Skip to main content
NCBI home page
Journal of Medical Toxicology logoLink to Journal of Medical Toxicology
. 2010 Apr 20;6(4):386–392. doi: 10.1007/s13181-010-0077-7

Timing and Frequency of Physostigmine Redosing for Antimuscarinic Toxicity

Christopher Rosenbaum 1, Steven B Bird 1,✉
PMCID: PMC3550455  PMID: 20405266

Abstract

We sought to determine how frequently antimuscarinic-poisoned patients receiving physostigmine receive multiple doses of physostigmine, the length of time between physostigmine doses, and what impact multiple doses of physostigmine have on the disposition and total length of hospital stay. We performed a retrospective chart review of patients given physostigmine for likely antimuscarinic toxicity. A total of 45 patients met inclusion criteria. We abstracted patient demographics, vital signs, physical exam findings, electrocardiograms, the timing and dose of physostigmine, the implicated antimuscarinic agents, and disposition from the hospital. We counted the number of patients who required multiple physostigmine doses and calculated the time to repeat dosing. Fourteen of the 45 patients (31%) given physostigmine for antimuscarinic toxicity received multiple doses: nine patients (20%) received two doses, three patients (6.6%) received three doses, and two patients (4.4%) received four doses. Less than 5.5 h elapsed between sequential physostigmine doses, and less than 6.5 h elapsed between the first and last dose. Forty-five percent of patients receiving one dose of physostigmine were discharged from the emergency department (ED) and 36% of patients receiving more than one dose of physostigmine were discharged from the ED. Whether admitted or discharged, there was no statistically significant difference in the length of hospital stay between patients receiving one or multiple doses of physostigmine. Repeated physostigmine administration is not frequently needed in medication-induced antimuscarinic toxicity. Patients are not likely to require further physostigmine redosing more than 6.5 h from their first dose.

Keywords: Physostigmine, Antimuscarinic, Anticholinergic, Toxicity

Full Text

The Full Text of this article is available as a PDF (192.7 KB).

References

  • 1.Proudfoot A. The early toxicology of physostigmine: a tale of beans, great men and egos. Toxicol Rev. 2006;25:99–138. doi: 10.2165/00139709-200625020-00004. [DOI] [PubMed] [Google Scholar]
  • 2.Burns MJ, Linden CH, Graudins A, et al. A comparison of physostigmine and benzodiazepines for the treatment of anticholinergic poisoning. Ann Emerg Med. 2000;35:374–381. doi: 10.1016/S0196-0644(00)70057-6. [DOI] [PubMed] [Google Scholar]
  • 3.Taylor P. Anticholinesterase agents. In: Hardman JL, editor. Goodman and Gilman’s The pharmacological basis of therapeutics. 10. New York: McGraw-Hill; 2001. pp. 175–191. [Google Scholar]
  • 4.Smilkstein MJ. As the pendulum swings: the saga of physostigmine. J Emerg Med. 1991;9:275–277. doi: 10.1016/0736-4679(91)90426-G. [DOI] [PubMed] [Google Scholar]
  • 5.Gilbert EH, Lowenstein SR, Koziol-McLain J, et al. Chart reviews in emergency medicine research: where are the methods? Ann Emerg Med. 1996;27:305–308. doi: 10.1016/S0196-0644(96)70264-0. [DOI] [PubMed] [Google Scholar]
  • 6.Rohm KD, Riechmann J, Boldt J, et al. Physostigmine for the prevention of postanaesthetic shivering following general anaesthesia—a placebo-controlled comparison with nefopam. Anaesthesia. 2005;60:433–438. doi: 10.1111/j.1365-2044.2005.04157.x. [DOI] [PubMed] [Google Scholar]
  • 7.Sopchak CA, Stork CM, Cantor RM, et al. Central anticholinergic syndrome due to Jimson weed physostigmine: therapy revisited? J Toxicol Clin Toxicol. 1998;36:43–45. doi: 10.3109/15563659809162583. [DOI] [PubMed] [Google Scholar]
  • 8.Vanderhoff BT, Mosser KH. Jimson weed toxicity: management of anticholinergic plant ingestion. Am Fam Physician. 1992;46:526–530. [PubMed] [Google Scholar]
  • 9.Shannon M. Toxicology reviews: physostigmine. Pediatr Emerg Care. 1998;14:224–226. doi: 10.1097/00006565-199806000-00015. [DOI] [PubMed] [Google Scholar]
  • 10.Belen B, Akman A, Yuksel N, et al. A case report of amitriptyline poisoning successfully treated with the application of plasma exchange. Ther Apher Dial. 2009;13:147–149. doi: 10.1111/j.1744-9987.2009.00669.x. [DOI] [PubMed] [Google Scholar]
  • 11.Stern TA. Continuous infusion of physostigmine in anticholinergic delirium: case report. J Clin Psychiatry. 1983;44:463–464. [PubMed] [Google Scholar]
  • 12.Boehnert MT, Lovejoy FH., Jr Value of the QRS duration versus the serum drug level in predicting seizures and ventricular arrhythmias after an acute overdose of tricyclic antidepressants. N Engl J Med. 1985;313:474–479. doi: 10.1056/NEJM198508223130804. [DOI] [PubMed] [Google Scholar]
  • 13.Raggi MA, Mandrioli R, Sabbioni C, et al. Atypical antipsychotics: pharmacokinetics, therapeutic drug monitoring and pharmacological interactions. Curr Med Chem. 2004;11:279–296. doi: 10.2174/0929867043456089. [DOI] [PubMed] [Google Scholar]
  • 14.Richelson E, Souder T. Binding of antipsychotic drugs to human brain receptors focus on newer generation compounds. Life Sci. 2000;68:29–39. doi: 10.1016/S0024-3205(00)00911-5. [DOI] [PubMed] [Google Scholar]
  • 15.Liang I. Anticholinergic poisoning. In: Linden CH, Irwin RS, editors. Manual of overdoses and poisonings. 1. Philadelphia: Lippincott Williams & Wilkins; 2006. pp. 30–34. [Google Scholar]
  • 16.Kirk MA. Anticholinergics and antihistamines. In: Shannon MW, Borron S, Burns MJ, editors. Haddad and Winchester’s clinical management of poisoning and drug overdose. 4. Philadelphia: Saunders Elsevier; 2007. pp. 721–734. [Google Scholar]
  • 17.Knudsen K, Heath A. Effects of self poisoning with maprotiline. Br Med J (Clin Res Ed) 1984;288:601–603. doi: 10.1136/bmj.288.6417.601. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 18.Burkhart K. Anticholinergic poisoning. In: Irwin RS, Rippe RJ, editors. Rippe and Irwin’s intensive care medicine. Philadelphia: Lipincott Williams & Wilkins; 2007. pp. 1499–1501. [Google Scholar]
  • 19.Snyder BD, Blonde L, McWhirter WR. Reversal of amitriptyline intoxication by physostigmine. JAMA. 1974;230:1433–1434. doi: 10.1001/jama.230.10.1433. [DOI] [PubMed] [Google Scholar]
  • 20.Burks JS, Walker JE, Rumack BH, et al. Tricyclic antidepressant poisoning. Reversal of coma, choreoathetosis, and myoclonus by physostigmine. Jama. 1974;230:1405–1407. doi: 10.1001/jama.230.10.1405. [DOI] [PubMed] [Google Scholar]
  • 21.Wright SP. Usefulness of physostigmine in imipramine poisoning. A dramatic response in a child resistant to other therapy. Clin Pediatr (Phila) 1976;15:1123–1128. doi: 10.1177/000992287601501208. [DOI] [PubMed] [Google Scholar]
  • 22.Janson PA, Watt JB, Hermos JA. Doxepin overdose. Success with physostigmine and failure with neostigmine in reversing toxicity. Jama. 1977;237:2632–2633. doi: 10.1001/jama.237.24.2632. [DOI] [PubMed] [Google Scholar]
  • 23.Beaver KM, Gavin TJ. Treatment of acute anticholinergic poisoning with physostigmine. Am J Emerg Med. 1998;16:505–507. doi: 10.1016/S0735-6757(98)90003-1. [DOI] [PubMed] [Google Scholar]
  • 24.Rumack BH. Anticholinergic poisoning: treatment with physostigmine. Pediatrics. 1973;52:449–451. [PubMed] [Google Scholar]
  • 25.Walker WE, Levy RC, Hanenson IB. Physostigmine—its use and abuse. JACEP. 1976;5:436–439. doi: 10.1016/s0361-1124(76)80253-5. [DOI] [PubMed] [Google Scholar]
  • 26.Pentel P, Peterson CD. Asystole complicating physostigmine treatment of tricyclic antidepressant overdose. Ann Emerg Med. 1980;9:588–590. doi: 10.1016/S0196-0644(80)80232-0. [DOI] [PubMed] [Google Scholar]
  • 27.Tobis J, Das BN. Cardiac complications in amitriptyline poisoning. Successful treatment with physostigmine. Jama. 1976;235:1474–1476. doi: 10.1001/jama.235.14.1474. [DOI] [PubMed] [Google Scholar]
  • 28.Suchard JR. Assessing physostigmine’s contraindication in cyclic antidepressant ingestions. J Emerg Med. 2003;25:185–191. doi: 10.1016/S0736-4679(03)00169-0. [DOI] [PubMed] [Google Scholar]
  • 29.Newton RW. Physostigmine salicylate in the treatment of tricyclic antidepressant overdosage. Jama. 1975;231:941–943. doi: 10.1001/jama.231.9.941. [DOI] [PubMed] [Google Scholar]
  • 30.Schneir AB, Offerman SR, Ly BT, et al. Complications of diagnostic physostigmine administration to emergency department patients. Ann Emerg Med. 2003;42:14–19. doi: 10.1067/mem.2003.232. [DOI] [PubMed] [Google Scholar]
  • 31.Rodgers GC, Jr, Von Kanel RL. Conservative treatment of jimsonweed ingestion. Vet Hum Toxicol. 1993;35:32–33. [PubMed] [Google Scholar]
  • 32.Weizberg M, Su M, Mazzola JL, et al. Altered mental status from olanzapine overdose treated with physostigmine. Clin Toxicol. 2006;44:319–325. doi: 10.1080/15563650600584535. [DOI] [PubMed] [Google Scholar]

Articles from Journal of Medical Toxicology are provided here courtesy of Springer

RESOURCES