Parenteral Manual

Neostigmine methylsulfate

Disclaimer: Official controlled document is the CHEO online copy. It is the responsibility of user to ensure that any paper copy version is the same as the online version before use.

Alternate Name(s): 
PROSTIGMIN®
Classification: 
Antidote, cholinergic agent, diagnostic agent
Original Date: 
August 2005
Revised Date: 
May 2009
Indications: 
  • Treatment of supraventricular tacycardia
  • Treatment of myasthenia gravis
  • Prevent and treat postoperative bladder distention and urinary retention
  • Reversal of the effects of nondepolarizing neuromuscular blocking agents after surgery
Reconstitution and Stability: 
  • Available as 0.5 mg/mL ampoules
  • Protect from light and freezing
  • Keep at room temperature
Compatibility: 

- Solutions Compatible: dextrose up to D10W, 0.9% NaCl, dextrose-saline combinations, ringer's solution, ringer's lactate

- Additive/Above Cassette Compatible: glycopyrrolate, pentobarbital, thiopental

- Y-site Compatible: heparin, KCl (40 mmol/L)

- Incompatible: no information

Administration: 

(For approved routes of administration by nursing personnel, refer to Policy for the Administration of Intravenous Medications.)

SC YES
IM YES
IV Push

YES
Usual dilution: undiluted
Infusion time: slowly over several minutes
Infusion rate: do not exceed 0.5 mg/minute
IV Intermittent Infusion

NO
IV Continuous Infusion NO

 

 

Dosage: 

(For neonatal dosages, refer to Neonatal IV Drug Manual.)

Pediatric:

-Supraventricular tachycardia:

  • 0.01 - 0.04 mg/kg/dose IV
  • Maximum: 2.5 mg/dose

- Myasthenia gravis:    

  • Diagnosis: 0.025-0.04 mg/kg IM as a single dose
  • Treatment: 0.01-0.04 mg/kg IM/IV/SC Q2-4H
  • Maximum: 2.5 mg/dose

- Reversal of nondepolarizing neuromuscular blockage:

  • Infants: 0.025-0.1 mg/kg/dose IV
  • Children: 0.025-0.08 mg/kg/dose IV

Adult:

- Myasthenia gravis:

  • Diagnosis: 0.02 mg/kg IM as a single dose
  • Treatment: 0.5-2.5 mg IM/IV/SC Q 1-3 hours
  • Maximum: 10 mg/24 hours

- Reversal of nondepolarizing neuromuscular blockage:

  • 0.5-2.5 mg IV repeat PRN
  • Maximum: 5 mg total dose

- Bladder atony:   

  • Prevention: 0.25 mg IM/SC Q4-6H for 2-3 days
  • Treatment: 0.5-1 mg IM/SC Q3H for 5 doses after bladder has emptied

DOSING ADJUSTMENT IN RENAL IMPAIRMENT:

  • CrCl 10-50 mL/min:  Administer 50% of normal dose
  • CrCl <10 mL/min:  Administer 25% of normal dose
Potential hazards of parenteral administration: 
  • Hypotension
  • Respiratory distress (Antidote: atropine and artificial ventilation)
  • Cholinergic effects: nausea, vomiting, diarrhea, salivation, dizziness, bradycardia
  • Tremor, weakness, muscle cramping
  • Thrombophlebitis
  • Incontinence

 

 

Notes: 
  • To counteract the adverse cholinergic effects, administer with an anticholinergic agent (ie. atropine, glycopyrrolate)
  • For diagnosis of myasthenia gravis, all cholinesterase medications should be discontinued at least 8 hours before neostigmine and atropine should be administered IV immediately prior to or IM 30 minutes before neostigmine
  • Monitor muscle strength, heart rate, respiratory rate
  • Onset: 1-20 minutes (IV), 20-30 minutes (IM)
  • Duration: 1-2 hours (IV), 2-4 hours (IM)
  • Have atropine and epinephrine on hand for any hypersensitivity reactions
  • Does not antagonize and may prolong the phase I block of depolarizing muscle relaxants (eg: succinylcholine).

The information contained on this website is provided for informational purposes only, as a guide to assist physicians, nurses and other healthcare providers in deciding on the appropriate care required for a particular patient. At all times, physicians, nurses and other healthcare providers must exercise their independent clinical judgment, based on their knowledge, training and experience, taking into account the specific facts and circumstances of each patient, when deciding on the appropriate course of investigation and/or treatment to recommend in a particular clinical situation.

CHEO has made every effort to ensure that the information contained on this website is as current and accurate as possible. However, changes can occur due to ongoing research and the constant influx of new information. Where possible, hospitals and healthcare practitioners should verify the information before acting on it.

Reliance on any information in this website is at the user's own risk. CHEO is not responsible or liable for any harm, loss or other consequences from the use or misuse of the information on this website.