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  • Questions I had so far...

    These are a few questions I got asked in my first few weeks into the role..


    Could Rivastigmine be used in someone with a pacemaker? ( as it can cause severe bradycardia in some )


    Brimonidine topical gel in a long term Loferpramine user ..contraindicated in BNF..Could you still use it?


    Would be very helpful to hear your views...


  • #2
    [QUOTE=fthom;n229430]These are a few questions I got asked in my first few weeks into the role..


    "Could Rivastigmine be used in someone with a pacemaker? ( as it can cause severe bradycardia in some )"

    Hmmm...caveat emptor..I like to research and find info but don't assume I always come up with the latest!

    http://www.pharmacytimes.com/publica...g-interactions

    "Case Report

    A recent report described a 65-year-old woman taking rivastigmine and atenolol who was admitted to the hospital with a recent history of syncope.1 After admission, she developed bradycardia (heart rate in the low 40s) with sinus pauses of more than 2 seconds. The atenolol was discontinued with little improvement in the bradycardia. Subsequently, the clinical pharmacist identified rivastigmine as a possible contributing factor, and its discontinuation was followed by resolution of the bradycardia. It seems likely that the additive negative effects of rivastigmine and atenolol on heart rate contributed to this reaction.

    The above case is consistent with the results of a French report of adverse drug interactions following the use of the cholinesterase inhibitors rivastigmine, donepezil, or galantamine. The most common adverse drug interactions reported (205 cases) were cardiovascular, specifically bradycardia, atrioventricular block, and hypotension.2

    Do Other Cholinesterase Inhibitors Cause Bradycardia?

    Other cholinesterase inhibitors seem to have the same interaction potential with regard to additive bradycardia. Donepezil and galantamine have cholinergic effects similar to rivastigmine, and all 3 drugs tend to reduce heart rate. When they are combined with other drugs that tend to reduce heart rate (eg, beta-blockers, digoxin, some calcium channel blockers, amiodarone), cholinesterase inhibitors may exhibit additive effects. Based on current evidence, it is not possible to say that one cholinesterase inhibitor is more or less likely than the others to result in additive bradycardia.

    How Can the Reaction be Treated?

    Stopping 1 or both drugs should result in resolution of the cardiovascular toxicity, but some clinicians have recommended insertion of a cardiac pacemaker so the patient can continue to receive the cholinesterase inhibitor. If the patient’s Alzheimer’s disease has improved following use of the cholinesterase inhibitor, the patient (and his or her family) may be reluctant to discontinue it." (My bold font)

    So questions to ask...were they on the rivastigmine prior to the insertion of the pacemaker? Was the improvement on rivastigmine prior to pacemaker considered significant? If yes and it was me or my relative, I'd be all for continuing.




    "Brimonidine topical gel in a long term Loferpramine user ..contraindicated in BNF..Could you still use it?"


    Things to consider before going against guidelines is the wide variation in dose due to individual's extent of affected area and liberal (or not so) application of the gel.

    NICE guidelines:

    "Brimonidine tartrate gel is contraindicated in people receiving monoamine oxidase inhibitors (for example selegiline or moclobemide) or tricyclic (such as imipramine) or tetracyclic (such as maprotiline, mianserin or mirtazapine) antidepressants."

    Checked out the Patient Information Leaflet. "- if you are taking certain medicines used for depression or Parkinson’s disease including so‑called monoamine oxidase(MAO) inhibitors (for example selegiline or moclobemide) or tricyclic antidepressants (such as imipramine) or tetracyclic antidepressants (such as maprotiline, mianserin or mirtazapin).
    - Use of Mirvaso when taking these medicines may result in a fall in blood pressure."

    Other dermatological references from varying countries concurred with this.


    "Would be very helpful to hear your views..."

    Hope it helps. I hope you have Stockley's Drug Interactions access at work. Imagine that'd help. Worth investigating. Sadly I'm at home so was slaving over a hot keyboard from multiple soucres for my humble (and not necessarily correct) answers.

    Good luck!


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