Should cholinesterase inhibitors, such as rivastigmine and physostigmine be withheld in patients with diabetes mellitus?
The package insert for physostigmine does list diabetes as a contraindication because it can theoretically stimulate pancreatic M3 receptors and change insulin requirements. However, in the acute management of anticholinergic delirium, there is no reason to limit use of these antidotes for patients with diabetes if indicated clinically. According to an open-cohort study of 22,660 patients diagnosed with Alzheimer’s Disease, chronic use of acetylcholinesterase inhibitors, including rivastigmine, was associated with favorable clinical outcomes, including a 24% reduction in all-cause mortality in patients with diabetes mellitus.
Physostigmine salicylate [package insert]. Gurnee, IL: Akron Pharmaceuticals; 2010.