Department of Clinical Toxicology, Prince of Wales Hospital, Randwick, Australia.
Faculty of Medicine, Prince of Wales Hospital Clinical School, University of NSW, Randwick, Australia.
Clin Toxicol (Phila). 2024 Feb;62(2):82-87. doi: 10.1080/15563650.2024.2319854. Epub 2024 Mar 11.
Anticholinergic agents are commonly taken in overdose, often causing delirium. The spectrum of anticholinergic delirium ranges from mild agitation to severe behavioural disturbance. Physostigmine is an effective treatment for anticholinergic delirium, but its availability is limited. As rivastigmine is readily available, it has been used to manage anticholinergic delirium; however, there is limited research investigating its use.
This was a retrospective review of patients with anticholinergic delirium treated in two toxicology units with rivastigmine (oral capsule or transdermal patch) from January 2019 to June 2023. The primary outcome was the use of further parenteral treatment (sedation or physostigmine) for delirium post rivastigmine administration.
Fifty patients were administered rivastigmine for the management of anticholinergic delirium. The median age was 36 years (interquartile range: 25-49 years) and 27 (54 per cent) were females. Features consistent with anticholinergic toxicity included tachycardia in 44 (88 per cent) and urinary retention requiring catheterisation in 40 (80 per cent). Forty-three patients (86 per cent) were treated with physostigmine before rivastigmine administration. Twenty-two were managed with transdermal rivastigmine (most commonly 9.5 mg/24 hour patch), and 28 with oral rivastigmine 6 mg. Further parenteral sedation and/or physostigmine treatment were required more often in patients given transdermal than oral rivastigmine [16/22 (73 per cent) versus 9/28 (32 per cent), = 0.010)]. No patients had bradycardia or gastrointestinal symptoms following rivastigmine administration. One patient with a history of epilepsy had a seizure, 1.5 hours post physostigmine administration and 7 hours post transdermal rivastigmine.
Rivastigmine has been increasingly used for the management of patients with anticholinergic delirium, due to the lack of availability of physostigmine. In this case series, rivastigmine transdermal patch appeared to be less effective than oral rivastigmine capsules, likely due to its slow onset of action and/or insufficient dose.
Rivastigmine can be used to treat anticholinergic delirium. In our case series oral rivastigmine appeared more effective than transdermal rivastigmine.
抗胆碱能药物在过量服用时很常见，常常会导致谵妄。抗胆碱能谵妄的范围从轻度激越到严重的行为障碍。毒扁豆碱是治疗抗胆碱能谵妄的有效药物，但它的供应有限。由于利伐斯的明容易获得，因此已被用于治疗抗胆碱能谵妄；然而，关于其使用的研究有限。
这是一项回顾性研究，纳入了 2019 年 1 月至 2023 年 6 月期间在两个毒理学单位接受利伐斯的明（口服胶囊或透皮贴剂）治疗的抗胆碱能谵妄患者。主要结局是利伐斯的明给药后，为治疗谵妄而进一步使用静脉治疗（镇静或毒扁豆碱）。
50 名患者接受利伐斯的明治疗抗胆碱能谵妄。中位年龄为 36 岁（四分位距：25-49 岁），27 名（54%）为女性。符合抗胆碱能毒性的特征包括心动过速 44 例（88%）和尿潴留需要导尿 40 例（80%）。在利伐斯的明给药前，43 名（86%）患者接受了毒扁豆碱治疗。22 名患者接受了透皮利伐斯的明治疗（最常见的是 9.5mg/24 小时贴剂），28 名患者接受了口服利伐斯的明 6mg。与口服利伐斯的明相比，接受透皮利伐斯的明治疗的患者更常需要进一步的静脉镇静和/或毒扁豆碱治疗[16/22（73%）与 9/28（32%），=0.010)]。利伐斯的明给药后，没有患者出现心动过缓或胃肠道症状。一名有癫痫病史的患者在接受毒扁豆碱后 1.5 小时和接受透皮利伐斯的明后 7 小时发生癫痫发作。
由于毒扁豆碱供应有限，利伐斯的明越来越多地用于治疗抗胆碱能谵妄患者。在本病例系列中，透皮利伐斯的明贴剂似乎不如口服利伐斯的明胶囊有效，可能是由于其起效缓慢和/或剂量不足。
利伐斯的明可用于治疗抗胆碱能谵妄。在我们的病例系列中，口服利伐斯的明似乎比透皮利伐斯的明更有效。
