effectiveness in pediatric patients have not been established. Use of Exelon Patch in children and adolescents (below 18 years of age) is not recommended.

Geriatric Use

Of the total number of subjects in clinical studies of Exelon Patch, 88% were 65 and over, while 53% were 75 and over. No overall differences in safety or effectiveness were observed between these subjects and younger subjects, and other reported clinical experience has not identified differences in responses between the elderly and younger patients, but greater sensitivity of some older individuals cannot be ruled out.

Renal Impairment

In patients with moderate to severe renal impairment (glomerular filtration rate [GFR] < 50 mL/min), clearance of oral rivastigmine was reduced [see CLINICAL PHARMACOLOGY]. In these patients, consider using the lowest dose Exelon Patch (4.6 mg/24 hours) for both initial and maintenance therapy.

Hepatic Impairment

In patients with mild or moderate hepatic impairment (Child-Pugh score 5-9), clearance of oral rivastigmine was reduced [see CLINICAL PHARMACOLOGY]. In these patients, consider using the lowest dose Exelon Patch (4.6 mg/24 hours) for both initial and maintenance therapy. No data are available on the use of rivastigmine in patients with severe hepatic impairment.

Low or High Body Weight

Because rivastigmine blood levels vary with weight [see CLINICAL PHARMACOLOGY], careful titration and monitoring should be performed in patients with low or high body weights. In patients with low body weight ( < 50 kg), monitor closely for toxicities (e.g., excessive nausea, vomiting), and consider reducing the maintenance dose to the 4.6 mg/24 hour Exelon Patch if such toxicities develop. In patients with body weight > 100 kg, consider the use of doses higher than 9.5 mg/24 hours.

Last reviewed on RxList: 9/17/2012
This monograph has been modified to include the generic and brand name in many instances.