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Antimuscarinic Toxicity Safely Managed with High-Dose Transdermal Rivastigmine: A Case Report
C James Watson1, Emilie M Burrill2,3, William S Jaffee1,4
1Tufts University School of Medicine, Boston, Massachusetts.
Introduction:
Antimuscarinic toxicity, which can cause delirium and unsafe behavior, may result from an adverse effect of prescribed medications or from non-medical substance use. Physostigmine shortages have prompted use of transdermal rivastigmine for management of antimuscarinic toxicity; however, symptom control is equivocal at standard dosing.
Case Report:
A patient with antimuscarinic toxicity was treated with physostigmine and transitioned to 26.6 milligrams/24 hours transdermal rivastigmine for sustained symptom control. He experienced no adverse effects and tolerated floor admission.
Discussion:
There is mechanistic plausibility supporting safe, sustained control of antimuscarinic toxicity with high-dose transdermal rivastigmine. Central distribution is more rapid than serum distribution and higher doses correlate with a shorter time to peak concentration.
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