Pyridostigmine

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Pyridostigmine
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]

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Overview

Pyridostigmine is a cholinesterase inhibitor that is FDA approved for the treatment of myasthenia gravis. Common adverse reactions include diaphoresis, diarrhea, excessive salivation, increased peristalsis, nausea and vomiting, stomach cramps, muscle fasciculation, asthenia, miosis and excessive bronchial secretion.

Adult Indications and Dosage

FDA-Labeled Indications and Dosage (Adult)

Myasthenia Gravis

Pyridostigmine bromide is available in tablets, each containing 60 mg pyridostigmine bromide.

  • Dosage: The size and frequency of the dosage must be adjusted to the needs of the individual patient. The average dose is ten 60-mg tablets daily, spaced to provide maximum relief when maximum strength is needed. In severe cases as many as 25 tablets a day may be required, while in mild cases one to six tablets a day may suffice.

Off-Label Use and Dosage (Adult)

Guideline-Supported Use

There is limited information regarding Off-Label Guideline-Supported Use of Pyridostigmine (patient information) in adult patients.

Non–Guideline-Supported Use

Prophylaxis of Organophosphate Poisoning
  • Dosage: 30 mg q8h[1]

Pediatric Indications and Dosage

FDA-Labeled Indications and Dosage (Pediatric)

Myasthenia Gravis

Pyridostigmine bromide is available in tablets, each containing 60 mg pyridostigmine bromide.

  • Dosage: The size and frequency of the dosage must be adjusted to the needs of the individual patient. The average dose is ten 60-mg tablets daily, spaced to provide maximum relief when maximum strength is needed. In severe cases as many as 25 tablets a day may be required, while in mild cases one to six tablets a day may suffice.

Off-Label Use and Dosage (Pediatric)

Guideline-Supported Use

There is limited information regarding Off-Label Guideline-Supported Use of Pyridostigmine (patient information) in pediatric patients.

Non–Guideline-Supported Use

There is limited information regarding Off-Label Non–Guideline-Supported Use of Pyridostigmine (patient information) in pediatric patients.

Contraindications

  • Pyridostigmine bromide is contraindicated in mechanical intestinal or urinary obstruction, and particular caution should be used in its administration to patients with bronchial asthma. Care should be observed in the use of atropine for counteracting side effects, as discussed below.

Warnings

  • Although failure of patients to show clinical improvement may reflect underdosage, it can also be indicative of overdosage. As is true of all cholinergic drugs, overdosage of pyridostigmine bromide may result in cholinergic crisis, a state characterized by increasing muscle weakness which, through involvement of the muscles of respiration, may lead to death. Myasthenic crisis due to an increase in the severity of the disease is also accompanied by extreme muscle weakness, and thus may be difficult to distinguish from cholinergic crisis on a symptomatic basis. Such differentiation is extremely important, since increases in doses of pyridostigmine bromide or other drugs of this class in the presence of cholinergic crisis or of a refractory or "insensitive" state could have grave consequences. *Osserman and Genkins indicate that the differential diagnosis of the two types of crisis may require the use of Tensilon (edrophonium chloride) as well as clinical judgment. The treatment of the two conditions obviously differs radically. Whereas the presence of myasthenic crisis suggests the need for more intensive anticholinesterase therapy, the diagnosis of cholinergic crisis, according to Osserman and Genkins, calls for the prompt withdrawal of all drugs of this type. The immediate use of atropine in cholinergic crisis is also recommended.
  • Atropine may also be used to abolish or obtund gastrointestinal side effects or other muscarinic reactions; but such use, by masking signs of overdosage, can lead to inadvertent induction of cholinergic crisis. For detailed information on the management of patients with myasthenia gravis, the physician is referred to one of the excellent reviews such as those by Osserman and Genkins, Grob or Schwab.

Adverse Reactions

Clinical Trials Experience

Postmarketing Experience

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

Drug Interactions

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

Use in Specific Populations

Pregnancy

Pregnancy Category (FDA): C

  • The safety of pyridostigmine bromide during pregnancy or lactation in humans has not been established. Therefore, use of pyridostigmine bromide in women who may become pregnant requires weighing the drug's potential benefits against its possible hazards to mother and child.


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

Labor and Delivery

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

Nursing Mothers

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

Pediatric Use

Safety and effectiveness in pediatric patients have not been established.

Geriatic Use

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

Gender

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

Race

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

Renal Impairment

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

Hepatic Impairment

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

Females of Reproductive Potential and Males

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

Immunocompromised Patients

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

Administration and Monitoring

Administration

  • Pyridostigmine bromide is available in tablets, each containing 60 mg pyridostigmine bromide.

Monitoring

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

IV Compatibility

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

Overdosage

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

Pharmacology

Pyridostigmine Structure.png
Pyridostigmine
Systematic (IUPAC) name
3-[(dimethylcarbamoyl)oxy]-1-methylpyridinium
Identifiers
CAS number 155-97-5
ATC code N07AA02
PubChem 4991
DrugBank DB00545
Chemical data
Formula C9H13N2O2 
Mol. mass 181.212 g/mol
SMILES eMolecules & PubChem
Pharmacokinetic data
Bioavailability 7.6 +/- 2.4%
Metabolism ?
Half life 1.78 +/- 0.24hrs
Excretion Renal
Therapeutic considerations
Pregnancy cat.

C(AU) C(US)

Legal status

POM(UK) -only(US)

Routes Oral, intravenous

Mechanism of Action

Pyridostigmine bromide inhibits the destruction of acetylcholine by cholinesterase and thereby permits freer transmission of nerve impulses across the neuromuscular junction.

Structure

  • Chemically, pyridostigmine bromide is 3-hydroxy-1-methylpyridinium bromide dimethylcarbamate. Its structural formula is:
Pyridostigmine Structure.png

Pharmacodynamics

  • Pyridostigmine is an analog of neostigmine, but differs from it in certain clinically significant respects; for example, pyridostigmine is characterized by a longer duration of action and fewer gastrointestinal side effects.

Pharmacokinetics

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

Nonclinical Toxicology

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

Clinical Studies

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

How Supplied

Pyridostigmine How Supplied.png

Storage

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

Images

Drug Images

Package and Label Display Panel

Pyridostigmine Label.png
Pyridostigmine Package.png
This image of the FDA label is provided by the National Library of Medicine.

Patient Counseling Information

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

Precautions with Alcohol

  • Alcohol-Pyridostigmine (patient information) interaction has not been established. Talk to your doctor about the effects of taking alcohol with this medication.

Brand Names

Look-Alike Drug Names

There is limited information regarding Pyridostigmine 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.

  1. Keeler JR, Hurst CG, Dunn MA (1991). "Pyridostigmine used as a nerve agent pretreatment under wartime conditions". JAMA. 266 (5): 693–5. PMID 2072481.



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