Case of the month: Rivastigmine (Exelon(R)) toxicity with evidence of respiratory depression

Şener, Selçuk Yusuf

doi:10.1136/emj.2004.017301

Cited by 10 publications

(5 citation statements)

References 12 publications

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“…She was discharged 3 days later in a stable condition. In two published cases of oral overdoses typical signs of cholinergic syndrome including dizziness, vomiting, salivation, miosis and cardiac and respiratory effects are described [9,10]. In both these cases the patients also presented with transient bradycardia, as is described in our case.…”

Section: Discussionsupporting

confidence: 67%

A Fatal Outcome After Unintentional Overdosing of Rivastigmine Patches

Lövborg

Jönsson²,

Hägg³

2012

CDS

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The presented case is a description of a rivastigmine overdose due to a medication error involving patches. This case indicates the importance of clear and unambiguous instructions to avoid administration errors with patches and to be vigilant to adverse drug reactions for early detection and correction of drug administration errors. In particular, instructions clearly indicating that only one patch should be applied at a time are important.

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Section: Discussionsupporting

confidence: 67%

A Fatal Outcome After Unintentional Overdosing of Rivastigmine Patches

Lövborg

Jönsson²,

Hägg³

2012

CDS

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“…14 Adult case reports report significant morbidity and death from rivastigmine exposure. [15][16][17] Our findings of higher rates of reported symptoms and health care facility evaluations with rivastigmine exposures are consistent with the increased morbidity seen in these prior case reports, and merit attention to more exposures from this drug in the years ahead.…”

Section: Discussionsupporting

confidence: 84%

Characteristics of Pediatric Exposures to Antidementia Drugs Reported to a Poison Control System

Thornton

Pchelnikova

Cantrell

2016

The Journal of Pediatrics

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“…[9][10][11][12][13] We present a case of transdermal rivastigmine toxicity. Although two cases of intentional overdose of oral rivastigmine are reported, 14,15 this case is unique in that significant toxicity from transdermal application is unreported, and the patient was successfully treated with pralidoxime alone.…”

Section: Introductionmentioning

confidence: 89%

Use of pralidoxime without atropine in rivastigmine (carbamate) toxicity

et al. 2009

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Some experimental models suggest that the use of pralidoxime in carbamate toxicity is deleterious. Although pretreatment with atropine minimizes the adverse effect of pralidoxime reported in these models, concerns over the risks of pralidoxime in humans with carbamate poisoning continue. We present a unique case of carbamate toxicity treated successfully with pralidoxime alone. An 80-year-old woman with Alzheimer’s dementia presented to the emergency department with 3-4 days of lightheadedness, vomiting, diarrhea, and bilateral lower extremity muscle pain. Extensive review of systems was otherwise negative. Her vital signs were BP, 207/85 mmHg; pulse, 101 beats/min; rectal temperature, 36.6 °C; respirations, 18/min; and SpO2, 95% breathing room air. Her bedside glucose measurement was 6.7 mmol/L. Physical examination revealed a confused, diaphoretic, ill-appearing woman with miosis and fasciculations of the tongue, eyelids, gastrocnemius and quadriceps bilaterally. The heart, lung, abdominal and head, eyes, ears, nose and throat examinations were otherwise unremarkable. Nine 5-cm2 rivastigmine patches (9.5 mg/24-hour) were found adherent to her torso and lower extremities. The patches were immediately removed and underlying skin cleansed with soap and water. Laboratory values including complete blood count, basic metabolic panel, calcium, magnesium, phosphorus, troponin, coagulation studies and urinalysis were unremarkable. Due to the absence of pulmonary muscarinic findings, no atropine was administered. However, 1 g of pralidoxime was administered intravenously over 30 min to treat fasciculations. Within 30 min of this treatment, there was significant improvement in symptoms and resolution of fasciculations. She was admitted to the hospital, required no further pralidoxime therapy and was discharged after 3 days. Rivastigmine is a reversible (carbamate) cholinesterase inhibitor used to treat dementia. In overdose, cholinergic crisis is expected and in this case was precipitated by patch overuse. We believe there was a causal relationship between pralidoxime administration and the prompt resolution of symptoms and fasciculations. This case of apparently safe and effective pralidoxime use without concomitant atropine administration in a patient with carbamate toxicity reinforces recent data demonstrating the potential safety of pralidoxime in carbamate toxicity.

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Case of the month: Rivastigmine (Exelon(R)) toxicity with evidence of respiratory depression

Cited by 10 publications

References 12 publications

A Fatal Outcome After Unintentional Overdosing of Rivastigmine Patches

A Fatal Outcome After Unintentional Overdosing of Rivastigmine Patches

Characteristics of Pediatric Exposures to Antidementia Drugs Reported to a Poison Control System

Use of pralidoxime without atropine in rivastigmine (carbamate) toxicity

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