Is there an oral alternative to Exelon (rivastigmine) patch?

Oral Rivastigmine as an Alternative to Exelon Patch

Yes, oral rivastigmine capsules are available and can be used as an alternative to the Exelon (rivastigmine) transdermal patch, with both formulations approved for treating mild-to-moderate Alzheimer's disease and Parkinson's disease dementia. 1

Available Oral Formulations

• Oral rivastigmine is available as capsules in four strengths: 1.5 mg, 3 mg, 4.5 mg, and 6 mg 1
• Rivastigmine oral solution is also available and can be interchanged with capsules at equal doses 1
• Both oral formulations should be taken with meals in divided doses (morning and evening) to minimize gastrointestinal side effects 1

Dosing Equivalence Between Formulations

• The 9.5 mg/24-hour patch is approximately equivalent to 6 mg oral twice daily (12 mg total daily dose) 2
• The 4.6 mg/24-hour patch is roughly equivalent to lower oral doses (3-4.5 mg twice daily) 3
• The 13.3 mg/24-hour patch (15 cm²) represents the highest available dose for patients requiring dose escalation 4

Key Tolerability Differences

• The transdermal patch demonstrates significantly fewer gastrointestinal side effects compared to oral capsules while maintaining similar efficacy 5, 6, 7
• Oral rivastigmine carries a higher risk of dose-related nausea, vomiting, diarrhea, anorexia, and weight loss 1
• When switching from oral to patch formulation, nausea occurs in only up to 3.2% and vomiting in up to 1.9% of patients 3

Critical Dosing Considerations for Oral Formulation

• Patients must always start at 1.5 mg twice daily and titrate gradually to maintenance doses, regardless of previous treatment 1
• For Alzheimer's disease: increase dose every 2 weeks minimum (1.5 mg → 3 mg → 4.5 mg → 6 mg twice daily) if tolerated 1
• For Parkinson's disease dementia: increase dose every 4 weeks minimum using the same titration schedule 1
• If treatment is interrupted for more than 3 days, restart at the lowest dose (1.5 mg twice daily) to prevent severe vomiting and potentially life-threatening complications such as esophageal rupture 1

When to Choose Oral Over Patch

• Oral formulation may be preferred if the patient has experienced application site reactions or allergic contact dermatitis from the patch 1
• However, patients with patch-related allergic contact dermatitis should only switch to oral rivastigmine after negative allergy testing and under close medical supervision, as some sensitized patients cannot tolerate rivastigmine in any form 1
• Oral formulation allows for more flexible dose titration in 1.5 mg increments 1

When to Choose Patch Over Oral

• The patch is preferred for patients with significant gastrointestinal intolerance to oral cholinesterase inhibitors 5, 6, 7
• The patch provides more consistent drug delivery over 24 hours with once-daily application 6, 7
• The patch may improve medication adherence due to ease of use and better tolerability 6, 7

Important Safety Warnings for Oral Formulation

• Dehydration from prolonged vomiting or diarrhea can lead to serious outcomes 1
• Caregivers must be instructed to monitor for gastrointestinal adverse reactions and contact the physician immediately if they occur 1
• Caregivers must understand that if therapy is interrupted for more than 3 days, they should not administer the next dose without physician consultation regarding proper retitration 1
• Oral rivastigmine is contraindicated in patients with known hypersensitivity to rivastigmine or other carbamate derivatives 1