Yes

Anticholinergic Agent; Anticholinergic Agent, Ophthalmic; Antidote; Antispasmodic Agent, Gastrointestinal; Ophthalmic Agent, Mydriatic

Preoperative medication to inhibit salivation and secretions; treatment of sinus bradycardia; treatment of exercise-induced bronchospasm; antidote for organophosphate pesticide poisoning; to produce mydriasis and cycloplegia for examination of the retina and optic disc and accurate measurement of refractive errors; uveitis

C

Hypersensitivity to atropine or any component; narrow-angle glaucoma; adhesions between the iris and lens; tachycardia; unstable cardiovascular status in acute hemorrhage; obstructive GI disease; paralytic ileus; intestinal atony of the elderly or debilitated patient; severe UC; toxic megacolon complicating UC; hepatic disease; obstructive uropathy; renal disease; myasthenia gravis; asthma; thyrotoxicosis

Heat prostration can occur in the presence of a high environmental temperature. Rule out intestinal obstruction before treating diarrhea. Psychosis can occur in sensitive individuals. The elderly may be sensitive to side effects. Use caution in patients with myocardial ischemia. Use caution in hyperthyroidism, autonomic neuropathy, BPH, CHF, tachyarrhythmias, hypertension, and hiatal hernia associated with reflux esophagitis. Use with caution in children with spastic paralysis.

>10%:

Dermatologic: Dry, hot skin

Gastrointestinal: Impaired GI motility, constipation, dry throat, dry mouth

Local: Irritation at injection site

Respiratory: Dry nose

Miscellaneous: Sweating (decreased)

1% to 10%:

Dermatologic: Increased sensitivity to light

Endocrine & metabolic: Decreased flow of breast milk

Gastrointestinal: Dysphagia

<1% (Limited to important or life-threatening symptoms): Orthostatic hypotension, tachycardia, palpitations, ventricular fibrillation, confusion, drowsiness, ataxia, fatigue, delirium, headache, loss of memory, restlessness, elderly may be at increased risk for confusion and hallucinations, increased intraocular pain, blurred vision, mydriasis

Symptoms of overdose include dilated, unreactive pupils; blurred vision; hot, dry flushed skin; dryness of mucous membranes; difficulty in swallowing, foul breath, diminished or absent bowel sounds, urinary retention, tachycardia, hyperthermia, hypertension, increased respiratory rate

Anticholinergic toxicity is caused by strong binding of the drug to cholinergic receptors. Anticholinesterase inhibitors reduce acetylcholinesterase, the enzyme that breaks down acetylcholine and thereby allows acetylcholine to accumulate and compete for receptor binding with the offending anticholinergic. For anticholinergic overdose with severe life-threatening symptoms, physostigmine 1-2 mg (0.5 mg or 0.02 mg/kg for children) S.C. or I.V., slowly may be given to reverse these effects.

Phenothiazine and TCAs may increase anticholinergic effects when used concurrently.

Sympathomimetic amines may cause tachyarrhythmias; avoid concurrent use.

Store injection at <40°C, avoid freezing

Blocks the action of acetylcholine at parasympathetic sites in smooth muscle, secretory glands and the CNS; increases cardiac output, dries secretions, antagonizes histamine and serotonin

Onset of effect: I.V.: Rapid

Absorption: Well absorbed from all dosage forms

Distribution: Widely distributes throughout the body; crosses the placenta; trace amounts appear in breast milk; crosses the blood-brain barrier

Metabolism: In the liver

Half-life: 2-3 hours

Elimination: Both metabolites and unchanged drug (30% to 50%) are excreted into urine

Note: Doses <0.1 mg have been associated with paradoxical bradycardia.

Preanesthetic: Oral, I.M., I.V., S.C.:

<5 kg: 0.02 mg/kg/dose 30-60 minutes preop then every 4-6 hours as needed. Use of a minimum dosage of 0.1 mg in neonates <5 kg will result in dosages >0.02 mg/kg. There is no documented minimum dosage in this age group.

>5 kg: 0.01-0.02 mg/kg/dose to a maximum 0.4 mg/dose 30-60 minutes preop; minimum dose: 0.1 mg

Bradycardia: I.V., intratracheal: 0.02 mg/kg, minimum dose 0.1 mg, maximum single dose: 0.5 mg in children and 1 mg in adolescents; may repeat in 5-minute intervals to a maximum total dose of 1 mg in children or 2 mg in adolescents. ( Note: For intratracheal administration, the dosage must be diluted with normal saline to a total volume of 1-2 mL). When treating bradycardia in neonates, reserve use for those patients unresponsive to improved oxygenation and epinephrine.

Children:

Bronchospasm: Inhalation: 0.03-0.05 mg/kg/dose 3-4 times/day

Preprocedure: Ophthalmic: 0.5% solution: Instill 1-2 drops twice daily for 1-3 days before the procedure

Uveitis: Ophthalmic: 0.5% solution: Instill 1-2 drops up to 3 times/day

Adults (doses <0.5 mg have been associated with paradoxical bradycardia):

Asystole: I.V.: 1 mg; may repeat every 3-5 minutes as needed

Preanesthetic: I.M., I.V., S.C.: 0.4-0.6 mg 30-60 minutes preop and repeat every 4-6 hours as needed

Bradycardia: I.V.: 0.5-1 mg every 5 minutes, not to exceed a total of 2 mg or 0.04 mg/kg; may give intratracheal in 1 mg/10 mL dilution only, intratracheal dose should be 2-2.5 times the I.V. dose

Neuromuscular blockade reversal: I.V.: 25-30 mcg/kg 30 seconds before neostigmine or 10 mcg/kg 30 seconds before edrophonium

Organophosphate or carbamate poisoning: I.V.: 1-2 mg/dose every 10-20 minutes until atropine effect (dry flushed skin, tachycardia, mydriasis, fever) is observed, then every 1-4 hours for at least 24 hours; up to 50 mg in first 24 hours and 2 g over several days may be given in cases of severe intoxication

Bronchospasm: Inhalation: 0.025-0.05 mg/kg/dose every 4-6 hours as needed (maximum: 5 mg/dose)

Ophthalmic solution: 1%:

Preprocedure: Instill 1-2 drops 1 hour before the procedure.

Uveitis: Instill 1-2 drops 4 times/day.

Ophthalmic ointment: Apply a small amount in the conjunctival sac up to 3 times/day. Compress the lacrimal sac by digital pressure for 1-3 minutes after instillation.

No data reported

Administer undiluted by rapid I.V. injection; slow injection may result in paradoxical bradycardia

Heart rate, blood pressure, pulse, mental status; intravenous administration requires a cardiac monitor

Atropine, at usual recommended cardiovascular doses, causes blockade of muscarinic receptors at the cardiac SA-node and is parasympatholytic (ie, blocks vagal activity increasing heart rate). A dose greater than or equal to 1 mg is recommended for the treatment of bradyarrhythmias. In administering atropine, it is important to recognize that lower doses (0.1 mg) may have vagalmimetic effects (ie, increase vagal tone causing paradoxical bradycardia). It is likely that the vagal tonic effects of atropine are mediated by blockade of muscarinic receptors at the level of the brain. Thus, it is important that the recommended dose of atropine be administered by rapid intravenous injection. Slow injection may result in paradoxical bradycardia. Atropine is also recommended as part of the ACLS protocol. In this situation, in the absence of vascular access, atropine can be administered intratracheally. For intratracheal administration, the dosage must be diluted with normal saline to a total volume of 1-2 mL.

May cause drowsiness; rarely may produce anticholinergic toxicity presenting as confusion, delirium, memory loss, restlessness, and hallucinations

May decrease the effects of phenothiazines. concurrent use with psychotropics may result in additive anticholinergic side effects (dry mouth, blurred vision, constipation)

No information available to require special precautions

>10% of patients experience dry mouth

Take exactly as directed, 30 minutes before meals. Maintain adequate hydration (2-3 L/day of fluids unless instructed to restrict fluid intake). Void before taking medication. You may experience dizziness, blurred vision, sensitivity to light (use caution when driving or engaging in tasks requiring alertness until response to drug is known); dry mouth, nausea, or vomiting (small frequent meals, frequent mouth care, sucking lozenges, or chewing gum may help); orthostatic hypotension (use caution when climbing stairs and when rising from lying or sitting position); constipation (increased exercise, fluid, or dietary fiber may reduce constipation, if not effective consult prescriber); increased sensitivity to heat and decreased perspiration (avoid extremes of heat, reduce exercise in hot weather); decreased milk if breast-feeding. Report hot, dry, flushed skin; blurred vision or vision changes; difficulty swallowing; chest pain, palpitations, or rapid heartbeat; painful or difficult urination; increased confusion, depression, or loss of memory; rapid or difficult respirations; muscle weakness or tremors; or eye pain.

Pregnancy/breast-feeding precautions: Inform prescriber if you are or intend to be pregnant. Consult prescriber if breast-feeding.

Observe for tachycardia if patient has cardiac problems

Injection, as sulfate: 0.1 mg/mL (5 mL, 10 mL); 0.3 mg/mL (1 mL, 30 mL); 0.4 mg/mL (1 mL, 20 mL, 30 mL); 0.5 mg/mL (1 mL, 5 mL, 30 mL); 0.8 mg/mL (0.5 mL, 1 mL); 1 mg/mL (1 mL, 10 mL)

Ointment, ophthalmic, as sulfate: 0.5%, 1% (3.5 g)

Solution, ophthalmic, as sulfate: 0.5% (1 mL, 5 mL); 1% (1 mL, 2 mL, 5 mL, 15 mL); 2% (1 mL, 2 mL); 3% (5 mL)

Tablet, as sulfate: 0.4 mg

Afzaal S, Shakoor A, Rabbani MU, et al, "High Dose Atropine in Organophosphorus Poisoning," Postgrad Med J, 1990, 66(771):70-1.

Amitai Y, Singer R, Almog S, et al, "Atropine Poisoning in Children During the Persian Gulf Crisis," JAMA, 1992, 268(5):642-4.

Berman JM and Bertoldi IM, "Preparation of Atropine Sulfate Ampuls for High-Dose Therapy," Am J Hosp Pharm, 1985, 42(5):1046.

Emergency Cardiac Care Committee and Subcommittees, American Heart Association, "Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiac Care, III: Adult Advanced Cardiac Life Support" and "VI: Pediatric Advanced Life Support," JAMA, 1992, 268(16):2199-241 and 2262-75.

Feinberg M, "The Problems of Anticholinergic Adverse Effects in Older Patients," Drugs Aging, 1993, 3(4):335-48.

Howarth DM, Dawson AH, Smith AJ, et al, "Calcium Channel Blocking Drug Overdose: An Australian Series," Hum Exp Toxicol, 1994, 13(3):161-6.

Meerstadt PW, "Atropine Poisoning in Early Infancy Due to Eumydrin Drops," Br Med J [Clin Res], 1982, 285(6336):196-7.

Shockley LW, "The Use of Inhaled Nebulized Atropine for the Treatment of Malathion Poisoning," J Toxicol Clin Toxicol, 1989, 27(3):183-92.

Tomassoni AJ and Prybys K, "Isolated Central Effects of Atropine Eye Drops Reversed by Physostigmine," Clin Toxicol, 1995, 33(5):505.