Pyridostigmine

Symptoms of excess cholinergic activity may occur (eg, salivation, sweating, urinary incontinence). Overdosage may result in cholinergic crisis (eg, muscle weakness), which must be distinguished from myasthenic crisis; discontinue immediately in the presence of cholinergic crisis.

May occur; have atropine and epinephrine ready to treat hypersensitivity reactions. Disease-related concerns:

Use with caution in patients with bradycardia or other cardiac arrhythmias.

Use with caution; additive effect with antiglaucoma drugs may cause or exacerbate problems with night vision.

Use with caution in patients with renal impairment; initial lower doses may be needed; titrate to effect.

Use with extreme caution in patients with asthma, bronchospastic disease, or COPD. Concurrent drug therapy issues:

Potentially significant interactions may exist, requiring dose or frequency adjustment, additional monitoring, and/or selection of alternative therapy. Consult drug interactions database for more detailed information. Special populations:

Use with caution in patients with bromide sensitivity.

Injection not indicated for use in neonates; may contain benzyl alcohol which has been associated with "gasping syndrome" in neonates. Dosage form specific issues:

Some dosage forms may contain sodium benzoate/benzoic acid; benzoic acid (benzoate) is a metabolite of benzyl alcohol; large amounts of benzyl alcohol (≥99 mg/kg/day) have been associated with a potentially fatal toxicity (“gasping syndrome”) in neonates; the “gasping syndrome” consists of metabolic acidosis, respiratory distress, gasping respirations, CNS dysfunction (including convulsions, intracranial hemorrhage), hypotension, and cardiovascular collapse (AAP ["Inactive" 1997]; CDC 1982); some data suggests that benzoate displaces bilirubin from protein binding sites (Ahlfors 2001); avoid or use dosage forms containing benzyl alcohol derivative with caution in neonates. See manufacturer's labeling.

Must be administered by trained personnel; use of peripheral nerve stimulation to monitor neuromuscular function recovery and continuous patient observation until recovery of normal respiration is recommended. To counteract anticholinergic effects, use of glycopyrrolate or atropine sulfate simultaneously with or prior to administration is recommended. May contain benzyl alcohol which has been associated with "gasping syndrome" in neonates.

Adequate facilities should be available for cardiopulmonary resuscitation when testing and adjusting dose for myasthenia gravis. Other warnings/precautions:

Inadequate reversal induced by nondepolarizing muscle relaxants is possible; manage with manual or mechanical ventilation until recovery is adequate (additional doses not recommended). Failure to produce prompt (within 30 minutes) reversal of neuromuscular blockade may occur in the presence of extreme debilitation, carcinomatosis, or with concomitant use of certain broad-spectrum antibiotics, or anesthetic agents and other drugs which enhance neuromuscular blockade or cause respiratory depression.

Only for pretreatment for exposure to Soman; discontinue pyridostigmine at the first sign of Soman exposure (do not administer pyridostigmine after Soman exposure); atropine and pralidoxime must be administered after Soman exposure (pyridostigmine pretreatment offers no benefit against Soman unless atropine and pralidoxime are administered once symptoms of poisoning appear). Use in conjunction with protective garments, including gas mask, hood and overgarments.