What is the recommended dose when transitioning a patient from oral Rivastigmine (generic name) to the patch?

Transitioning from Oral Rivastigmine to the Transdermal Patch

For patients on high-dose oral rivastigmine (≥6 mg twice daily or 12 mg/day total), switch directly to the 9.5 mg/24-hour patch without titration; for patients on lower oral doses (<6 mg twice daily), start with the 4.6 mg/24-hour patch for 4 weeks before increasing to the 9.5 mg/24-hour patch. 1

Dose Conversion Algorithm

For Patients on High-Dose Oral Rivastigmine (≥12 mg/day)

• Switch directly to 9.5 mg/24-hour patch without any titration period 1
• Apply the first patch the day after the last oral dose 1
• This direct conversion is well-tolerated and maintains therapeutic efficacy 1, 2

For Patients on Lower-Dose Oral Rivastigmine (<12 mg/day)

• Start with 4.6 mg/24-hour patch for the first 4 weeks 1
• Increase to 9.5 mg/24-hour patch after the initial 4-week period 1
• This gradual approach minimizes gastrointestinal side effects during the transition 1

For Patients Switching from Other Oral Cholinesterase Inhibitors

• Use the same low-dose titration regimen: start with 4.6 mg/24-hour patch for 4 weeks, then increase to 9.5 mg/24-hour patch 1
• This conservative approach is recommended regardless of the dose of donepezil or galantamine the patient was receiving 1

Expected Tolerability During Transition

Gastrointestinal Side Effects

• Nausea occurs in only 3.2% of patients switching from oral rivastigmine to the patch 1
• Vomiting occurs in only 1.9% of patients during the transition 1
• These rates are substantially lower than with oral formulations, representing a key advantage of the patch 1, 2
• When switching from donepezil, nausea occurs in up to 3.8% and vomiting in 0.8% of patients 1

Skin Reactions

• Application site reactions occur in approximately 22-25% of patients but are mostly mild to moderate 3
• Less than 9% of patients require treatment for application site reactions 3
• Discontinuation due to skin reactions occurs in only 1.7-3.5% of patients 3
• No serious skin reactions have been reported in clinical trials 3

Clinical Advantages of the Patch Formulation

Patient Satisfaction and Adherence

• 72% of patients rate the patch as "very easy to use" compared to only 30% for oral capsules 2
• 60% of patients report satisfaction with the patch versus only 14% with capsules 2
• The once-daily application improves adherence compared to twice-daily oral dosing 2

Pharmacokinetic Benefits

• The transdermal route provides sustained absorption through the skin, avoiding the peak-trough fluctuations of oral dosing 1, 2
• This steady-state delivery may contribute to the reduced gastrointestinal side effects 1

Important Clinical Considerations

Timing of the Switch

• Apply the first patch on the morning after the last oral dose 1
• No washout period is necessary 1
• Maintain the patch application schedule at approximately the same time each day 1

Dose Escalation Beyond 9.5 mg/24-hour

• For patients requiring higher doses, the 13.3 mg/24-hour patch is available for all stages of Alzheimer's disease 4, 3
• The 13.3 mg/24-hour patch has a similar tolerability profile to lower doses 3
• Consider dose escalation if cognitive or functional decline continues despite adequate trial of 9.5 mg/24-hour patch 4

Common Pitfalls to Avoid

Avoid Using Transdermal Patches for Acute Situations

• Do not use transdermal rivastigmine for acute anticholinergic delirium or rapid symptom control 5
• The transdermal patch has a slow onset of action and is significantly less effective than oral rivastigmine for acute management 5
• In one case series, 73% of patients given transdermal rivastigmine required additional parenteral treatment compared to only 32% given oral rivastigmine 5

Avoid Premature Discontinuation

• Most application site reactions are mild and do not require discontinuation 3
• Rotating application sites can minimize local skin reactions 3
• Allow at least 6-12 months to assess treatment response after the transition 6

Patient Education Points

• Instruct patients to apply the patch to clean, dry, hairless skin on the upper or lower back, upper arm, or chest 1
• Rotate application sites daily to minimize skin irritation 3
• Remove the old patch before applying a new one 1
• Avoid applying the patch to areas where lotion, cream, or powder has been recently used 1