Neostigmine

PROSTIGMIN

What it isPeripheral acetylcholinesterase inhibitor; reversal of neuromuscular blockade and treatment of myasthenia.

Why this oneIt restores neuromuscular transmission after surgery without entering the CNS.

What limits it⚑ Give with glycopyrrolate or atropine to prevent bradycardia and bronchospasm; it cannot reliably reverse deep blockade.

FDA-approved for

FDA dosing	Population	Start	Target	Max
Reversal of non-depolarizing NMBA — shorter-acting (e.g., rocuronium) or twitch >10% baseline/2nd twitch present	Adults & peds (all ages)	0.03 mg/kg IV	0.03 mg/kg IV	0.07 mg/kg or 5 mg total, whichever is less
Reversal of non-depolarizing NMBA — longer-acting (e.g., vecuronium, pancuronium) or twitch near 10% baseline	Adults & peds (all ages)	0.07 mg/kg IV	0.07 mg/kg IV	0.07 mg/kg or 5 mg total, whichever is less

Renal No dose adjustment; half-life prolonged in renal impairment — monitor longer

Hepatic No dose adjustment in hepatic impairment

Maximum total dose 0.07 mg/kg or 5 mg, whichever is less

IV use only; inject slowly over at least 1 minute
Give an anticholinergic (atropine or glycopyrrolate) prior to or concomitantly to lessen bradycardia
Use peripheral nerve stimulator (train-of-four) monitoring to time dosing and assess recovery
Maintain ventilation and patent airway until full recovery

Bradycardia — pretreat with anticholinergic
Caution in coronary artery disease, cardiac arrhythmias, recent acute coronary syndrome, or myasthenia gravis
Neuromuscular dysfunction with large doses when blockade is minimal
Differentiate cholinergic crisis from myasthenic crisis
Hypersensitivity/anaphylaxis — have atropine and anaphylaxis treatment available

Pregnancy No adequate human data; anticholinesterases may cause uterine irritability/premature labor near term; use only if clearly needed

Lactation Not studied; unknown whether present in human milk

NO BOXED WARNINGS

Principal riskBradycardia unless an antimuscarinic is co-given

Direct muscarinic antagonism0 / 4