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  

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Interactions

Interaction Checker

and physostigmine

No Results

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    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 (67)

              • 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.

              • pilocarpine ophthalmic

                physostigmine and pilocarpine ophthalmic 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

              Keep atropine ready for potential cholinergic sx

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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.

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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

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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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              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.
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              Code Definition
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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.