IN THE TREATMENT OF MYASTHENIA GRAVIS, NEOSTIGMINE BROMIDE IS GIVEN BY MOUTH IN A TOTAL DAILY DOSE USUALLY BETWEEN 75 AND 300 MG, DIVIDED THROUGHOUT THE DAY, AND IF NECESSARY THE NIGHT, ACCORDING TO RESPONSE; LARGER PORTIONS OF THE TOTAL DOSE MAY BE GIVEN AT TIMES OF GREATER FATIGUE. THE MAXIMUM DAILY DOSE THAT MOST PATIENTS CAN TOLERATE IS 180 MG. A USUAL TOTAL DAILY DOSE IN CHILDREN IS 15 TO 90 MG BY MOUTH. IN PATIENTS IN WHOM ORAL THERAPY IS IMPRACTICAL NEOSTIGMINE METILSULFATE MAY BE GIVEN IN DOSES OF 0.5 TO 2.5 MG BY INTRAMUSCULAR OR SUBCUTANEOUS INJECTION AT INTERVALS, GIVING A TOTAL DAILY DOSE USUALLY IN THE RANGE 5 TO 20 MG. SINGLE DOSES IN CHILDREN HAVE RANGED FROM 200 TO 500 MICROGRAMS.
IN THE TREATMENT OF NEONATAL MYASTHENIA GRAVIS DOSES IN THE RANGE 50 TO 250 MICROGRAMS OF THE METILSULFATE BY INTRAMUSCULAR OR SUBCUTANEOUS INJECTION, OR 1 TO 5 MG OF THE BROMIDE BY MOUTH, HAVE BEEN GIVEN USUALLY EVERY 4 HOURS (30 MINUTES BEFORE FEEDS); TREATMENT IS RARELY NEEDED BEYOND 8 WEEKS OF AGE.
TO REVERSE NEUROMUSCULAR BLOCKADE PRODUCED BY COMPETITIVE NEUROMUSCULAR BLOCKERS, THE USUAL ADULT DOSE IN THE UK IS 50 TO 70 MICROGRAMS/KG GIVEN BY INTRAVENOUS INJECTION OVER A PERIOD OF 60 SECONDS; IN THE USA LOWER DOSES OF 0.5 TO 2 MG ARE USED. ADDITIONAL NEOSTIGMINE MAY BE GIVEN UNTIL THE MUSCLE POWER IS NORMAL BUT A TOTAL OF 5 MG SHOULD NOT BE EXCEEDED. SIMILAR DOSES MAY BE USED IN CHILDREN; THE BNFC RECOMMENDS A DOSE OF 50 TO 80 MICROGRAMS/KG IN NEONATES AND CHILDREN, TO A MAXIMUM OF 2.5 MG IN THOSE UNDER 12 YEARS OF AGE. THE PATIENT SHOULD BE WELL VENTILATED UNTIL COMPLETE RECOVERY OF NORMAL RESPIRATION IS ASSURED. TO COUNTERACT ANY MUSCARINIC EFFECTS IN ADULTS 0.6 TO 1.2 MG OF ATROPINE SULFATE IS GIVEN BY INTRAVENOUS INJECTION WITH OR BEFORE THE DOSE OF NEOSTIGMINE; NEONATES AND CHILDREN UP TO 18 YEARS OF AGE MAY BE GIVEN 20 MICROGRAMS/KG OF ATROPINE SULFATE (TO A MAXIMUM OF 600 MICROGRAMS IN THOSE AGED 1 MONTH AND OVER). IT HAS BEEN SUGGESTED THAT IN THE PRESENCE OF BRADYCARDIA ATROPINE SULFATE SHOULD BE GIVEN SEVERAL MINUTES BEFORE NEOSTIGMINE. GLYCOPYRRONIUM BROMIDE HAS BEEN USED AS AN ALTERNATIVE TO ATROPINE SULFATE.
IN THE TREATMENT OF PARALYTIC ILEUS AND POSTOPERATIVE URINARY RETENTION, DOSES OF 15 TO 30 MG OF THE BROMIDE BY MOUTH, OR MORE USUALLY 500 MICROGRAMS OF THE METILSULFATE BY SUBCUTANEOUS OR INTRAMUSCULAR INJECTION, HAVE BEEN USED.
THE DOSAGE OF NEOSTIGMINE MAY NEED TO BE ADJUSTED IN PATIENTS WITH RENAL IMPAIRMENT.
INTRATHECAL NEOSTIGMINE HAS BEEN ADDED TO SPINAL LOCAL ANAESTHETICS OR OPIOIDS AS AN ADJUNCT TO PROLONG REGIONAL ANALGESIA AND IMPROVE HAEMODYNAMIC STABILITY. A SYSTEMATIC REVIEW OF STUDIES OF SUCH USE FOUND THAT ALTHOUGH NEOSTIGMINE IN DOSES UP TO 500 MICROGRAMS PRODUCED A VERY MODEST INCREASE IN ANALGESIA IN THE PERIOPERATIVE AND PERIPARTUM SETTING, IT DID NOT APPEAR TO IMPROVE HAEMODYNAMIC STABILITY AND THE INCIDENCE OF ADVERSE EFFECTS WAS GREATLY INCREASED, EVEN AT LOW DOSES. THE DISADVANTAGES WERE FELT TO OUTWEIGH WHATEVER BENEFITS SUCH THERAPY MIGHT HAVE.