pyridostigmine (Rx)

Brand and Other Names:Mestinon, Regonol
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Dosing & Uses

AdultPediatric

Dosage Forms & Strengths

inj solution

  • 5mg/mL

tablet, controlled release

  • 180mg

tablet

  • 60mg

syrup

  • 60mg/5mL (240mL)

Myasthenia Gravis

Tablets/syrup: 600 mg/day spaced to provide maximum relief

Sustained release: 180-540 mg PO qDay or q12hr; not to exceed 1.5 g/day

Reversal of Nondepolarizing Muscle Relaxants

0.1-0.25 mg/kg/dose  

10-20 mg generally effective; full recovery may occur as early as <15 min but may require >30 min

To minimize side effects 0.6-1.2 mg IV atropine sulfate recommended immediately prior to pyridostigmine

Pretreatment for Soman Nerve Gas Exposure

30 mg PO q8hr beginning several hours prior to exposre

Discontinue at first sign of nerve agent exposure then begin atropine and pralidoxime

Dosage Forms & Strengths

inj solution

  • 5mg/mL

tablet, controlled release

  • 180mg

tablet

  • 60mg

syrup

  • 60mg/5mL (240mL)

Myasthenia Gravis

Children

  • 7 mg/kg/day PO divided q4hr
  • 0.05-0.15 mg/kg IV/IM q4-6hr; not to exceed 10 mg/dose  

Neonates

  • 5 mg PO q4-6hr
  • 0.05-0.15 mg/kg IV/IM q4-6hr; not to exceed 10 mg/dose  

Reversal of Nondepolarizing Muscle Relaxants

0.1-0.25 mg/kg/dose IV

Dosing range: 0.1-0.25 mg/kg/dose; full recovery may occur as early as <15 min but may require >30 min

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Interactions

Interaction Checker

and pyridostigmine

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      Serious - Use Alternative

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            Contraindicated (0)

              Serious - Use Alternative (2)

              • ponesimod

                ponesimod, pyridostigmine. Either increases effects of the other by pharmacodynamic synergism. Avoid or Use Alternate Drug. Consult cardiologist if considering treatment. Coadministration of ponesimod with drugs that decrease HR may have additive effects on decreasing HR and should generally not be initiated in these patients.

              • triamcinolone acetonide injectable suspension

                triamcinolone acetonide injectable suspension, pyridostigmine. unspecified interaction mechanism. Avoid or Use Alternate Drug. Concomitant use of anticholinesterase agents and corticosteroids may produce severe weakness in patients with myasthenia gravis. If possible, withdraw anticholinesterase agents at least 24 hours before initiating corticosteroid therapy.

              Monitor Closely (65)

              • aclidinium

                pyridostigmine increases and aclidinium decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor.

              • amifampridine

                amifampridine and pyridostigmine both increase cholinergic effects/transmission. Use Caution/Monitor.

              • amitriptyline

                pyridostigmine increases and amitriptyline decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Modify Therapy/Monitor Closely.

              • amoxapine

                pyridostigmine increases and amoxapine decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor.

              • anticholinergic/sedative combos

                pyridostigmine increases and anticholinergic/sedative combos decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor.

              • atracurium

                pyridostigmine increases and atracurium decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor.

              • atropine

                pyridostigmine increases and atropine decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor.

              • atropine IV/IM

                pyridostigmine increases and atropine IV/IM decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor. .

              • belladonna alkaloids

                pyridostigmine increases and belladonna alkaloids decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor.

              • belladonna and opium

                pyridostigmine increases and belladonna and opium decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor.

              • bethanechol

                bethanechol and pyridostigmine both increase cholinergic effects/transmission. Use Caution/Monitor.

              • carbachol

                carbachol and pyridostigmine both increase cholinergic effects/transmission. Use Caution/Monitor.

              • cevimeline

                cevimeline and pyridostigmine both increase cholinergic effects/transmission. Use Caution/Monitor.

              • cisatracurium

                pyridostigmine increases and cisatracurium decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor.

              • clomipramine

                pyridostigmine increases and clomipramine decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor.

              • cyclizine

                pyridostigmine increases and cyclizine decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor.

              • cyclobenzaprine

                pyridostigmine increases and cyclobenzaprine decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor.

              • darifenacin

                pyridostigmine increases and darifenacin decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor.

              • dicyclomine

                pyridostigmine increases and dicyclomine decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor.

              • diphenhydramine

                pyridostigmine increases and diphenhydramine decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor.

              • donepezil

                donepezil and pyridostigmine both increase cholinergic effects/transmission. Use Caution/Monitor.

              • dosulepin

                pyridostigmine increases and dosulepin decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor.

              • doxepin

                pyridostigmine increases and doxepin decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor.

              • echothiophate iodide

                echothiophate iodide and pyridostigmine both increase cholinergic effects/transmission. Use Caution/Monitor.

              • fesoterodine

                pyridostigmine increases and fesoterodine decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor.

              • flavoxate

                pyridostigmine increases and flavoxate decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor.

              • galantamine

                galantamine and pyridostigmine both increase cholinergic effects/transmission. Use Caution/Monitor.

              • glycopyrrolate

                pyridostigmine increases and glycopyrrolate decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor.

              • glycopyrrolate inhaled

                pyridostigmine increases and glycopyrrolate inhaled decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor.

              • henbane

                pyridostigmine increases and henbane decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor.

              • homatropine

                pyridostigmine increases and homatropine decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor.

              • huperzine A

                huperzine A and pyridostigmine both increase cholinergic effects/transmission. Use Caution/Monitor.

              • hyoscyamine

                pyridostigmine increases and hyoscyamine decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor.

              • hyoscyamine spray

                pyridostigmine increases and hyoscyamine spray decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor. .

              • imipramine

                pyridostigmine increases and imipramine decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor.

              • ipratropium

                pyridostigmine increases and ipratropium decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor.

              • lofepramine

                pyridostigmine increases and lofepramine decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor.

              • maprotiline

                pyridostigmine increases and maprotiline decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor.

              • meclizine

                pyridostigmine increases and meclizine decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor.

              • methscopolamine

                pyridostigmine increases and methscopolamine decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor.

              • neostigmine

                neostigmine and pyridostigmine both increase cholinergic effects/transmission. Use Caution/Monitor.

              • nortriptyline

                pyridostigmine increases and nortriptyline decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor.

              • onabotulinumtoxinA

                pyridostigmine increases and onabotulinumtoxinA decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor.

              • orphenadrine

                pyridostigmine increases and orphenadrine decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor.

              • oxybutynin

                pyridostigmine increases and oxybutynin decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor.

              • oxybutynin topical

                pyridostigmine increases and oxybutynin topical decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor.

              • oxybutynin transdermal

                pyridostigmine increases and oxybutynin transdermal decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor.

              • pancuronium

                pyridostigmine increases and pancuronium decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor.

              • physostigmine

                physostigmine and pyridostigmine both increase cholinergic effects/transmission. Use Caution/Monitor.

              • pilocarpine

                pilocarpine and pyridostigmine both increase cholinergic effects/transmission. Use Caution/Monitor.

              • pralidoxime

                pyridostigmine increases and pralidoxime decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor.

              • propantheline

                pyridostigmine increases and propantheline decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor.

              • protriptyline

                pyridostigmine increases and protriptyline decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor.

              • rapacuronium

                pyridostigmine increases and rapacuronium decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor.

              • rivastigmine

                pyridostigmine and rivastigmine both increase cholinergic effects/transmission. Use Caution/Monitor.

              • rocuronium

                pyridostigmine increases and rocuronium decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor.

              • scopolamine

                pyridostigmine increases and scopolamine decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor.

              • solifenacin

                pyridostigmine increases and solifenacin decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor.

              • succinylcholine

                pyridostigmine and succinylcholine both increase cholinergic effects/transmission. Use Caution/Monitor.

              • tiotropium

                pyridostigmine increases and tiotropium decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor.

              • tolterodine

                pyridostigmine increases and tolterodine decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor.

              • trimipramine

                pyridostigmine increases and trimipramine decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor.

              • trospium chloride

                pyridostigmine increases and trospium chloride decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor.

              • umeclidinium bromide

                pyridostigmine increases and umeclidinium bromide decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor. Monitor when umeclidinium bromide is coadministered with cholinergic agents.

              • vecuronium

                pyridostigmine increases and vecuronium decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor.

              Minor (6)

              • desipramine

                pyridostigmine increases and desipramine decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Minor/Significance Unknown.

              • donepezil

                donepezil increases effects of pyridostigmine by pharmacodynamic synergism. Minor/Significance Unknown.

              • galantamine

                galantamine increases effects of pyridostigmine by pharmacodynamic synergism. Minor/Significance Unknown.

              • pantothenic acid

                pantothenic acid, pyridostigmine. Either increases effects of the other by pharmacodynamic synergism. Minor/Significance Unknown.

              • procainamide

                procainamide decreases effects of pyridostigmine by pharmacodynamic antagonism. Minor/Significance Unknown.

              • trazodone

                pyridostigmine increases and trazodone decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Minor/Significance Unknown.

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              Adverse Effects

              Fewer GI effects than neostigmine

              Frequency Not Defined

              Cholinergic effects (N/V, increases peristalsis, increases salivation, urinary frequency

              Weakness

              Hypotension

              ECG changes

              Loss of consciousness

              Convulsions

              Drowsiness

              Thrombophlebitis

              Urticaria

              Arrhythmia

              Laryngospasm

              Bradycardia

              Cardiac standstill (rare)

              Cholinergic crisis (rare)

              Transient rash in bromide-sensitive patients

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              Warnings

              Black Box Warning

              Therapy must be administered by trained personnel

              Contraindications

              Hypersensitivity

              Mechanical intestinal or urinary obstruction

              Cautions

              Caution in epilepsy, asthma, COPD, recent MI, hypertension, vagotonia, hyperthyroidism, dysrhythmia

              Keep atropine and epinephrine immediately available to treat hypersensitivity reactions resulting from therapy

              Injection unstable in alkaline solutions

              If symptoms of excess cholinergic activity occur discontinue therapy

              Anticholinesterase sensitivity may develop for brief or prolonged periods

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              Pregnancy & Lactation

              Pregnancy Category: B

              Lactation: Compatible

              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.

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              Pharmacology

              Mechanism of Action

              Anticholinesterase agent which inhibits metabolism of acetylcholine by acetylcholinesterase thereby enhancing its cholinergic effects fascilitating impulses across myoneural junction

              Pharmacokinetics

              Half-Life: 1-2 hr (IV)

              Onset: 15-30 min (PO/IM); 2-5 min (IV)

              Duration: 6-8 hr (PO); 2-3 hr (IV)

              Bioavailability: 10-20%

              Distribution: ~19 L

              Metabolism: Liver microsomal enzymes

              Metabolites: 3-hydroxy-N-methylpyridinium

              Total Body Clearance: 8.5-9.7 mL/min/kg

              Excretion: Urine (80-90%)

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              Administration

              IV Compatibilities

              Syringe: glycopyrrolate

              Y-site: heparin, hydrocortisone Na-succinate, KCl, vit B/C

              Other Information

              IV Administration: very slow injection

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              Images

              BRAND FORM. UNIT PRICE PILL IMAGE
              Mestinon Timespan oral
              -
              180 mg tablet
              Regonol injection
              -
              5 mg/mL solution
              Mestinon oral
              -
              60 mg/5 mL solution
              pyridostigmine bromide oral
              -
              60 mg tablet
              pyridostigmine bromide oral
              -
              60 mg/5 mL solution
              pyridostigmine bromide oral
              -
              60 mg/5 mL solution
              pyridostigmine bromide oral
              -
              60 mg tablet
              pyridostigmine bromide oral
              -
              180 mg tablet
              pyridostigmine bromide oral
              -
              60 mg tablet
              pyridostigmine bromide oral
              -
              60 mg tablet
              pyridostigmine bromide oral
              -
              180 mg tablet
              pyridostigmine bromide oral
              -
              180 mg tablet

              Copyright © 2010 First DataBank, Inc.

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              Patient Handout

              Select a drug:
              Patient Education
              pyridostigmine bromide injection

              NO MONOGRAPH AVAILABLE AT THIS TIME

              USES: Consult your pharmacist.

              HOW TO USE: Consult your pharmacist.

              SIDE EFFECTS: Consult your pharmacist.In the US -Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088 or at www.fda.gov/medwatch.In Canada - Call your doctor for medical advice about side effects. You may report side effects to Health Canada at 1-866-234-2345.

              PRECAUTIONS: Consult your pharmacist.

              DRUG INTERACTIONS: Consult your pharmacist.Keep a list of all your medications with you, and share the list with your doctor and pharmacist.

              OVERDOSE: If someone has overdosed and has serious symptoms such as passing out or trouble breathing, call 911. Otherwise, call a poison control center right away. US residents can call their local poison control center at 1-800-222-1222. Canada residents can call a provincial poison control center.

              NOTES: No monograph available at this time.

              MISSED DOSE: Consult your pharmacist.

              STORAGE: Consult your pharmacist.Do not flush medications down the toilet or pour them into a drain unless instructed to do so. Properly discard this product when it is expired or no longer needed. Consult your pharmacist or local waste disposal company for more details about how to safely discard your product.

              Information last revised July 2016. Copyright(c) 2021 First Databank, Inc.

              IMPORTANT: HOW TO USE THIS INFORMATION: This is a summary and does NOT have all possible information about this product. This information does not assure that this product is safe, effective, or appropriate for you. This information is not individual medical advice and does not substitute for the advice of your health care professional. Always ask your health care professional for complete information about this product and your specific health needs.

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              Formulary

              FormularyPatient Discounts

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              The above information is provided for general informational and educational purposes only. Individual plans may vary and formulary information changes. Contact the applicable plan provider for the most current information.

              Tier Description
              1 This drug is available at the lowest co-pay. Most commonly, these are generic drugs.
              2 This drug is available at a middle level co-pay. Most commonly, these are "preferred" (on formulary) brand drugs.
              3 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs.
              4 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.
              5 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.
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              NC NOT COVERED – Drugs that are not covered by the plan.
              Code Definition
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              Medscape prescription drug monographs are based on FDA-approved labeling information, unless otherwise noted, combined with additional data derived from primary medical literature.