Dosing & Uses
Dosage Forms & Strengths
IM autoinjector
- atropine (2.1mg/0.7mL) plus pralidoxime chloride (600mg/2mL) in 2 separate chambers; when activated, sequentially administers both drugs IM through a single needle
Organophosphate Poisoning
Indicated for treatment of poisoning by organophosphorus nerve agents as well as organophosphorus insecticides in adults and pediatric patients weighing >41 kg (90 pounds)
2.1 mg atropine/0.7 mL + 600 mg pralidoxime/2 mL IM
Maximum dose: Not to exceed 3 injections unless medical care support available
3 autoinjectors should be available for use in each patient (including healthcare providers) at risk for organophosphorus poisoning; use 1 for mild symptoms plus 2 more for severe symptoms
See also Administration
Mild symptoms
- ≥2 mild symptoms: 1 injection IM; if after 10-15 min there are no severe symptoms experienced, no further injections are necessary
- Additional doses: If, at any time following the first injection, the patient develops any of the severe symptoms, administer 2 additional IM injections in rapid succession
- Mild symptoms: Bradycardia, chest tightness, breathing difficulties, blurred vision, increased salivation (eg, sudden drooling), miosis, nausea or vomiting, runny nose, stomach cramps (acute onset), salivation, teary eyes, wheezing/coughing, tremors/muscular twitching, airway secretions increased
Severe symptoms
- Any severe symptom listed below: 3 injections IM in rapid succession
- Severe symptoms: Confused/strange behavior, involuntary urination/defecation, muscular twitching/generalized weakness (severe), severe breathing difficulties or copious secretion from lung or airway, convulsions, unconsciousness
Dosing Modifications
Renal impairment
- Pralidoxime can cause decreased renal function
- Patients with severe renal impairment may require less frequent doses after initial dose
Hepatic impairment
- Patients with severe hepatic impairment may require less frequent doses after initial dose
Dosing Considerations
Three autoinjectors should be available for use in each patient (including healthcare providers) at risk for organophosphorus poisoning; one (1) for mild symptoms plus two (2) more for severe symptoms; note that individuals may not have all symptoms included under mild or severe symptom category
Only administer drug to patients experiencing symptoms of organophosphorus poisoning in a situation where exposure is known or suspected; autoinjector is intended as an initial treatment of symptoms of organophosphorus nerve agent or insecticide poisonings as soon as symptoms appear; definitive medical care should be sought immediately
The autoinjector should be administered by healthcare providers with adequate training in recognition and treatment of nerve agent or insecticide intoxication
Close supervision of all treated patients is indicated for at least 48 to 72 hours
Dosage Forms & Strengths
IM autoinjector
- atropine (2.1mg/0.7mL) plus pralidoxime chloride (600mg/2mL) in 2 separate chambers; when activated, sequentially administers both drugs IM through a single needle
Organophosphate Poisoning
Indicated for treatment of poisoning by organophosphorus nerve agents as well as organophosphorus insecticides in adults and pediatric patients weighing >41 kg (90 pounds)
≤41 kg: Safety and efficacy not established
>41 kg: 2.1 mg atropine/0.7 mL + 600 mg pralidoxime/2 mL IM
Maximum dose: Not to exceed 3 injections unless medical care support available
3 autoinjectors should be available for use in each patient (including healthcare providers) at risk for organophosphorus poisoning; use 1 for mild symptoms plus 2 more for severe symptoms
Mild symptoms
- ≥2 mild symptoms: 1 injection IM; if after 10-15 min there are no severe symptoms experienced, no further injections are necessary
- Additional doses: If, at any time following the first injection, the patient develops any of the severe symptoms, administer 2 additional IM injections in rapid succession
- Mild symptoms: Bradycardia, chest tightness, breathing difficulties, blurred vision, increased salivation (eg, sudden drooling), miosis, nausea or vomiting, runny nose, stomach cramps (acute onset), salivation, teary eyes, wheezing/coughing, tremors/muscular twitching, airway secretions increased
Severe symptoms
- Any severe symptom listed below: 3 injections IM in rapid succession
- Severe symptoms: Confused/strange behavior, involuntary urination/defecation, muscular twitching/generalized weakness (severe), severe breathing difficulties or copious secretion from lung or airway, convulsions, unconsciousness
Dosing Modifications
Renal impairment
- Pralidoxime can cause decreased renal function
- Patients with severe renal impairment may require less frequent doses after initial dose
Hepatic impairment
- Patients with severe hepatic impairment may require less frequent doses after initial dose
Dosing Considerations
Three autoinjectors should be available for use in each patient (including healthcare providers) at risk for organophosphorus poisoning; one (1) for mild symptoms plus two (2) more for severe symptoms; note that individuals may not have all symptoms included under mild or severe symptom category
Only administer drug to patients experiencing symptoms of organophosphorus poisoning in a situation where exposure is known or suspected; autoinjector is intended as an initial treatment of symptoms of organophosphorus nerve agent or insecticide poisonings as soon as symptoms appear; definitive medical care should be sought immediately
The autoinjector should be administered by healthcare providers with adequate training in recognition and treatment of nerve agent or insecticide intoxication
Close supervision of all treated patients is indicated for at least 48 to 72 hours
Older individuals may be more susceptible to atropine effects
Interactions
Interaction Checker
No Results
Contraindicated
Serious - Use Alternative
Significant - Monitor Closely
Minor
Contraindicated (0)
Serious - Use Alternative (9)
- eluxadoline
atropine, eluxadoline. Either increases effects of the other by pharmacodynamic synergism. Avoid or Use Alternate Drug. Avoid coadministration with other drugs that cause constipation. Increases risk for constipation related serious adverse reactions. .
- glucagon
glucagon increases effects of atropine by Other (see comment). Avoid or Use Alternate Drug. Comment: Coadministration of anticholinergic drugs and glucagon increase the risk of gastrointestinal adverse reactions due to additive effects on inhibition of gastrointestinal motility. .
- glucagon intranasal
glucagon intranasal increases effects of atropine by Other (see comment). Avoid or Use Alternate Drug. Comment: Coadministration of anticholinergic drugs and glucagon increase the risk of gastrointestinal adverse reactions due to additive effects on inhibition of gastrointestinal motility. .
- glycopyrronium tosylate topical
glycopyrronium tosylate topical, atropine. Either increases effects of the other by pharmacodynamic synergism. Avoid or Use Alternate Drug. Coadministration of glycopyrronium tosylate topical with other anticholinergic medications may result in additive anticholinergic adverse effects.
- macimorelin
atropine, macimorelin. unspecified interaction mechanism. Avoid or Use Alternate Drug. Drugs that may blunt the growth hormone (GH) response to macrimorelin may impact the accuracy of the diagnostic test. Allow sufficient washout time of drugs affecting GH release before administering macimorelin.
- pramlintide
pramlintide, atropine. Either increases effects of the other by pharmacodynamic synergism. Contraindicated. Synergistic inhibition of GI motility.
pramlintide, pralidoxime. Either increases effects of the other by pharmacodynamic synergism. Contraindicated. Synergistic inhibition of GI motility. - revefenacin
revefenacin and atropine both decrease cholinergic effects/transmission. Avoid or Use Alternate Drug. Coadministration may cause additive anticholinergic effects.
- secretin
atropine decreases effects of secretin by pharmacodynamic antagonism. Avoid or Use Alternate Drug. Concomitant use of anticholinergic drugs may cause a hyporesponse to stimulation testing with secretin. Discontinue anticholinergic drugs at least 5 half-lives before administering secretin.
- umeclidinium bromide/vilanterol inhaled
atropine, umeclidinium bromide/vilanterol inhaled. Either increases toxicity of the other by pharmacodynamic synergism. Avoid or Use Alternate Drug. Concomitant use with other anticholinergic-containing drugs may lead to additive anticholinergic adverse effects.
Monitor Closely (119)
- abobotulinumtoxinA
abobotulinumtoxinA increases effects of atropine by pharmacodynamic synergism. Use Caution/Monitor. Use of anticholinergic drugs after administration of botulinum toxin-containing products may potentiate systemic anticholinergic effects. .
- aclidinium
pralidoxime and aclidinium both decrease cholinergic effects/transmission. Use Caution/Monitor.
atropine and aclidinium both decrease cholinergic effects/transmission. Use Caution/Monitor. - amantadine
atropine, amantadine. Mechanism: pharmacodynamic synergism. Use Caution/Monitor. Potential for increased anticholinergic adverse effects.
- amitriptyline
pralidoxime and amitriptyline both decrease cholinergic effects/transmission. Use Caution/Monitor.
- amitriptyline
atropine and amitriptyline both decrease cholinergic effects/transmission. Modify Therapy/Monitor Closely.
- amoxapine
pralidoxime and amoxapine both decrease cholinergic effects/transmission. Use Caution/Monitor.
atropine and amoxapine both decrease cholinergic effects/transmission. Use Caution/Monitor. - anticholinergic/sedative combos
anticholinergic/sedative combos and atropine both decrease cholinergic effects/transmission. Use Caution/Monitor.
anticholinergic/sedative combos and pralidoxime both decrease cholinergic effects/transmission. Use Caution/Monitor. - aripiprazole
atropine decreases levels of aripiprazole by inhibition of GI absorption. Applies only to oral form of both agents. Use Caution/Monitor.
aripiprazole increases effects of atropine by pharmacodynamic synergism. Use Caution/Monitor. Additive anticholinergic effects, possible hypoglycemia.
aripiprazole increases effects of pralidoxime by pharmacodynamic synergism. Use Caution/Monitor. Additive anticholinergic effects, possible hypoglycemia.
atropine decreases levels of aripiprazole by pharmacodynamic antagonism. Use Caution/Monitor.
pralidoxime decreases levels of aripiprazole by pharmacodynamic antagonism. Use Caution/Monitor.
pralidoxime decreases levels of aripiprazole by inhibition of GI absorption. Applies only to oral form of both agents. Use Caution/Monitor. - atracurium
atracurium and pralidoxime both decrease cholinergic effects/transmission. Use Caution/Monitor.
atracurium and atropine both decrease cholinergic effects/transmission. Use Caution/Monitor. - atropine
atropine and pralidoxime both decrease cholinergic effects/transmission. Use Caution/Monitor.
- belladonna alkaloids
atropine and belladonna alkaloids both decrease cholinergic effects/transmission. Use Caution/Monitor.
- atropine IV/IM
atropine IV/IM and pralidoxime both decrease cholinergic effects/transmission. Use Caution/Monitor.
- belladonna alkaloids
belladonna alkaloids and pralidoxime both decrease cholinergic effects/transmission. Use Caution/Monitor.
- belladonna and opium
belladonna and opium and pralidoxime both decrease cholinergic effects/transmission. Use Caution/Monitor.
atropine and belladonna and opium both decrease cholinergic effects/transmission. Use Caution/Monitor. - benperidol
atropine decreases levels of benperidol by inhibition of GI absorption. Applies only to oral form of both agents. Use Caution/Monitor.
pralidoxime decreases levels of benperidol by inhibition of GI absorption. Applies only to oral form of both agents. Use Caution/Monitor.
benperidol increases effects of atropine by pharmacodynamic synergism. Use Caution/Monitor. Additive anticholinergic effects, possible hypoglycemia.
pralidoxime decreases levels of benperidol by pharmacodynamic antagonism. Use Caution/Monitor.
benperidol increases effects of pralidoxime by pharmacodynamic synergism. Use Caution/Monitor. Additive anticholinergic effects, possible hypoglycemia.
atropine decreases levels of benperidol by pharmacodynamic antagonism. Use Caution/Monitor. - benztropine
benztropine and pralidoxime both decrease cholinergic effects/transmission. Use Caution/Monitor.
atropine and benztropine both decrease cholinergic effects/transmission. Use Caution/Monitor. Additive anticholinergic adverse effects may be seen with concurrent use. - bethanechol
bethanechol increases and atropine decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor.
bethanechol increases and pralidoxime decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor. - buprenorphine, long-acting injection
buprenorphine, long-acting injection increases effects of atropine by pharmacodynamic synergism. Use Caution/Monitor. Coadministration of buprenorphine with anticholinergic drugs may increase risk of urinary retention and/or severe constipation, which may lead to paralytic ileus.
- carbachol
carbachol increases and pralidoxime decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor.
- carbachol
carbachol increases and atropine decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor.
- cevimeline
cevimeline increases and pralidoxime decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor.
cevimeline increases and atropine decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor. - chlorpromazine
pralidoxime decreases levels of chlorpromazine by pharmacodynamic antagonism. Use Caution/Monitor.
chlorpromazine increases effects of atropine by pharmacodynamic synergism. Use Caution/Monitor. Additive anticholinergic effects, possible hypoglycemia.
chlorpromazine increases effects of pralidoxime by pharmacodynamic synergism. Use Caution/Monitor. Additive anticholinergic effects, possible hypoglycemia.
pralidoxime decreases levels of chlorpromazine by inhibition of GI absorption. Applies only to oral form of both agents. Use Caution/Monitor.
atropine decreases levels of chlorpromazine by inhibition of GI absorption. Applies only to oral form of both agents. Use Caution/Monitor.
atropine decreases levels of chlorpromazine by pharmacodynamic antagonism. Use Caution/Monitor. - cisatracurium
cisatracurium and pralidoxime both decrease cholinergic effects/transmission. Use Caution/Monitor.
atropine and cisatracurium both decrease cholinergic effects/transmission. Use Caution/Monitor. - clomipramine
pralidoxime and clomipramine both decrease cholinergic effects/transmission. Use Caution/Monitor.
atropine and clomipramine both decrease cholinergic effects/transmission. Use Caution/Monitor. - clozapine
pralidoxime decreases levels of clozapine by inhibition of GI absorption. Applies only to oral form of both agents. Use Caution/Monitor.
atropine decreases levels of clozapine by inhibition of GI absorption. Applies only to oral form of both agents. Use Caution/Monitor.
clozapine increases effects of atropine by pharmacodynamic synergism. Use Caution/Monitor. Additive anticholinergic effects, possible hypoglycemia.
clozapine increases effects of pralidoxime by pharmacodynamic synergism. Use Caution/Monitor. Additive anticholinergic effects, possible hypoglycemia.
atropine decreases levels of clozapine by pharmacodynamic antagonism. Use Caution/Monitor.
pralidoxime decreases levels of clozapine by pharmacodynamic antagonism. Use Caution/Monitor. - cyclizine
cyclizine and pralidoxime both decrease cholinergic effects/transmission. Use Caution/Monitor.
atropine and cyclizine both decrease cholinergic effects/transmission. Use Caution/Monitor. - cyclobenzaprine
cyclobenzaprine and pralidoxime both decrease cholinergic effects/transmission. Use Caution/Monitor.
atropine and cyclobenzaprine both decrease cholinergic effects/transmission. Use Caution/Monitor. - darifenacin
darifenacin and pralidoxime both decrease cholinergic effects/transmission. Use Caution/Monitor.
atropine and darifenacin both decrease cholinergic effects/transmission. Use Caution/Monitor. - desipramine
pralidoxime and desipramine both decrease cholinergic effects/transmission. Use Caution/Monitor.
- dicyclomine
atropine and dicyclomine both decrease cholinergic effects/transmission. Use Caution/Monitor.
- dicyclomine
dicyclomine and pralidoxime both decrease cholinergic effects/transmission. Use Caution/Monitor.
- digoxin
atropine increases levels of digoxin by unknown mechanism. Use Caution/Monitor.
- diphenhydramine
atropine and diphenhydramine both decrease cholinergic effects/transmission. Use Caution/Monitor.
diphenhydramine and pralidoxime both decrease cholinergic effects/transmission. Use Caution/Monitor. - donepezil
donepezil increases and atropine decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor.
donepezil increases and pralidoxime decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor. - donepezil transdermal
donepezil transdermal, atropine. Either decreases effects of the other by pharmacodynamic antagonism. Modify Therapy/Monitor Closely.
- dosulepin
pralidoxime and dosulepin both decrease cholinergic effects/transmission. Use Caution/Monitor.
- dosulepin
atropine and dosulepin both decrease cholinergic effects/transmission. Use Caution/Monitor.
- doxepin
pralidoxime and doxepin both decrease cholinergic effects/transmission. Use Caution/Monitor.
atropine and doxepin both decrease cholinergic effects/transmission. Use Caution/Monitor. - droperidol
atropine decreases levels of droperidol by pharmacodynamic antagonism. Use Caution/Monitor.
atropine decreases levels of droperidol by inhibition of GI absorption. Applies only to oral form of both agents. Use Caution/Monitor.
pralidoxime decreases levels of droperidol by inhibition of GI absorption. Applies only to oral form of both agents. Use Caution/Monitor.
droperidol increases effects of atropine by pharmacodynamic synergism. Use Caution/Monitor. Additive anticholinergic effects, possible hypoglycemia.
pralidoxime decreases levels of droperidol by pharmacodynamic antagonism. Use Caution/Monitor.
droperidol increases effects of pralidoxime by pharmacodynamic synergism. Use Caution/Monitor. Additive anticholinergic effects, possible hypoglycemia. - echothiophate iodide
echothiophate iodide increases and atropine decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor.
echothiophate iodide increases and pralidoxime decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor. - fentanyl
fentanyl, atropine. Either increases toxicity of the other by pharmacodynamic synergism. Modify Therapy/Monitor Closely. Coadministration of fentanyl with anticholinergics may increase risk for urinary retention and/or severe constipation, which may lead to paralytic ileus.
- fesoterodine
fesoterodine and pralidoxime both decrease cholinergic effects/transmission. Use Caution/Monitor.
- fentanyl intranasal
fentanyl intranasal, atropine. Either increases toxicity of the other by pharmacodynamic synergism. Modify Therapy/Monitor Closely. Coadministration of fentanyl with anticholinergics may increase risk for urinary retention and/or severe constipation, which may lead to paralytic ileus.
- fentanyl transdermal
fentanyl transdermal, atropine. Either increases toxicity of the other by pharmacodynamic synergism. Modify Therapy/Monitor Closely. Coadministration of fentanyl with anticholinergics may increase risk for urinary retention and/or severe constipation, which may lead to paralytic ileus.
- fentanyl transmucosal
fentanyl transmucosal, atropine. Either increases toxicity of the other by pharmacodynamic synergism. Modify Therapy/Monitor Closely. Coadministration of fentanyl with anticholinergics may increase risk for urinary retention and/or severe constipation, which may lead to paralytic ileus.
- fesoterodine
atropine and fesoterodine both decrease cholinergic effects/transmission. Use Caution/Monitor.
- flavoxate
flavoxate and pralidoxime both decrease cholinergic effects/transmission. Use Caution/Monitor.
atropine and flavoxate both decrease cholinergic effects/transmission. Use Caution/Monitor. - fluphenazine
atropine decreases levels of fluphenazine by pharmacodynamic antagonism. Use Caution/Monitor.
fluphenazine increases effects of atropine by pharmacodynamic synergism. Use Caution/Monitor. Additive anticholinergic effects, possible hypoglycemia.
fluphenazine increases effects of pralidoxime by pharmacodynamic synergism. Use Caution/Monitor. Additive anticholinergic effects, possible hypoglycemia.
atropine decreases levels of fluphenazine by inhibition of GI absorption. Applies only to oral form of both agents. Use Caution/Monitor.
pralidoxime decreases levels of fluphenazine by inhibition of GI absorption. Applies only to oral form of both agents. Use Caution/Monitor.
pralidoxime decreases levels of fluphenazine by pharmacodynamic antagonism. Use Caution/Monitor. - galantamine
galantamine increases and atropine decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor.
galantamine increases and pralidoxime decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor. - glycopyrrolate
glycopyrrolate and pralidoxime both decrease cholinergic effects/transmission. Use Caution/Monitor.
atropine and glycopyrrolate both decrease cholinergic effects/transmission. Use Caution/Monitor. - glycopyrrolate inhaled
atropine and glycopyrrolate inhaled both decrease cholinergic effects/transmission. Use Caution/Monitor.
glycopyrrolate inhaled and pralidoxime both decrease cholinergic effects/transmission. Use Caution/Monitor. - haloperidol
atropine decreases levels of haloperidol by inhibition of GI absorption. Applies only to oral form of both agents. Use Caution/Monitor.
haloperidol increases effects of atropine by pharmacodynamic synergism. Use Caution/Monitor. Additive anticholinergic effects, possible hypoglycemia.
haloperidol increases effects of pralidoxime by pharmacodynamic synergism. Use Caution/Monitor. Additive anticholinergic effects, possible hypoglycemia.
atropine decreases levels of haloperidol by pharmacodynamic antagonism. Use Caution/Monitor.
pralidoxime decreases levels of haloperidol by pharmacodynamic antagonism. Use Caution/Monitor.
pralidoxime decreases levels of haloperidol by inhibition of GI absorption. Applies only to oral form of both agents. Use Caution/Monitor. - henbane
henbane and pralidoxime both decrease cholinergic effects/transmission. Use Caution/Monitor.
atropine and henbane both decrease cholinergic effects/transmission. Use Caution/Monitor. - homatropine
atropine and homatropine both decrease cholinergic effects/transmission. Use Caution/Monitor.
homatropine and pralidoxime both decrease cholinergic effects/transmission. Use Caution/Monitor. - huperzine A
huperzine A increases and atropine decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor.
huperzine A increases and pralidoxime decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor. - hyoscyamine
atropine and hyoscyamine both decrease cholinergic effects/transmission. Use Caution/Monitor.
hyoscyamine and pralidoxime both decrease cholinergic effects/transmission. Use Caution/Monitor. - hyoscyamine spray
atropine and hyoscyamine spray both decrease cholinergic effects/transmission. Use Caution/Monitor.
hyoscyamine spray and pralidoxime both decrease cholinergic effects/transmission. Use Caution/Monitor. - iloperidone
atropine decreases levels of iloperidone by inhibition of GI absorption. Applies only to oral form of both agents. Use Caution/Monitor.
pralidoxime decreases levels of iloperidone by inhibition of GI absorption. Applies only to oral form of both agents. Use Caution/Monitor.
iloperidone increases effects of atropine by pharmacodynamic synergism. Use Caution/Monitor. Additive anticholinergic effects, possible hypoglycemia.
pralidoxime decreases levels of iloperidone by pharmacodynamic antagonism. Use Caution/Monitor.
iloperidone increases effects of pralidoxime by pharmacodynamic synergism. Use Caution/Monitor. Additive anticholinergic effects, possible hypoglycemia.
atropine decreases levels of iloperidone by pharmacodynamic antagonism. Use Caution/Monitor. - imipramine
atropine and imipramine both decrease cholinergic effects/transmission. Use Caution/Monitor.
pralidoxime and imipramine both decrease cholinergic effects/transmission. Use Caution/Monitor. - incobotulinumtoxinA
atropine, incobotulinumtoxinA. Either increases effects of the other by pharmacodynamic synergism. Use Caution/Monitor. Use of anticholinergic drugs after administration of botulinum toxin-containing products may potentiate systemic anticholinergic effects.
- ipratropium
ipratropium and pralidoxime both decrease cholinergic effects/transmission. Use Caution/Monitor. Due to the poor systemic absorption of ipratropium, interaction unlikely at regularly recommended dosages.
- ipratropium
atropine and ipratropium both decrease cholinergic effects/transmission. Use Caution/Monitor. Due to the poor systemic absorption of ipratropium, interaction unlikely at regularly recommended dosages.
- lofepramine
atropine and lofepramine both decrease cholinergic effects/transmission. Use Caution/Monitor.
pralidoxime and lofepramine both decrease cholinergic effects/transmission. Use Caution/Monitor. - loxapine
pralidoxime decreases levels of loxapine by pharmacodynamic antagonism. Use Caution/Monitor.
loxapine increases effects of atropine by pharmacodynamic synergism. Use Caution/Monitor. Additive anticholinergic effects, possible hypoglycemia.
loxapine increases effects of pralidoxime by pharmacodynamic synergism. Use Caution/Monitor. Additive anticholinergic effects, possible hypoglycemia.
pralidoxime decreases levels of loxapine by inhibition of GI absorption. Applies only to oral form of both agents. Use Caution/Monitor.
atropine decreases levels of loxapine by inhibition of GI absorption. Applies only to oral form of both agents. Use Caution/Monitor.
atropine decreases levels of loxapine by pharmacodynamic antagonism. Use Caution/Monitor. - loxapine inhaled
loxapine inhaled increases effects of atropine by pharmacodynamic synergism. Use Caution/Monitor. Additive anticholinergic effects, possible hypoglycemia.
pralidoxime decreases levels of loxapine inhaled by pharmacodynamic antagonism. Use Caution/Monitor.
loxapine inhaled increases effects of pralidoxime by pharmacodynamic synergism. Use Caution/Monitor. Additive anticholinergic effects, possible hypoglycemia.
atropine decreases levels of loxapine inhaled by pharmacodynamic antagonism. Use Caution/Monitor. - maprotiline
atropine and maprotiline both decrease cholinergic effects/transmission. Use Caution/Monitor.
pralidoxime and maprotiline both decrease cholinergic effects/transmission. Use Caution/Monitor. - meclizine
meclizine and pralidoxime both decrease cholinergic effects/transmission. Use Caution/Monitor.
atropine and meclizine both decrease cholinergic effects/transmission. Use Caution/Monitor. - methscopolamine
methscopolamine and pralidoxime both decrease cholinergic effects/transmission. Use Caution/Monitor.
atropine and methscopolamine both decrease cholinergic effects/transmission. Use Caution/Monitor. - metoclopramide intranasal
atropine will decrease the level or effect of metoclopramide intranasal by Other (see comment). Use Caution/Monitor. Coadministration of metoclopramide intranasal with drugs that impair GI motility may decrease systemic absorption of metoclopramide. Monitor for reduced therapeutic effect.
- neostigmine
neostigmine increases and pralidoxime decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor.
- neostigmine
neostigmine increases and atropine decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor.
- nortriptyline
pralidoxime and nortriptyline both decrease cholinergic effects/transmission. Use Caution/Monitor.
atropine and nortriptyline both decrease cholinergic effects/transmission. Use Caution/Monitor. - olanzapine
atropine decreases levels of olanzapine by pharmacodynamic antagonism. Use Caution/Monitor.
atropine decreases levels of olanzapine by inhibition of GI absorption. Applies only to oral form of both agents. Use Caution/Monitor.
pralidoxime decreases levels of olanzapine by inhibition of GI absorption. Applies only to oral form of both agents. Use Caution/Monitor.
olanzapine increases effects of atropine by pharmacodynamic synergism. Use Caution/Monitor. Additive anticholinergic effects, possible hypoglycemia.
pralidoxime decreases levels of olanzapine by pharmacodynamic antagonism. Use Caution/Monitor.
olanzapine increases effects of pralidoxime by pharmacodynamic synergism. Use Caution/Monitor. Additive anticholinergic effects, possible hypoglycemia. - oliceridine
atropine increases toxicity of oliceridine by Other (see comment). Use Caution/Monitor. Comment: Anticholinergic drugs may increase risk of urinary retention and/or severe constipation, which may lead to paralytic ileus. Monitor for signs of urinary retention or reduced gastric motility if oliceridine is coadministered with anticholinergics.
- onabotulinumtoxinA
onabotulinumtoxinA and pralidoxime both decrease cholinergic effects/transmission. Use Caution/Monitor.
- onabotulinumtoxinA
atropine and onabotulinumtoxinA both decrease cholinergic effects/transmission. Use Caution/Monitor.
- orphenadrine
atropine and orphenadrine both decrease cholinergic effects/transmission. Use Caution/Monitor.
pralidoxime and orphenadrine both decrease cholinergic effects/transmission. Use Caution/Monitor. - oxybutynin
atropine and oxybutynin both decrease cholinergic effects/transmission. Use Caution/Monitor.
oxybutynin and pralidoxime both decrease cholinergic effects/transmission. Use Caution/Monitor. - oxybutynin topical
atropine and oxybutynin topical both decrease cholinergic effects/transmission. Use Caution/Monitor.
oxybutynin topical and pralidoxime both decrease cholinergic effects/transmission. Use Caution/Monitor. - oxybutynin transdermal
oxybutynin transdermal and pralidoxime both decrease cholinergic effects/transmission. Use Caution/Monitor.
atropine and oxybutynin transdermal both decrease cholinergic effects/transmission. Use Caution/Monitor. - paliperidone
atropine decreases levels of paliperidone by inhibition of GI absorption. Applies only to oral form of both agents. Use Caution/Monitor.
atropine decreases levels of paliperidone by pharmacodynamic antagonism. Use Caution/Monitor.
pralidoxime decreases levels of paliperidone by pharmacodynamic antagonism. Use Caution/Monitor.
paliperidone increases effects of atropine by pharmacodynamic synergism. Use Caution/Monitor. Additive anticholinergic effects, possible hypoglycemia.
paliperidone increases effects of pralidoxime by pharmacodynamic synergism. Use Caution/Monitor. Additive anticholinergic effects, possible hypoglycemia.
pralidoxime decreases levels of paliperidone by inhibition of GI absorption. Applies only to oral form of both agents. Use Caution/Monitor. - pancuronium
atropine and pancuronium both decrease cholinergic effects/transmission. Use Caution/Monitor.
pancuronium and pralidoxime both decrease cholinergic effects/transmission. Use Caution/Monitor. - perphenazine
atropine decreases levels of perphenazine by inhibition of GI absorption. Applies only to oral form of both agents. Use Caution/Monitor.
perphenazine increases effects of atropine by pharmacodynamic synergism. Use Caution/Monitor. Additive anticholinergic effects, possible hypoglycemia.
perphenazine increases effects of pralidoxime by pharmacodynamic synergism. Use Caution/Monitor. Additive anticholinergic effects, possible hypoglycemia.
atropine decreases levels of perphenazine by pharmacodynamic antagonism. Use Caution/Monitor.
pralidoxime decreases levels of perphenazine by pharmacodynamic antagonism. Use Caution/Monitor.
pralidoxime decreases levels of perphenazine by inhibition of GI absorption. Applies only to oral form of both agents. Use Caution/Monitor. - physostigmine
physostigmine increases and pralidoxime decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor.
physostigmine increases and atropine decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor. - pilocarpine
pilocarpine increases and atropine decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor.
pilocarpine increases and pralidoxime decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor. - pimozide
atropine decreases levels of pimozide by inhibition of GI absorption. Applies only to oral form of both agents. Use Caution/Monitor.
pralidoxime decreases levels of pimozide by inhibition of GI absorption. Applies only to oral form of both agents. Use Caution/Monitor.
pimozide increases effects of atropine by pharmacodynamic synergism. Use Caution/Monitor. Additive anticholinergic effects, possible hypoglycemia.
pralidoxime decreases levels of pimozide by pharmacodynamic antagonism. Use Caution/Monitor.
pimozide increases effects of pralidoxime by pharmacodynamic synergism. Use Caution/Monitor. Additive anticholinergic effects, possible hypoglycemia.
atropine decreases levels of pimozide by pharmacodynamic antagonism. Use Caution/Monitor. - prabotulinumtoxinA
atropine, prabotulinumtoxinA. Either increases effects of the other by pharmacodynamic synergism. Use Caution/Monitor. Use of anticholinergic drugs after administration of botulinum toxin-containing products may potentiate systemic anticholinergic effects.
- prochlorperazine
pralidoxime decreases levels of prochlorperazine by inhibition of GI absorption. Applies only to oral form of both agents. Use Caution/Monitor.
pralidoxime decreases levels of prochlorperazine by pharmacodynamic antagonism. Use Caution/Monitor.
prochlorperazine increases effects of pralidoxime by pharmacodynamic synergism. Use Caution/Monitor. Additive anticholinergic effects, possible hypoglycemia. - pralidoxime
atropine and pralidoxime both decrease cholinergic effects/transmission. Use Caution/Monitor.
- prochlorperazine
atropine decreases levels of prochlorperazine by inhibition of GI absorption. Applies only to oral form of both agents. Use Caution/Monitor.
atropine decreases levels of prochlorperazine by pharmacodynamic antagonism. Use Caution/Monitor.
prochlorperazine increases effects of atropine by pharmacodynamic synergism. Use Caution/Monitor. Additive anticholinergic effects, possible hypoglycemia. - promethazine
pralidoxime decreases levels of promethazine by inhibition of GI absorption. Applies only to oral form of both agents. Use Caution/Monitor.
atropine decreases levels of promethazine by inhibition of GI absorption. Applies only to oral form of both agents. Use Caution/Monitor.
promethazine increases effects of atropine by pharmacodynamic synergism. Use Caution/Monitor. Additive anticholinergic effects, possible hypoglycemia.
promethazine increases effects of pralidoxime by pharmacodynamic synergism. Use Caution/Monitor. Additive anticholinergic effects, possible hypoglycemia.
atropine decreases levels of promethazine by pharmacodynamic antagonism. Use Caution/Monitor.
pralidoxime decreases levels of promethazine by pharmacodynamic antagonism. Use Caution/Monitor. - propantheline
pralidoxime and propantheline both decrease cholinergic effects/transmission. Use Caution/Monitor.
atropine and propantheline both decrease cholinergic effects/transmission. Use Caution/Monitor. - protriptyline
pralidoxime and protriptyline both decrease cholinergic effects/transmission. Use Caution/Monitor.
atropine and protriptyline both decrease cholinergic effects/transmission. Use Caution/Monitor. - pyridostigmine
pyridostigmine increases and atropine decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor.
pyridostigmine increases and pralidoxime decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor. - quetiapine
atropine decreases levels of quetiapine by pharmacodynamic antagonism. Use Caution/Monitor.
atropine decreases levels of quetiapine by inhibition of GI absorption. Applies only to oral form of both agents. Use Caution/Monitor.
pralidoxime decreases levels of quetiapine by inhibition of GI absorption. Applies only to oral form of both agents. Use Caution/Monitor.
quetiapine increases effects of atropine by pharmacodynamic synergism. Use Caution/Monitor. Additive anticholinergic effects, possible hypoglycemia.
pralidoxime decreases levels of quetiapine by pharmacodynamic antagonism. Use Caution/Monitor.
quetiapine increases effects of pralidoxime by pharmacodynamic synergism. Use Caution/Monitor. Additive anticholinergic effects, possible hypoglycemia. - rapacuronium
pralidoxime and rapacuronium both decrease cholinergic effects/transmission. Use Caution/Monitor.
atropine and rapacuronium both decrease cholinergic effects/transmission. Use Caution/Monitor. - rimabotulinumtoxinB
atropine, rimabotulinumtoxinB. Either increases effects of the other by pharmacodynamic synergism. Use Caution/Monitor. Anticholinergics may enhance botulinum toxin effects. Closely monitor for increased neuromuscular blockade.
- risperidone
pralidoxime decreases levels of risperidone by inhibition of GI absorption. Applies only to oral form of both agents. Use Caution/Monitor.
pralidoxime decreases levels of risperidone by pharmacodynamic antagonism. Use Caution/Monitor.
risperidone increases effects of pralidoxime by pharmacodynamic synergism. Use Caution/Monitor. Additive anticholinergic effects, possible hypoglycemia. - risperidone
atropine decreases levels of risperidone by inhibition of GI absorption. Applies only to oral form of both agents. Use Caution/Monitor.
atropine decreases levels of risperidone by pharmacodynamic antagonism. Use Caution/Monitor.
risperidone increases effects of atropine by pharmacodynamic synergism. Use Caution/Monitor. Additive anticholinergic effects, possible hypoglycemia. - rivastigmine
rivastigmine increases and pralidoxime decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor.
- rocuronium
atropine and rocuronium both decrease cholinergic effects/transmission. Use Caution/Monitor.
pralidoxime and rocuronium both decrease cholinergic effects/transmission. Use Caution/Monitor. - scopolamine
atropine and scopolamine both decrease cholinergic effects/transmission. Use Caution/Monitor.
pralidoxime and scopolamine both decrease cholinergic effects/transmission. Use Caution/Monitor. - solifenacin
atropine and solifenacin both decrease cholinergic effects/transmission. Use Caution/Monitor.
pralidoxime and solifenacin both decrease cholinergic effects/transmission. Use Caution/Monitor. - succinylcholine
succinylcholine increases and atropine decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor.
succinylcholine increases and pralidoxime decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor. - thioridazine
pralidoxime decreases levels of thioridazine by pharmacodynamic antagonism. Use Caution/Monitor.
thioridazine increases effects of atropine by pharmacodynamic synergism. Use Caution/Monitor. Additive anticholinergic effects, possible hypoglycemia.
thioridazine increases effects of pralidoxime by pharmacodynamic synergism. Use Caution/Monitor. Additive anticholinergic effects, possible hypoglycemia.
pralidoxime decreases levels of thioridazine by inhibition of GI absorption. Applies only to oral form of both agents. Use Caution/Monitor.
atropine decreases levels of thioridazine by inhibition of GI absorption. Applies only to oral form of both agents. Use Caution/Monitor.
atropine decreases levels of thioridazine by pharmacodynamic antagonism. Use Caution/Monitor. - thiothixene
pralidoxime decreases levels of thiothixene by inhibition of GI absorption. Applies only to oral form of both agents. Use Caution/Monitor.
pralidoxime decreases levels of thiothixene by pharmacodynamic antagonism. Use Caution/Monitor.
atropine decreases levels of thiothixene by pharmacodynamic antagonism. Use Caution/Monitor.
thiothixene increases effects of atropine by pharmacodynamic synergism. Use Caution/Monitor. Additive anticholinergic effects, possible hypoglycemia.
thiothixene increases effects of pralidoxime by pharmacodynamic synergism. Use Caution/Monitor. Additive anticholinergic effects, possible hypoglycemia.
atropine decreases levels of thiothixene by inhibition of GI absorption. Applies only to oral form of both agents. Use Caution/Monitor. - tiotropium
pralidoxime and tiotropium both decrease cholinergic effects/transmission. Use Caution/Monitor.
atropine and tiotropium both decrease cholinergic effects/transmission. Use Caution/Monitor. - tolterodine
pralidoxime and tolterodine both decrease cholinergic effects/transmission. Use Caution/Monitor.
atropine and tolterodine both decrease cholinergic effects/transmission. Use Caution/Monitor. - trazodone
pralidoxime and trazodone both decrease cholinergic effects/transmission. Use Caution/Monitor.
- trifluoperazine
atropine decreases levels of trifluoperazine by inhibition of GI absorption. Applies only to oral form of both agents. Use Caution/Monitor.
atropine decreases levels of trifluoperazine by pharmacodynamic antagonism. Use Caution/Monitor.
trifluoperazine increases effects of atropine by pharmacodynamic synergism. Use Caution/Monitor. Additive anticholinergic effects, possible hypoglycemia. - trifluoperazine
pralidoxime decreases levels of trifluoperazine by inhibition of GI absorption. Applies only to oral form of both agents. Use Caution/Monitor.
pralidoxime decreases levels of trifluoperazine by pharmacodynamic antagonism. Use Caution/Monitor.
trifluoperazine increases effects of pralidoxime by pharmacodynamic synergism. Use Caution/Monitor. Additive anticholinergic effects, possible hypoglycemia. - trihexyphenidyl
atropine and trihexyphenidyl both decrease cholinergic effects/transmission. Use Caution/Monitor. Potential for additive anticholinergic effects.
- trimipramine
pralidoxime and trimipramine both decrease cholinergic effects/transmission. Use Caution/Monitor.
atropine and trimipramine both decrease cholinergic effects/transmission. Use Caution/Monitor. - trospium chloride
pralidoxime and trospium chloride both decrease cholinergic effects/transmission. Use Caution/Monitor.
atropine and trospium chloride both decrease cholinergic effects/transmission. Use Caution/Monitor. - umeclidinium bromide
umeclidinium bromide and atropine both decrease cholinergic effects/transmission. Use Caution/Monitor. If possible, avoid coadministration of additional anticholinergic agents
- vecuronium
pralidoxime and vecuronium both decrease cholinergic effects/transmission. Use Caution/Monitor.
- vecuronium
atropine and vecuronium both decrease cholinergic effects/transmission. Use Caution/Monitor.
- ziprasidone
atropine decreases levels of ziprasidone by inhibition of GI absorption. Applies only to oral form of both agents. Use Caution/Monitor.
atropine decreases levels of ziprasidone by pharmacodynamic antagonism. Use Caution/Monitor.
pralidoxime decreases levels of ziprasidone by pharmacodynamic antagonism. Use Caution/Monitor.
ziprasidone increases effects of atropine by pharmacodynamic synergism. Use Caution/Monitor. Additive anticholinergic effects, possible hypoglycemia.
ziprasidone increases effects of pralidoxime by pharmacodynamic synergism. Use Caution/Monitor. Additive anticholinergic effects, possible hypoglycemia.
pralidoxime decreases levels of ziprasidone by inhibition of GI absorption. Applies only to oral form of both agents. Use Caution/Monitor. - zotepine
atropine decreases levels of zotepine by pharmacodynamic antagonism. Use Caution/Monitor.
atropine decreases levels of zotepine by inhibition of GI absorption. Applies only to oral form of both agents. Use Caution/Monitor.
pralidoxime decreases levels of zotepine by inhibition of GI absorption. Applies only to oral form of both agents. Use Caution/Monitor.
pralidoxime decreases levels of zotepine by pharmacodynamic antagonism. Use Caution/Monitor.
Minor (10)
- amitriptyline
amitriptyline increases levels of atropine by unknown mechanism. Minor/Significance Unknown.
- amoxapine
amoxapine increases levels of atropine by unknown mechanism. Minor/Significance Unknown.
- atenolol
atropine increases levels of atenolol by unknown mechanism. Minor/Significance Unknown.
- chlorpromazine
chlorpromazine increases toxicity of atropine by unknown mechanism. Minor/Significance Unknown.
- clomipramine
clomipramine increases levels of atropine by unknown mechanism. Minor/Significance Unknown.
- desipramine
atropine and desipramine both decrease cholinergic effects/transmission. Minor/Significance Unknown.
desipramine increases levels of atropine by unknown mechanism. Minor/Significance Unknown. - dimenhydrinate
dimenhydrinate increases toxicity of pralidoxime by pharmacodynamic synergism. Minor/Significance Unknown. Additive anticholinergic effects.
dimenhydrinate increases toxicity of atropine by pharmacodynamic synergism. Minor/Significance Unknown. Additive anticholinergic effects. - donepezil
donepezil decreases effects of pralidoxime by pharmacodynamic antagonism. Minor/Significance Unknown.
donepezil decreases effects of atropine by pharmacodynamic antagonism. Minor/Significance Unknown. - doxepin
doxepin increases levels of atropine by unknown mechanism. Minor/Significance Unknown.
- galantamine
galantamine decreases effects of pralidoxime by pharmacodynamic antagonism. Minor/Significance Unknown.
Adverse Effects
Frequency Not Defined
Injection site reaction (muscle tightness, pain)
Atropine
- Dry mouth
- Blurred vision
- Dry eyes
- Photophobia
- Confusion
- Headache
- Dizziness
Pralidoxime
- Vision changes
- Dizziness, headache
- Drowsiness
- Nausea
- Tachycardia
- Increased blood pressure
- Muscular weakness
- Dry mouth
- Emesis
- Rash
- Dry skin
- Hyperventilation
- Decreased renal function
- Manic behavior
- Transient elevation of LFTs
Warnings
Contraindications
None
Cautions
Caution in patients with known cardiovascular disease or cardiac conduction problems
May inhibit sweating and lead to hyperthermia; avoid excessive exercise and heat exposure
Caution in susceptible individuals at risk for acute glaucoma
Caution in patients with bladder outflow obstruction owing to risk of urinary retention
Caution with partial pyloric stenosis because of risk of complete pyloric obstruction
May cause inspiration of bronchial secretions and formation of dangerous viscid plugs in individuals with chronic lung disease; monitor respiratory status
Individual should not rely solely upon atropine and pralidoxime to provide complete protection from chemical nerve agents and insecticide poisoning (eg, primary protection is the wearing of protective garments)
Elderly individuals may be more susceptible to the effects of atropine
Patients with organophosphorus nerve agent or organophosphorus insecticide poisoning who have received atropine/pralidoxime may exhibit accelerated reversal of the neuromuscular blocking effects of succinylcholine and mivacurium; monitor for neuromuscular effects with concomitant succinylcholine or mivacurium use
Pregnancy & Lactation
Pregnancy
Atropine readily crosses the placental barrier and enters fetal circulation; there are no adequate data on developmental risk associated with use of atropine, pralidoxime, or combination in pregnant women
Lactation
Atropine has been reported to be excreted in human milk; unknown whether pralidoxime is excreted in human milk
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.Pharmacology
Mechanism of Action
Atropine: Competitively blocks the effects of acetylcholine, including excess acetylcholine due to organophosphorus poisoning, at muscarinic cholinergic receptors on smooth muscle, cardiac muscle, secretory gland cells, and in peripheral autonomic ganglia and the central nervous system
Pralidoxime: Reactivates acetylcholinesterase which has been inactivated by phosphorylation due to an organophosphorous nerve agent or insecticide; reactivated acetylcholinesterase hydrolyzes excess acetylcholine, which is clinically important because only a small proportion of active acetylcholinesterase is needed to maintain vital functions
Absorption
Atropine
- Rapidly and well absorbed after IM administration
- Peak plasma concentration: 13 ng/mL
- Peak plasma time: 31 minutes
Pralidoxime
- Rapidly absorbed after IM injection
- Peak plasma concentration: 7 mcg/mL
- Peak plasma time: 28 minutes
Distribution
Atropine
- Rapidly and widely throughout the body
- Crosses blood brain barrier and enteres fetal circulation
- Protein bound: 14-22%
Pralidoxime
- Distributed throughout the extracellular wate
- No protein binding
- Vd: 0.6-2.7 L/kg (may increase in severe organophosphate intoxication)
Metabolism
Atropine: Liver via enzymatic hydrolysis
Pralidoxime: Hepatic
Elimination
Atropine
- Half-life: 2.4 hr
- Excretion: 50-60% unchanged in urine
Pralidoxime
- Half-life: 2 hr
- Excretion: 72-94% in urine (partly unchanged and partly as a metabolite)
Administration
IM Administration
ATNAA: Administer IM in the lateral thigh muscle or buttocks; see prescribing information for complete detailed administration instructions
DuoDote: Administer IM into the mid-lateral thigh; see prescribing information for complete detailed administration instructions
Storage
Store at 25°C (77°F); excursions permitted to 15-30°C (59-86°F)
Keep from freezing
Protect from light
Images
Formulary
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