Physostigmine

Physostigmine
Adult Indications & Dosage
Pediatric Indications & Dosage
Contraindications
Warnings & Precautions
Adverse Reactions
Drug Interactions
Use in Specific Populations
Administration & Monitoring
Overdosage
Pharmacology
Clinical Studies
How Supplied
Images
Patient Counseling Information
Precautions with Alcohol
Brand Names
Look-Alike Names

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Alberto Plate [2]

Disclaimer

WikiDoc MAKES NO GUARANTEE OF VALIDITY. WikiDoc is not a professional health care provider, nor is it a suitable replacement for a licensed healthcare provider. WikiDoc is intended to be an educational tool, not a tool for any form of healthcare delivery. The educational content on WikiDoc drug pages is based upon the FDA package insert, National Library of Medicine content and practice guidelines / consensus statements. WikiDoc does not promote the administration of any medication or device that is not consistent with its labeling. Please read our full disclaimer here.

Overview

Physostigmine is a central nervous system agent, cholinesterase inhibitor and anti glaucoma that is FDA approved for the treatment of clinical or toxic dosages of drugs capable of producing the anticholinergic syndrome. Common adverse reactions include diaphoresis, abnormal defecation, excessive salivation and nausea and vomiting.

Adult Indications and Dosage

FDA-Labeled Indications and Dosage (Adult)

Past Anesthesia Care

• Dosage: 0.5 to 1.0 mg intramuscularly or intravenously. IV administration should be at allow controlled rate of no more than 1 mg per minute. Dosage may be repeated at intervals of 10 to 30 minutes if desired patient response is not obtained.

Clinical or Toxic Dosages of Drugs Capable of Producing the Anticholinergic Syndrome

• Case report of a 68-year-old male patient admitted to the ICU for treatment of a severe thioridazine intoxication.

Off-Label Use and Dosage (Adult)

Guideline-Supported Use

There is limited information regarding Off-Label Guideline-Supported Use of Physostigmine in adult patients.

Non–Guideline-Supported Use

Reversal of Postoperative Reactions to Scopolamine

• Dosage: 1.0-1.2 milligrams IV. Unique dose.

Reversal of Postoperative Reactions to Scopolamine in Post-Partum

• Clinical trial of 5 postpartum patients.

Pediatric Indications and Dosage

FDA-Labeled Indications and Dosage (Pediatric)

Clinical or Toxic Dosages of Drugs Capable of Producing the Anticholinergic Syndrome

• Case report of a 27 month-old patient with amitriptyline overdose.

Off-Label Use and Dosage (Pediatric)

Guideline-Supported Use

There is limited information regarding Off-Label Guideline-Supported Use of Physostigmine in pediatric patients.

Non–Guideline-Supported Use

There is limited information regarding Off-Label Non–Guideline-Supported Use of Physostigmine in pediatric patients.

Contraindications

Physostigmine Salicylate Injection should not be used in the presence of asthma, gangrene, diabetes, cardiovascular disease, mechanical obstruction of the intestine or urogenital tract or any vagotonic state, and in patients receiving choline esters and depolarizing neuromuscular blocking agents (decamethonium, succinylcholine).

For post-anesthesia, the concomitant use of atropine with physostigmine salicylate is not recommended, since the atropine antagonizes the action of physostigmine.

Warnings

• Contains sodium bisulfite, a sulfite that may cause allergic-type reactions including anaphylactic symptoms and life-threatening or less severe asthmatic episodes in certain susceptible people. The overall prevalence of sulfite sensitivity in the general population is unknown and probably low. Sulfite sensitivity is seen more frequently in asthmatic than in non-asthmatic people.
• If excessive symptoms of salivation, emesis, urination and defecation occur, the use of Physostigmine Salicylate Injection should be terminated. If excessive sweating or nausea occur, the dosage should be reduced.
• Intravenous administration should be at a slow, controlled rate, no more than 1 mg per minute. Rapid administration can cause bradycardia, hypersalivation leading to a respiratory difficulties and possible convulsions. An overdosage of Physostigmine Salicylate Injection can cause a cholinergic crisis.

Adverse Reactions

Clinical Trials Experience

Cardiovascular Effects

• Asystole
• Bradyarrhythmia
• Cardiac dysrhythmia
• Hypertension
• Increased cardiac output
• Increased pulmonary arterial wedge pressure
• Tachycardia

Gastrointestinal Effects

• Abnormal defecation
• Excessive salivation
• Hyperperistalsis
• Nausea and vomiting

Musculoeskeletal Effects

• Muscle fasciculation
• Muscle weakness

Renal Effects

• Polyuria
• Urinary incontinence

Respiratory Effects

• Bronchospasm
• Excessive bronchial secretion

Postmarketing Experience

There is limited information regarding Physostigmine Postmarketing Experience in the drug label.

Drug Interactions

There is limited information regarding Physostigmine Drug Interactions in the drug label.

Use in Specific Populations

Pregnancy

Pregnancy Category (FDA): There is no FDA guidance on usage of Physostigmine in women who are pregnant.
Pregnancy Category (AUS): There is no Australian Drug Evaluation Committee (ADEC) guidance on usage of Physostigmine in women who are pregnant.

Labor and Delivery

There is no FDA guidance on use of Physostigmine during labor and delivery.

Nursing Mothers

There is no FDA guidance on the use of Physostigmine in women who are nursing.

Pediatric Use

There is no FDA guidance on the use of Physostigmine in pediatric settings.

Geriatic Use

There is no FDA guidance on the use of Physostigmine in geriatric settings.

Gender

There is no FDA guidance on the use of Physostigmine with respect to specific gender populations.

Race

There is no FDA guidance on the use of Physostigmine with respect to specific racial populations.

Renal Impairment

There is no FDA guidance on the use of Physostigmine in patients with renal impairment.

Hepatic Impairment

There is no FDA guidance on the use of Physostigmine in patients with hepatic impairment.

Females of Reproductive Potential and Males

There is no FDA guidance on the use of Physostigmine in women of reproductive potentials and males.

Immunocompromised Patients

There is no FDA guidance one the use of Physostigmine in patients who are immunocompromised.

Administration and Monitoring

Administration

There is limited information regarding Physostigmine Administration in the drug label.

Monitoring

There is limited information regarding Physostigmine Monitoring in the drug label.

IV Compatibility

There is limited information regarding the compatibility of Physostigmine and IV administrations.

Overdosage

There is limited information regarding Physostigmine overdosage. If you suspect drug poisoning or overdose, please contact the National Poison Help hotline (1-800-222-1222) immediately.

Pharmacology

There is limited information regarding Physostigmine Pharmacology in the drug label.

Mechanism of Action

There is limited information regarding Physostigmine Mechanism of Action in the drug label.

Structure

There is limited information regarding Physostigmine Structure in the drug label.

Pharmacodynamics

There is limited information regarding Physostigmine Pharmacodynamics in the drug label.

Pharmacokinetics

There is limited information regarding Physostigmine Pharmacokinetics in the drug label.

Nonclinical Toxicology

There is limited information regarding Physostigmine Nonclinical Toxicology in the drug label.

Clinical Studies

There is limited information regarding Physostigmine Clinical Studies in the drug label.

How Supplied

There is limited information regarding Physostigmine How Supplied in the drug label.

Storage

There is limited information regarding Physostigmine Storage in the drug label.

Images

Drug Images

{{#ask: Page Name::Physostigmine |?Pill Name |?Drug Name |?Pill Ingred |?Pill Imprint |?Pill Dosage |?Pill Color |?Pill Shape |?Pill Size (mm) |?Pill Scoring |?NDC |?Drug Author |format=template |template=DrugPageImages |mainlabel=- |sort=Pill Name }}

Package and Label Display Panel

{{#ask: Label Page::Physostigmine |?Label Name |format=template |template=DrugLabelImages |mainlabel=- |sort=Label Page }}

Patient Counseling Information

There is limited information regarding Physostigmine Patient Counseling Information in the drug label.

Precautions with Alcohol

Alcohol-Physostigmine interaction has not been established. Talk to your doctor about the effects of taking alcohol with this medication.

Brand Names

There is limited information regarding Physostigmine Brand Names in the drug label.

Look-Alike Drug Names

There is limited information regarding Physostigmine Look-Alike Drug Names in the drug label.

Drug Shortage Status

Price

References

The contents of this FDA label are provided by the National Library of Medicine.

Physostigmine

Clinical data
ATC code	S01EB05 (WHO) V03AB19 (WHO)
Identifiers
IUPAC name 1,2,3,3a,8,8a-hexahydro-1,3a, 8-trimethyl-, methylcarbamate (ester), (3aS,8aR)-pyrrolo(2,3-b)indol-5-ol
CAS Number	57-47-6
PubChem CID	5983
DrugBank	APRD00406
E number	{{#property:P628}}
ECHA InfoCard	{{#property:P2566}}
Chemical and physical data
Formula	C15H21N3O2
Molar mass	275.346 g/mol

WikiDoc Resources for Physostigmine
Articles
Most recent articles on Physostigmine Most cited articles on Physostigmine Review articles on Physostigmine Articles on Physostigmine in N Eng J Med, Lancet, BMJ
Media
Powerpoint slides on Physostigmine Images of Physostigmine Photos of Physostigmine Podcasts & MP3s on Physostigmine Videos on Physostigmine
Evidence Based Medicine
Cochrane Collaboration on Physostigmine Bandolier on Physostigmine TRIP on Physostigmine
Clinical Trials
Ongoing Trials on Physostigmine at Clinical Trials.gov Trial results on Physostigmine Clinical Trials on Physostigmine at Google
Guidelines / Policies / Govt
US National Guidelines Clearinghouse on Physostigmine NICE Guidance on Physostigmine NHS PRODIGY Guidance FDA on Physostigmine CDC on Physostigmine
Books
Books on Physostigmine
News
Physostigmine in the news Be alerted to news on Physostigmine News trends on Physostigmine
Commentary
Blogs on Physostigmine
Definitions
Definitions of Physostigmine
Patient Resources / Community
Patient resources on Physostigmine Discussion groups on Physostigmine Patient Handouts on Physostigmine Directions to Hospitals Treating Physostigmine Risk calculators and risk factors for Physostigmine
Healthcare Provider Resources
Symptoms of Physostigmine Causes & Risk Factors for Physostigmine Diagnostic studies for Physostigmine Treatment of Physostigmine
Continuing Medical Education (CME)
CME Programs on Physostigmine
International
Physostigmine en Espanol Physostigmine en Francais
Business
Physostigmine in the Marketplace Patents on Physostigmine
Experimental / Informatics
List of terms related to Physostigmine

Please Take Over This Page and Apply to be Editor-In-Chief for this topic: There can be one or more than one Editor-In-Chief. You may also apply to be an Associate Editor-In-Chief of one of the subtopics below. Please mail us [3] to indicate your interest in serving either as an Editor-In-Chief of the entire topic or as an Associate Editor-In-Chief for a subtopic. Please be sure to attach your CV and or biographical sketch.

Overview

Physostigmine (also known as eserine) is a parasympathomimetic, specifically, a reversible cholinesterase inhibitor obtained from the Calabar bean. By interfering with the metabolism of acetylcholine, physostigmine indirectly stimulates both nicotinic and muscarinic receptors. The chemical was synthesized for the first time in 1935 by the chemists Percy Lavon Julian and Josef Pikl.

Clinical uses

Physostigmine is used to treat glaucoma and delayed gastric emptying. Because it is a tertiary amine, it can cross the blood-brain barrier and so it is also used to treat the central nervous system effects of atropine, scopolamine and other anticholinergic drug overdoses. Intravenous injection of physostigmine (0.5mg-2mg) can be used to reverse GHB overdose, although careful control of dose is needed to avoid convulsions; often a small dose of an anticonvulsant such as diazepam is administered first to counteract the lowering of seizure threshold from the physostigmine. Possible side effects include depression, and overdose can cause a cholinergic syndrome. It is available in the U.S. under the trade names Antilirium, Eserine Salicylate, Isopto Eserine, and Eserine Sulfate.

Historical information

The following historical information is from the 1911 edition of the Encyclopedia Britannica:

The British pharmacopoeia contains an alcoholic extract of the bean, intended for internal administration; but the alkaloid is now always employed. This is used as the sulphate, which has the empirical formula of (C₁₅H₂₁N₃O₂)₂, H₂SO₄, plus an unknown number of molecules of water. It occurs in small yellowish crystals, which are turned red by exposure to light or air. They are readily soluble in water or alcohol and possess a bitter taste. The dose should invariably be administered by hypodermic injection. For the use of the oculist, who constantly employs this drug, it is also prepared in lamellae for insertion within the conjunctival sac. Each of these contains one-thousandth part of a grain of physostigmine sulphate, a quantity which is perfectly efficient. Physostigmine has no action on the unbroken skin. When swallowed it rapidly causes a great increase in the salivary secretion, being one of the most powerful sialogogues known. It has been shown that the action is due to a direct influence on the secreting gland-cells themselves. After a few minutes the salivation is arrested owing to the constricting influence of the drug upon the blood vessels that supply the glands. There is also felt a sense of constriction in the pharynx, due to the action of the drug on its muscular fibers.

A similar stimulation of the non-striped muscle in the alimentary canal results in violent vomiting and purging, if a large dose has been taken. Physostigmine, indeed, stimulates nearly all the non-striped muscles in the body, and this action upon the muscular coats of the arteries, and especially of the arterioles, causes a great rise in blood-pressure shortly after its absorption, which is very rapid. The terminals of the vagus nerve are also stimulated, causing the heart to beat more slowly. Later in its action, the drug depresses the intra-cardiac motor ganglia, causing prolongation of diastole and finally arrest of the heart in dilatation. A large lethal dose kills by this action, but the minimum lethal dose by its combined action on the respiration and the heart. The respiration is at first accelerated by a dose of physostigmine, but is afterwards slowed and ultimately arrested. The initial hastening is due to a stimulation of the vagus terminals in the lung, as it does not occur if these nerves are previously divided. The final arrest is due to paralysis of the respiratory centre in the medulla oblongata, hastened by a quasi-asthmatic contraction of the non-striped muscular tissue in the bronchial tubes, and by a "water-logging" of the lungs due to an increase in the amount of bronchial secretion. It may here be stated that the non-striped muscular tissue of the bladder, the uterus and the spleen is also stimulated, as well as that of the iris. It is only in very large doses that the voluntary muscles are poisoned, there being induced in them a tremor which may simulate ordinary convulsions. The action is a direct one upon the muscular tissue (cf. the case of the gland-cells), since it occurs in an animal whose motor nerves have been paralyzed by curare. Consciousness is entirely unaffected by physostigmine, there being apparently no action on any part of the brain above the medulla oblongata.

But the influence of the alkaloid upon the spinal cord is very marked and characteristic. The reflex functions of the cord are entirely abolished, and it has been experimentally shown that this is due to a direct influence upon the cells in the anterior cornua. It is precisely the reverse of the typical action of strychnine. Near the termination of a fatal case there is a paralysis of the sensory columns of the cord, so that general sensibility is lowered. The alkaloid calabarine is, on the other hand, a stimulant of the motor and reflex functions of the cord, so that only the pure alkaloid physostigmine and not any preparation of Calabar bean itself should be used when it is desired to obtain this action. Besides the secretions already mentioned as being stimulated, the bile, the tears and the perspiration are increased by the exhibition of this drug.

Whether administered in the form of the official lamella or by subcutaneous injection, physostigmine causes a contraction of the pupil more marked than in the case of any other known drug. That this action is a direct and not a nervous one is shown by the fact that if the eye be suddenly shaded the pupil will dilate a little, showing that the nerves which cause dilatation are still competent after the administration of physostigmine. Besides the sphincter pupillae, the fibers of the ciliary muscle are stimulated. There is consequently spasm of accommodation, so that clear vision of distant objects becomes impossible. The intra-ocular tension is markedly lowered.This action, at first sight somewhat obscure, is due to the extreme pupillary contraction which removes the mass of the iris from pressing upon the spaces of Fontana, through which the intraocular fluids normally make a very slow escape from the eye into its efferent lymphatics.

There is a marked antagonism in nearly all important particulars between the actions of physostigmine and of atropine. The details of this antagonism, as well as nearly all our knowledge of this valuable drug, we owe to Sir Thomas Fraser, who introduced it into therapeutics. The clinical uses of physostigmine are based upon the facts of its pharmacology, as above detailed. It has been recommended in cases of chronic constipation, and of want of tone in the muscular wall of the urinary bladder. It has undoubtedly been of value in many cases of tetanus, in which it must be given in maximal doses. (The tetanus antitoxin should invariably be employed as well.) Sir Thomas Fraser differs from nearly all other authorities in regarding the drug as useless in cases of strychnine poisoning, and the question must be left open. There is some doubtful evidence of the value of the alkaloid in chorea. The oculist uses it for at least six purposes. Its stimulant action on the iris and ciliary muscle is employed when they are weak or paralyzed. It is used in all cases where one needs to reduce the intra-ocular tension, and for this and other reasons in glaucoma. It is naturally the most efficient agent in relieving the discomfort or intolerable pain of photophobia; and it is the best means of breaking down adhesions of the iris, and of preventing prolapse of the iris after injuries to the cornea.

In fact it is hardly possible to over-estimate its value in ophthalmology. The drug has been highly and widely recommended in general paralysis, but there remains grave doubt as to its utility in this disease. Physostigimine has also been advocated for treatment of Datura poisoning, but clinical studies have not found any discernable benefit.

References

• Brenner, G. M. (2000). Pharmacology. Philadelphia, PA: W.B. Saunders Company. ISBN 0-7216-7757-6
• Canadian Pharmacists Association (2000). Compendium of Pharmaceuticals and Specialties (25th ed.). Toronto, ON: Webcom. ISBN 0-919115-76-4
• Template:1911
• Yates SW, Viera AJ. Physostigmine in the treatment of gamma-hydroxybutyric acid overdose. Mayo clinic proceedings. 2000 Apr;75(4):401-2.