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Adverse Effects of Physostigmine

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A Correction to this article was published on 14 August 2019

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Abstract

Introduction

Physostigmine is a tertiary amine carbamate acetylcholinesterase inhibitor. Its ability to cross the blood-brain barrier makes it an effective antidote to reverse anticholinergic delirium. Physostigmine is underutilized following the publication of patients with sudden cardiac arrest after physostigmine administration in patients with tricyclic antidepressant (TCA) overdoses. We completed a narrative literature review to identify reported adverse effects associated with physostigmine administration.

Discussion

One hundred sixty-one articles and a total of 2299 patients were included. Adverse effects occurred in 415 (18.1%) patients. Hypersalivation (206; 9.0%) and nausea and vomiting (96; 4.2%) were the most common adverse effects. Fifteen (0.61%) patients had seizures, all of which were self-limited or treated successfully without complication. Symptomatic bradycardia occurred in 8 (0.35%) patients including 3 patients with bradyasystolic arrests. Ventricular fibrillation occurred in one (0.04%) patient with underlying coronary artery disease. Of the 394 patients with TCA overdose, adverse effects were described in 14 (3.6%). Adverse effects occurred in 7.7% of patients treated with an overdose of an anticholinergic agent compared with 20.6% of patients with non-anticholinergic agents. Five (0.22%) fatalities were identified.

Conclusions

In conclusion, significant adverse effects associated with the use of physostigmine were infrequently reported. Seizures were self-limited or resolved with benzodiazepines, and all patients recovered neurologically intact. Physostigmine should be avoided in patients with QRS prolongation on EKG, and caution should be used in patients with a history of coronary artery disease and overdoses with QRS prolonging medications. Based upon our review, physostigmine is a safe antidote to treat anticholinergic overdose.

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Change history

  • 14 August 2019

    In “Adverse Effects of Physostigmine” by Arens et al in the July 2019 issue of JMT, reference #27 contains an error.

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Authors and Affiliations

  1. Minnesota Poison Control System, Minneapolis, MN, USA

    Ann M. Arens

  2. Hennepin Healthcare, Department of Emergency Medicine, Hennepin County Medical Center, 701 Park Avenue, MC-R2, Minneapolis, MN, 55415, USA

    Ann M. Arens

  3. California Poison Control System, San Francisco Division, San Francisco, CA, USA

    Tom Kearney

  4. San Francisco School of Pharmacy, University of California, San Francisco, CA, USA

    Tom Kearney

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  1. Ann M. Arens
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Arens, A.M., Kearney, T. Adverse Effects of Physostigmine. J. Med. Toxicol. 15, 184–191 (2019). https://doi.org/10.1007/s13181-019-00697-z

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