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Key points

  • We recommend to consult your poison centre with the use of this antidote.
  • Rivastigmine is relatively contraindicated in patients with cardiac conduction abnormalities such as heart[AE1.1][AE1.2] block, QRS widening from sodium channel blockers, QTc prolongation, bradycardia or sick sinus syndrome, unexplained syncopal episodes, severe asthma/COPD, or a seizure disorder/epilepsy.
  • Rivastigmine has a slower onset of action and a longer duration of action than that of physostigmine.
  • The use of rivastigmine for anticholinergic delirium is only indicated if physostigmine cannot be given (i.e. unavailable or salicylate allergy).

+ Synonyms and other terms

  • Rivastigmine hydrogen tartrate
  • Rivastigmine patch
  • Rivastigmine transdermal system
  • Exelon®
  • Exelon® patch

     

+ Indications

  • Anticholinergic delirium (moderate/severe) where physostigmine salicylate cannot be given due to either (i) medication unavailable or (ii) confirmed salicylate allergy.

+ Dosage

+ Pediatric Dose

  • If weight is less than 35 kg, consider using half-doses compared to adult dose recommendations.
    • Initial dose:  3mg PO. If oral route is not tolerated or unavailable, see “Initial transdermal patch dose” below.
      • If delirium persists 60 to 90 minutes following initial PO dose, consider an additional oral or transdermal follow-up dose.
        • Follow up dose:
          • Oral: 1.5 mg PO every 1 to 2 h, up to 2 doses (maximum daily dose of 6mg PO)
          • Transdermal Patch: Apply 4.6 mg/24h on upper back (maximum daily dose: 3 mg PO + 1 patch)
      • Initial transdermal patch dose (if oral route is not tolerated or unavailable): Apply 4.6 mg/24h to upper back.
        • If delirium persists and the oral option becomes available: give 1.5 mg PO every 1 - 2 hours, up to 2 doses (maximum daily dose: 3mg PO + 1 patch)
    • If weight is greater than 35kg: refer to Adult Dose 

+ Adult Dose

  • Initial dose:  6mg PO. If the oral route is not tolerated or unavailable, see “Initial transdermal patch dose” below. 
    • If delirium persists 60 to 90 minutes following initial PO dose, consider an additional oral or transdermal follow-up dose.
      • Follow-up dose:
        • Oral : 3 mg PO every 1 to 2 h, up to 2 doses (maximum daily dose: 12 mg PO). 
        • Transdermal Patch: apply 9.5 mg/24h on upper back (maximum daily dose: 6 mg PO + 1 patch).
  • Initial transdermal patch dose (if oral route is not tolerated or unavailable):  Apply 9.5 mg/24h patch or 13.3 mg/24h (consider higher dose in obese patients) to upper back. 
    • If delirium persists and the oral option becomes available: give 3 mg PO every 1  2 hours, up to 2 doses (maximum daily dose: 6 mg PO + 1 patch).
       

+ Renal Impairment

  • No data suggests that the dose should be modified for short-term use.

+ Hepatic Impairment

  • Consider using half-doses if mild-moderate hepatic impairment, due to reduced rivastigmine clearance.
  • Contraindicated in severe liver impairment.

     

+ Hemodialysis Patient

  • No data suggests that the dose should be modified for short-term use.

+ Pregnancy

  • Reasonable to use rivastigmine during pregnancy if the anticipated toxic effects pose a significant risk of morbidity or mortality.
  • No data suggests that the dose should be modified for short-term use.

     

+ Obese or Overweight Patient

  • If weight >100kg: When oral dosing is not possible, consider initial patch dose 13.3 mg/24h (rather than 9.5 mg/24h).
     

+ Adverse effects

  • Nausea, vomiting, diarrhea, dizziness, somnolence, and bradycardia.
  • Overdosage could lead to cholinergic toxidrome, including bradycardia, syncope, bronchospasm, salivation, weakness, seizures.
     

+ Monitoring

  • Observe the patient for at least 12 hours after last oral dose given or after patch removal, to ensure symptoms do not recur (due to rivastigmine’s prolonged duration of action).
  • Cardiac monitoring and a neurological examination are recommended regularly to detect cholinergic signs (e.g. bradycardia, bronchospasm), that would indicate a need to reduce the dose or remove the transdermal patch.
     

+ End of treatment

  • Sustained resolution of anticholinergic symptoms, with no recurrence of anticholinergic delirium at least 12h after last oral dose or after patch removal.

+ Special Notes on Administration

Enteral route (PO or via N)

  • According to the manufacturer’s product monograph, opening the capsules and crushing their contents is not recommended. Assessment should be performed on a case-by-case basis.
  • A liquid formulation is available in Canada. The solution may be swallowed directly or mixed with water, fruit juice, or a carbonated beverage. 

Transdermal Patch (TD): 

  • Apply to the upper back. 

+ Available products

  • Rivastigmine Tartrate capsule1.5mg, Apotex, DIN 02336715
  • Rivastigmine Tartrate capsule 3mg, Apotex, DIN 02336723
  • Rivastigmine Tartrate capsule 4.5mg, Apotex, DIN 02336731
  • Rivastigmine Tartrate capsule 6 mg, Apotex, DIN 02336758
  • Rivastigmine hydrogen tartrate, Oral solution, 2mg/mL, DIN 02245240
  • Rivastigmine Transdermal Patch, 4.6 mg/24h, Exelon patch 5, DIN 02302845
  • Rivastigmine Transdermal Patch, 9.5mg/24h, Exelon patch 10, DIN 02302853
  • Rivastigmine Transdermal Patch, 13.3 mg/24h, Exelon patch 15, DIN 02432803

** other generics are available**
 

+ Amount required to treat a person weighting 70kg during 24 hours

  • At least 12 mg PO, including one capsule of 6mg and 2 capsules of 3mg 
  • At least one patch of 4.6 mg/24, one patch of 9.5 mg/24h and one patch of 13.3mg/24h
     

+ References

Berg, M., Strand, A., Garrett, N. D., Keric, A., & Wilkinson, J. (2025). Rivastigmine as an alternative treatment for anticholinergic toxidrome in light of the physostigmine shortage: A case series. The American Journal of Emergency Medicine, 94, 144–147. https://doi.org/10.1016/j.ajem.2025.04.047

Chiew, A. L., Holford, A. G., Chan, B. S. H., & Isoardi, K. Z. (2024). Rivastigmine for the management of anticholinergic delirium. Clinical Toxicology (Philadelphia, Pa.), 62(2), 82–87.

Fratta, K. A., Ginder, M., & Haggerty, D. A. (2023). Oral and Transdermal Rivastigmine for the Treatment of Anticholinergic Delirium: A Case Report. The Journal of Emergency Medicine, 65(4), e366–e368.

Gilbert, B. W., Santiago, R. D., Huffman, J. B., Yoder, N. M., & Hunninghake, J. C. (2025). Transdermal rivastigmine as a therapeutic option in severe diphenhydramine‐induced anticholinergic toxicity: A case report and literature review. Pharmacotherapy, 45(7), 462–467.

Greene S. C. (2023). Rivastigmine Use in the Treatment of Antimuscarinic Delirium. Journal of medical toxicology : official journal of the American College of Medical Toxicology, 19(3), 284–287.

Mullins M. E. (2022). Physostigmine should be used more readily for antimuscarinic toxicity: CON. British journal of clinical pharmacology, 88(1), 61–63.

Lambson, J. E., Hinckley, P., & Moss, M. J. (2025). Rivastigmine to treat anticholinergic toxicity following drug overdose–case series. Toxicology Communications, 9(1), 2463801.

Yakey, B., Vohra, V., Martin, A., & King, A. M. (2023). Treatment of pediatric antimuscarinic delirium with oral rivastigmine. Oxford medical case reports, 2023(9), omad096.

Trautman, W., Scanlon, M., Ferguson, E., & Pizon, A. F. (2023). Use of rivastigmine for reversal of antimuscarinic agitation and encephalopathy in pediatric patients [Conference abstract No. 42]. Clinical Toxicology, 61(Suppl. 2), 21–22.
 


Last updated : 2026-07-22