Acetyl- and butyrylcholinesterase inhibitor
ATC code: N06DA03 (Rivastigmine)
Brand names
Exelon Patch, Exelon, Prometax, Rivastig
A pseudo-irreversible inhibitor of both acetyl- and butyrylcholinesterase in the CNS. Butyrylcholinesterase plays a larger role in advanced Alzheimer's and in Lewy body dementia – inhibiting it offers advantages in these groups. Available as oral and transdermal patch. The patch gives steady levels with less GI side effect risk.
First line
First-line for mild-to-moderate Alzheimer's disease per 2018, 2024, and SEN 2024 alongside donepezil and galantamine. Transdermal patch 4.6 mg/24 h titrated to 9.5 mg/24 h is preferred due to less nausea and vomiting than the oral form. Efficacy is comparable to donepezil.
First line
Drug of choice for Parkinson's disease dementia per 2024 and the Spanish SEN 2023 consensus. Also effective in dementia with Lewy bodies (off-label in most countries). Advantage over donepezil reflects butyrylcholinesterase activity relevant in these dementia types.
Approved for Parkinson's disease dementia in most European countries.
The drug is promoted for these uses outside international guidelines. Each entry below is analyzed against AEMPS, FDA, EMA, Cochrane and major RCTs.
Not recommended
Rivastigmine is an inhibitor of both acetylcholinesterase and butyrylcholinesterase. It is prescribed only for mild-to-moderate Alzheimer's disease and for Parkinson's disease dementia ( 2018 and NG97 guidelines). In biohacker circles, rivastigmine is promoted as a dual cholinesterase inhibitor for memory enhancement in healthy adults. No clinical studies in healthy adults confirm an effect on memory. The drug has serious risks: bradycardia, gastrointestinal effects (nausea, vomiting, diarrhea, marked weight loss), and skin reactions at the patch site. If rivastigmine was recommended to a healthy person for memory, consider seeking a second opinion.
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Not indicated.
Not used during lactation.
Reference information, not a clinical decision. Discuss feeding pauses or changes with your physician or an IBCLC.
Rivastigmine is evaluated for the following indications with varying evidence strength: Alzheimer disease (evidence tier A), Dementia (evidence tier A), Memory and concentration enhancement (evidence tier F). See the full indication matrix with dosing and citations above on this page.
Common side effects of Rivastigmine (≥ 1 in 100): Nausea and vomiting (more pronounced with oral form), Reduced appetite and weight loss, Diarrhea, Dizziness and weakness, Skin irritation under the patch. See the Safety section for uncommon and serious reactions.
FDA category B. Not indicated.
Not used during lactation.
Rivastigmine is contraindicated in: Hypersensitivity to rivastigmine or other carbamates; Severe hepatic impairment; Dermatitis at prior patch site (transdermal); Pregnancy and lactation; Age under 18. Full list in the Safety section.