glycopyrronium + neostigmine metilsulfate: clinical use

Prescribing considerations

• Confirm that residual block is from a non-depolarising competitive neuromuscular blocker and assess recovery in an appropriately monitored setting.
• Use particular caution with bronchospasm, significant cardiovascular disease, bradycardia, arrhythmias, recent myocardial infarction, hypotension, renal impairment, epilepsy, Parkinsonism, peptic ulceration, hyperthyroidism or thyrotoxicosis.
• Consider antimuscarinic risks in prostatic enlargement, paralytic ileus, pyloric stenosis and closed-angle glaucoma.
• Closely observe patients with raised temperature, especially children, because glycopyrronium inhibits sweating.
• Consider potential effects at the muscle end plate in myasthenia gravis.

Contraindications and cautions

• Hypersensitivity to glycopyrronium, neostigmine or an excipient.
• Mechanical obstruction of the gastrointestinal or urinary tract.
• Concomitant suxamethonium.
• Prolonged QT interval; avoid the combination.

Monitoring

• Return of neuromuscular function and adequacy of ventilation.
• Heart rate, rhythm, blood pressure and cardiac conduction.
• Airway secretions and signs of bronchospasm.
• Temperature where fever or impaired sweating is a concern.
• Urinary retention and gastrointestinal activity in susceptible patients.

Clinical pharmacology

Neostigmine is a reversible anticholinesterase that enhances acetylcholine-mediated neuromuscular transmission. Glycopyrronium is a peripheral antimuscarinic that counters neostigmine-induced muscarinic effects and has limited penetration of the central nervous system.

Formulation and product differences

• Fixed-ratio, clear and colourless intravenous solution supplied in single-use glass ampoules.
• Contains sodium but is classified by the product information as essentially sodium-free.
• Compatibility with other medicinal products has not been established; do not mix, and discard unused solution after opening.

Injection

Route: Parenteral

Strengths: 0.5 mg + 2.5 mg/mL