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      Dosing & Uses

      AdultPediatric

      Dosage Forms & Strengths

      injectable solution

      • 1mg/mL

      Anticholinergic Toxicity

      Initial: 0.5-2 mg slow IVP (not to exceed 1 mg/min); keep atropine nearby for immediate use

      If no response, repeat q20min PRN

      If initial dose effective, may give additional 1-4 mg q30-60min PRN

      Rarely used; indicated only when life-threatening symptoms related to anticholinergic toxicity

      Useful for diagnostic as opposed to therapeutic reasons

      Dosage Forms & Strengths

      injectable solution

      • 1mg/mL

      Anticholinergic Toxicity

      0.02 mg/kg/dose slow IVP (not to exceed 0.5 mg/min); may repeat q5-10min PRN, not to exceed cumulative dose of 2 mg  

      Next:

      Interactions

      Interaction Checker

      and physostigmine

      No Results

         activity indicator 
        No Interactions Found
        Interactions Found

        Contraindicated

          Serious - Use Alternative

            Significant - Monitor Closely

              Minor

                All Interactions Sort By:
                 activity indicator 

                Contraindicated (0)

                  Serious - Use Alternative (1)

                  • triamcinolone acetonide injectable suspension

                    triamcinolone acetonide injectable suspension, physostigmine. unspecified interaction mechanism. Avoid or Use Alternate Drug. Concomitant use of anticholinesterase agents and corticosteroids may produce severe weakness in patients with myasthenia gravis. If possible, withdraw anticholinesterase agents at least 24 hours before initiating corticosteroid therapy.

                  Monitor Closely (66)

                  • aclidinium

                    physostigmine increases and aclidinium decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor.

                  • amifampridine

                    amifampridine and physostigmine both increase cholinergic effects/transmission. Use Caution/Monitor.

                  • amitriptyline

                    physostigmine increases and amitriptyline decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Modify Therapy/Monitor Closely.

                  • amoxapine

                    physostigmine increases and amoxapine decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor.

                  • anticholinergic/sedative combos

                    physostigmine increases and anticholinergic/sedative combos decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor.

                  • atracurium

                    physostigmine increases and atracurium decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor.

                  • atropine

                    physostigmine increases and atropine decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor.

                  • atropine IV/IM

                    physostigmine increases and atropine IV/IM decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor. .

                  • belladonna alkaloids

                    physostigmine increases and belladonna alkaloids decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor.

                  • belladonna and opium

                    physostigmine increases and belladonna and opium decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor.

                  • bethanechol

                    bethanechol and physostigmine both increase cholinergic effects/transmission. Use Caution/Monitor.

                  • carbachol

                    carbachol and physostigmine both increase cholinergic effects/transmission. Use Caution/Monitor.

                  • cevimeline

                    cevimeline and physostigmine both increase cholinergic effects/transmission. Use Caution/Monitor.

                  • cisatracurium

                    physostigmine increases and cisatracurium decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor.

                  • clomipramine

                    physostigmine increases and clomipramine decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor.

                  • cyclizine

                    physostigmine increases and cyclizine decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor.

                  • cyclobenzaprine

                    physostigmine increases and cyclobenzaprine decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor.

                  • darifenacin

                    physostigmine increases and darifenacin decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor.

                  • dicyclomine

                    physostigmine increases and dicyclomine decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor.

                  • diphenhydramine

                    physostigmine increases and diphenhydramine decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor.

                  • donepezil

                    donepezil and physostigmine both increase cholinergic effects/transmission. Use Caution/Monitor.

                  • dosulepin

                    physostigmine increases and dosulepin decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor.

                  • doxepin

                    physostigmine increases and doxepin decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor.

                  • echothiophate iodide

                    echothiophate iodide and physostigmine both increase cholinergic effects/transmission. Use Caution/Monitor.

                  • fesoterodine

                    physostigmine increases and fesoterodine decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor.

                  • flavoxate

                    physostigmine increases and flavoxate decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor.

                  • galantamine

                    galantamine and physostigmine both increase cholinergic effects/transmission. Use Caution/Monitor.

                  • glycopyrrolate

                    physostigmine increases and glycopyrrolate decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor.

                  • glycopyrrolate inhaled

                    physostigmine increases and glycopyrrolate inhaled decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor.

                  • henbane

                    physostigmine increases and henbane decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor.

                  • homatropine

                    physostigmine increases and homatropine decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor.

                  • huperzine A

                    huperzine A and physostigmine both increase cholinergic effects/transmission. Use Caution/Monitor.

                  • hyoscyamine

                    physostigmine increases and hyoscyamine decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor.

                  • hyoscyamine spray

                    physostigmine increases and hyoscyamine spray decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor. .

                  • imipramine

                    physostigmine increases and imipramine decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor.

                  • ipratropium

                    physostigmine increases and ipratropium decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor.

                  • lofepramine

                    physostigmine increases and lofepramine decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor.

                  • maprotiline

                    physostigmine increases and maprotiline decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor.

                  • meclizine

                    physostigmine increases and meclizine decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor.

                  • methscopolamine

                    physostigmine increases and methscopolamine decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor.

                  • neostigmine

                    neostigmine and physostigmine both increase cholinergic effects/transmission. Use Caution/Monitor.

                  • nortriptyline

                    physostigmine increases and nortriptyline decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor.

                  • onabotulinumtoxinA

                    physostigmine increases and onabotulinumtoxinA decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor.

                  • orphenadrine

                    physostigmine increases and orphenadrine decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor.

                  • oxybutynin

                    physostigmine increases and oxybutynin decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor.

                  • oxybutynin topical

                    physostigmine increases and oxybutynin topical decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor.

                  • oxybutynin transdermal

                    physostigmine increases and oxybutynin transdermal decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor.

                  • pancuronium

                    physostigmine increases and pancuronium decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor.

                  • pilocarpine

                    physostigmine and pilocarpine both increase cholinergic effects/transmission. Use Caution/Monitor.

                  • pralidoxime

                    physostigmine increases and pralidoxime decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor.

                  • propantheline

                    physostigmine increases and propantheline decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor.

                  • protriptyline

                    physostigmine increases and protriptyline decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor.

                  • pyridostigmine

                    physostigmine and pyridostigmine both increase cholinergic effects/transmission. Use Caution/Monitor.

                  • rapacuronium

                    physostigmine increases and rapacuronium decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor.

                  • rivastigmine

                    physostigmine and rivastigmine both increase cholinergic effects/transmission. Use Caution/Monitor.

                  • rocuronium

                    physostigmine increases and rocuronium decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor.

                  • scopolamine

                    physostigmine increases and scopolamine decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor.

                  • solifenacin

                    physostigmine increases and solifenacin decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor.

                  • succinylcholine

                    physostigmine and succinylcholine both increase cholinergic effects/transmission. Use Caution/Monitor.

                  • tiotropium

                    physostigmine increases and tiotropium decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor.

                  • tolterodine

                    physostigmine increases and tolterodine decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor.

                  • trihexyphenidyl

                    physostigmine increases and trihexyphenidyl decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor.

                  • trimipramine

                    physostigmine increases and trimipramine decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor.

                  • trospium chloride

                    physostigmine increases and trospium chloride decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor.

                  • umeclidinium bromide

                    physostigmine increases and umeclidinium bromide decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor. Monitor when umeclidinium bromide is coadministered with cholinergic agents.

                  • vecuronium

                    physostigmine increases and vecuronium decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor.

                  Minor (22)

                  • acebutolol

                    acebutolol, physostigmine. Either increases effects of the other by pharmacodynamic synergism. Minor/Significance Unknown. Additive bradycardia.

                  • atenolol

                    atenolol, physostigmine. Either increases effects of the other by pharmacodynamic synergism. Minor/Significance Unknown. Additive bradycardia.

                  • betaxolol

                    betaxolol, physostigmine. Either increases effects of the other by pharmacodynamic synergism. Minor/Significance Unknown. Additive bradycardia.

                  • bisoprolol

                    bisoprolol, physostigmine. Either increases effects of the other by pharmacodynamic synergism. Minor/Significance Unknown. Additive bradycardia.

                  • carvedilol

                    carvedilol, physostigmine. Either increases effects of the other by pharmacodynamic synergism. Minor/Significance Unknown. Additive bradycardia.

                  • celiprolol

                    celiprolol, physostigmine. Either increases effects of the other by pharmacodynamic synergism. Minor/Significance Unknown. Additive bradycardia.

                  • desipramine

                    physostigmine increases and desipramine decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Minor/Significance Unknown.

                  • donepezil

                    donepezil increases effects of physostigmine by pharmacodynamic synergism. Minor/Significance Unknown.

                  • esmolol

                    esmolol, physostigmine. Either increases effects of the other by pharmacodynamic synergism. Minor/Significance Unknown. Additive bradycardia.

                  • galantamine

                    galantamine increases effects of physostigmine by pharmacodynamic synergism. Minor/Significance Unknown.

                  • labetalol

                    labetalol, physostigmine. Either increases effects of the other by pharmacodynamic synergism. Minor/Significance Unknown. Additive bradycardia.

                  • metoprolol

                    metoprolol, physostigmine. Either increases effects of the other by pharmacodynamic synergism. Minor/Significance Unknown. Additive bradycardia.

                  • nadolol

                    nadolol, physostigmine. Either increases effects of the other by pharmacodynamic synergism. Minor/Significance Unknown. Additive bradycardia.

                  • nebivolol

                    nebivolol, physostigmine. Either increases effects of the other by pharmacodynamic synergism. Minor/Significance Unknown. Additive bradycardia.

                  • pantothenic acid

                    pantothenic acid, physostigmine. Either increases effects of the other by pharmacodynamic synergism. Minor/Significance Unknown.

                  • penbutolol

                    penbutolol, physostigmine. Either increases effects of the other by pharmacodynamic synergism. Minor/Significance Unknown. Additive bradycardia.

                  • pindolol

                    pindolol, physostigmine. Either increases effects of the other by pharmacodynamic synergism. Minor/Significance Unknown. Additive bradycardia.

                  • procainamide

                    procainamide decreases effects of physostigmine by pharmacodynamic antagonism. Minor/Significance Unknown.

                  • propranolol

                    propranolol, physostigmine. Either increases effects of the other by pharmacodynamic synergism. Minor/Significance Unknown. Additive bradycardia.

                  • sotalol

                    sotalol, physostigmine. Either increases effects of the other by pharmacodynamic synergism. Minor/Significance Unknown. Additive bradycardia.

                  • timolol

                    timolol, physostigmine. Either increases effects of the other by pharmacodynamic synergism. Minor/Significance Unknown. Additive bradycardia.

                  • trazodone

                    physostigmine increases and trazodone decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Minor/Significance Unknown.

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                  Adverse Effects

                  Frequency Not Defined

                  Seizure

                  Cardiovascular collapse

                  Bradycardia

                  Bronchospasm

                  Dyspnea

                  Diaphoresis

                  Diarrhea

                  Hyperperistalsis

                  Cholinergic Sx

                  Hallucinations

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                  Warnings

                  Contraindications

                  Salicylate allergy

                  Asthma, gangrene, diabetes, cardiovascular disease, mechanical obstruction of the intestinal or urogenital tract or any vagotonic state

                  Concurrency with choline esters or depolarizing neuromuscular blocking agents

                  Cautions

                  Overdosage may result in cholinergic crisis (eg, excessive salivation and sweating, miosis, nausea, vomiting, diarrhea, bradycardia or tachycardia, hypotension or hypertension, confusion, seizures, coma, severe muscle weakness, paralysis); if overdosage occurs, mechanical ventilation with repeated bronchial aspiration and IV atropine are recommended

                  Possible bradycardia, hypersalivation leading to respiratory problems, and/or seizures associated with rapid IV administration; asystole also has been reported; administer at a slow controlled rate

                  Discontinue therapy if excessive salivation, vomiting, urination, or defecation occurs; reduce dosage if excessive sweating or nausea occurs; atropine sulfate injection should always be readily available; observe patient for evidence of bronchial constriction; perform cardiac monitoring

                  Injections may contain sulfites, which may cause allergic-type reactions (including anaphylaxis and life-threatening or less severe asthmatic episodes) in certain susceptible individuals

                  Use with caution in patients with epilepsy, parkinsonian syndrome, or bradycardia

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                  Pregnancy & Lactation

                  Pregnancy Category: C

                  Lacation: Unknown if excreted in breast milk; caution advised

                  Pregnancy Categories

                  A: Generally acceptable. Controlled studies in pregnant women show no evidence of fetal risk.

                  B: May be acceptable. Either animal studies show no risk but human studies not available or animal studies showed minor risks and human studies done and showed no risk.

                  C: Use with caution if benefits outweigh risks. Animal studies show risk and human studies not available or neither animal nor human studies done.

                  D: Use in LIFE-THREATENING emergencies when no safer drug available. Positive evidence of human fetal risk.

                  X: Do not use in pregnancy. Risks involved outweigh potential benefits. Safer alternatives exist.

                  NA: Information not available.

                  Previous
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                  Pharmacology

                  Onset: 5-10 min

                  Duration: 30-60 min

                  Mechanism of Action

                  Indirect acting parasympathomimetic via inhibition of acetylcholinesterase

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                  Images

                  No images available for this drug.
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                  Patient Handout

                  A Patient Handout is not currently available for this monograph.
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                  Formulary

                  FormularyPatient Discounts

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                  The above information is provided for general informational and educational purposes only. Individual plans may vary and formulary information changes. Contact the applicable plan provider for the most current information.

                  View explanations for tiers and restrictions
                  Tier Description
                  1 This drug is available at the lowest co-pay. Most commonly, these are generic drugs.
                  2 This drug is available at a middle level co-pay. Most commonly, these are "preferred" (on formulary) brand drugs.
                  3 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs.
                  4 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.
                  5 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.
                  6 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.
                  NC NOT COVERED – Drugs that are not covered by the plan.
                  Code Definition
                  PA Prior Authorization
                  Drugs that require prior authorization. This restriction requires that specific clinical criteria be met prior to the approval of the prescription.
                  QL Quantity Limits
                  Drugs that have quantity limits associated with each prescription. This restriction typically limits the quantity of the drug that will be covered.
                  ST Step Therapy
                  Drugs that have step therapy associated with each prescription. This restriction typically requires that certain criteria be met prior to approval for the prescription.
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                  Drugs that have restrictions other than prior authorization, quantity limits, and step therapy associated with each prescription.
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                  Medscape prescription drug monographs are based on FDA-approved labeling information, unless otherwise noted, combined with additional data derived from primary medical literature.
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