Letter in response to Rivastigmine for the treatment of anticholinergic delirium following severe procyclidine intoxication

Hughes, Adrienne; Moore, Kerry; Mah, Nathan D.; Birmingham, Asha R.; Clark, Roger K.; Thompson, James T.; Hendrickson, Robert G.

doi:10.1080/15563650.2020.1869757

Cited by 13 publications

(5 citation statements)

References 2 publications

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“…Hughes et al . treated an adult female with a more aggressive course of oral rivastigmine (12 mg) following acute diphenhydramine toxicity with symptom improvement within 2 hours, complete resolution within 24 hours, and no adverse effects or recurring antimuscarinic toxicity [ 7 ]. Transdermal rivastigmine use has been described in the treatment of psychotic symptoms from non-pharmaceutical scopolamine intoxication in six patients [ 8 ].…”

Section: Discussionmentioning

confidence: 99%

“…Rivastigmine may confer potential therapeutic benefits over physostigmine with the latter’s widespread shortage. These include its slower rate of penetration into the central nervous system, longer duration of action thereby reducing dosing frequency, theoretical potential for less severe side effects, and multiple drug delivery formulations [ 2 , 7 ]. It may also be favorable when prolonged delirium is anticipated.…”

Section: Discussionmentioning

confidence: 99%

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Treatment of pediatric antimuscarinic delirium with oral rivastigmine

Yakey,

Vohra,

Martin

et al. 2023

Oxford Medical Case Reports

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Antimuscarinic drug toxicity is a common pediatric emergency, which produces central and peripheral symptoms. Treatment of agitation and hyperactive antimuscarinic delirium, with first-line agents like cholinesterase inhibitors or benzodiazepines, is imperative to prevent severe toxicity. Intravenous physostigmine salicylate is a cholinesterase inhibitor that is commonly used to treat central antimuscarinic delirium. Its chemical structure facilitates crossing of the blood–brain barrier. Overlapping nationwide physostigmine and benzodiazepine shortages have prompted consideration of therapeutic alternatives. Rivastigmine is a long-acting cholinesterase inhibitor with a similar chemical structure to physostigmine. It represents a potential therapeutic option for antimuscarinic delirium. Rivastigmine offers potential benefits over physostigmine including a longer duration of action, slower rate of central nervous system penetration, more favorable side effect profile, and availability in multiple formulations. A paucity of literature exists describing the use of rivastigmine for central antimuscarinic delirium. We describe the effective use of oral rivastigmine in a child with central antimuscarinic delirium.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Treatment of pediatric antimuscarinic delirium with oral rivastigmine

Yakey,

Vohra,

Martin

et al. 2023

Oxford Medical Case Reports

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“…In our study, rivastigmine was used following successful reversal of delirium with physostigmine due to favourable pharmacokinetics with longer duration of action (10 h). Rivastigmine has been used to treat prolonged delirium in anticholinergic syndrome as it could reduce symptom recurrence and decrease need for re‐dosing 13,14 . Furthermore, bromocriptine was chosen as it has minimal side effects and has been suggested for the management of extrapyramidal symptoms such as rigidity and dystonia 15 .…”

Section: Discussionmentioning

confidence: 99%

“…Rivastigmine has been used to treat prolonged delirium in anticholinergic syndrome as it could reduce symptom recurrence and decrease need for re‐dosing. 13 , 14 Furthermore, bromocriptine was chosen as it has minimal side effects and has been suggested for the management of extrapyramidal symptoms such as rigidity and dystonia. 15 This proposed treatment as highlighted by the case may provide substantial opportunity to lessen or shorten symptoms of this adverse reaction.…”

Section: Discussionmentioning

confidence: 99%

Case series profile of olanzapine post‐injection delirium/sedation syndrome

Seebaluck

Downes

Brown

et al. 2022

Brit J Clinical Pharma

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Olanzapine pamoate is an intramuscular depot injection for the treatment of schizophrenia. Approximately 1.4% of patients develop a serious adverse event called post‐injection delirium/sedation syndrome (PDSS), characterised by drowsiness, anticholinergic and extrapyramidal symptoms. The objective is to investigate olanzapine PDSS presentations including clinical features and treatment approach. This is a retrospective review of olanzapine PDSS patients from three toxicology units and the NSW Poisons Information Centre between 2017 and 2022. Adult patients were included if they had intramuscular olanzapine then developed PDSS criteria. Clinical symptoms, treatment, timing and length of symptoms were extracted into a preformatted Excel database. There were 18 patients included in the series, with a median age of 49 years (interquartile range [IQR]: 38–58) and male predominance (89%). Median onset time post injection was 30 min (IQR: 11–38). PDSS symptoms predominate with drowsiness, confusion and dysarthria. Median length of symptoms was 24 h (IQR: 20–54). Most common treatment included supportive care without any pharmacological intervention (n = 10), benzodiazepine (n = 4) and benztropine (n = 3). In one case, bromocriptine and physostigmine followed by oral rivastigmine were given to manage antidopaminergic and anticholinergic symptoms respectively. This proposed treatment combination could potentially alleviate some of the symptoms but needs further studies to validate the findings. In conclusion, this case series supports the characterisation of PDSS symptomology predominantly being anticholinergic with similar onset (<1 h) and duration (<72 h). Bromocriptine is proposed to manage PDSS if patients develop severe dopamine blockade and physostigmine followed by rivastigmine for anticholinergic delirium.

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“…Rivastigmine was used following successful reversal of delirium with physostigmine due to favourable pharmacokinetics with longer duration of action (10h). Rivastigmine has been used to treat prolonged delirium in anti-cholinergic syndrome as it could reduce symptom recurrence and decrease need for re-dosing 12,13 . Furthermore, bromocriptine was chosen as it has been suggested for the management of extrapyramidal symptoms such as rigidity and dystonia 14 .…”

Section: Discussionmentioning

confidence: 99%

Case Series Profile of Olanzapine Post-Injection Delitrium/Sedation Syndrome

Seebaluck¹,

Downes

Brown

et al. 2022

Preprint

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Olanzapine pamoate is an intramuscular depot injection for the treatment of schizophrenia. Approximately 1.4% of patients develop a serious adverse event called Post Injection Delirium/Sedation Syndrome (PDSS); characterised by drowsiness, anticholinergic and extrapyramidal symptoms. The objective is to investigate olanzapine PDSS presentations including clinical features and treatment approach. This is a retrospective review of olanzapine PDSS patients from three toxicology units and the NSW Poisons Information between 2017 and 2022. Adult patients were included if they had intramuscular olanzapine then developed PDSS criteria. Clinical symptoms, treatment, timing and length of symptoms were extracted into a preformatted Excel database. There were 18 patients included in the series, with a median age of 49 years (IQR: 38-58) and male predominance (89%). Median onset time post injection was 30 minutes (IQR: 11-38). PDSS symptoms predominate with drowsiness, confusion and dysarthria. Median length of symptoms was 24 hours (IQR: 20-54). Most common treatment included supportive care without any pharmacological intervention (n=10), benzodiazepine (n=4) and benztropine (n=3). In one case, bromocriptine and physostigmine followed by oral rivastigmine were given to manage anti-dopaminergic and anti-cholinergic symptoms respectively. This proposed treatment combination could alleviate some of the symptoms. In conclusion, this case series supports the characterisation of PDSS symptomology predominantly being anti-cholinergic with similar onset (<1 hour) and duration (<72hours). A combination of bromocriptine and physostigmine followed by rivastigmine is proposed to manage PDSS if patients develop severe dopamine blockade or anti-cholinergic delirium.

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Letter in response to Rivastigmine for the treatment of anticholinergic delirium following severe procyclidine intoxication

Cited by 13 publications

References 2 publications

Treatment of pediatric antimuscarinic delirium with oral rivastigmine

Treatment of pediatric antimuscarinic delirium with oral rivastigmine

Case series profile of olanzapine post‐injection delirium/sedation syndrome

Case Series Profile of Olanzapine Post-Injection Delitrium/Sedation Syndrome

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