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Caregivers should be advised of the high incidence of nausea and vomiting associated with the use of the drug along with the possibility of anorexia and weight lossCaregivers should be encouraged to monitor for these adverse events and inform the physician if they occurIt is critical to inform caregivers that if therapy has been interrupted for more than several daysthe next dose should not be administered until they have discussed this with the physiciansee WARNINGS AND PRECAUTIONS

Overdosage with cholinesterase inhibitors can result in cholinergic crisis characterized by severe nauseavomitingsalivationsweatingbradycardiahypotensionrespiratory depressioncollapse and convulsionsIncreasing muscle weakness is a possibility and may result in death if respiratory muscles are involvedAtypical responses in blood pressure and heart rate have been reported with other drugs that increase cholinergic activity when coadministered with quaternary anticholinergics such as glycopyrrolateAdditional symptoms associated with rivastigmine overdose are diarrheaabdominal paindizzinesstremorheadachesomnolenceconfusional statehyperhidrosishypertensionhallucinations and malaiseDue to the short half-life of rivastigminedialysishemodialysisperitoneal dialysisor hemofiltrationwould not be clinically indicated in the event of an overdose.

Because strategies for the management of overdose are continually evolvingit is advisable to contact a Poison Control Center to determine the latest recommendations for the management of an overdose of any drug.

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After a minimum of 2 weeks and if well toleratedincrease the dose to 3 mg twice a daySubsequent increases to 4.5 mg twice a day and 6 mg twice a day should be attempted after a minimum of 2 weeks at the previous dose and if well toleratedThe maximum dose is 6 mg twice a day12 mg per day

In a study of 26 weeks duration702 patients were randomized to doses of 3 mg6 mgor 9 mg per day of EXELON or to placeboeach given in divided dosesThe fixed-dose study designwhich included a 12-week forced-dose titration phase and a 14-week maintenance phaseled to a high dropout rate in the 9 mg per day group because of poor tolerabilityAt 26 weeks of treatmentsignificant differences were observed for the ADAS-cog mean change from baseline for the 9 mg per day and 6 mg per day groupscompared to placeboNo significant differences were observed between any of the EXELON-dose groups and placebo for the analysis of the CIBIC-Plus mean rating of changeAlthough no significant differences were observed between EXELON treatment groupsthere was a trend toward numerical superiority with higher doses.

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