Is Physostigmine Effective for Cardiac Toxicity of Tricyclic Antidepressant Drugs?

Bigger, J. Thomas; Kantor, Shepard J.; Glassman, Alexander H.; Perel, James M.

doi:10.1001/jama.1977.03270400015002

Cited by 11 publications

(1 citation statement)

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“…When combined with the loss of antimuscarinic-mediated tachycardia, physostigmine administration may result in bradycardia and asystole in severe TCA toxicity [20,36]. Closer inspection of patients with these bradyasystolic events suggests they are more likely the result of severe TCA toxicity heralded by bradycardia and wide complex arrhythmias rather than the administration of physostigmine alone [20,47]. While these cases serve as cautionary tales, in our review, life-threatening bradyarrhythmias were isolated to TCA overdose patients with evidence of QRS prolongation prior to receiving physostigmine and in 1 patient with a concurrent propranolol overdose.…”

Section: Use Of Physostigmine In Tricyclic Antidepressant Toxicitymentioning

confidence: 99%

Adverse Effects of Physostigmine

Arens

Kearney

2019

J. Med. Toxicol.

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Introduction Physostigmine is a tertiary amine carbamate acetylcholinesterase inhibitor. Its ability to cross the blood-brain barrier makes it an effective antidote to reverse anticholinergic delirium. Physostigmine is underutilized following the publication of patients with sudden cardiac arrest after physostigmine administration in patients with tricyclic antidepressant (TCA) overdoses. We completed a narrative literature review to identify reported adverse effects associated with physostigmine administration. Discussion One hundred sixty-one articles and a total of 2299 patients were included. Adverse effects occurred in 415 (18.1%) patients. Hypersalivation (206; 9.0%) and nausea and vomiting (96; 4.2%) were the most common adverse effects. Fifteen (0.61%) patients had seizures, all of which were self-limited or treated successfully without complication. Symptomatic bradycardia occurred in 8 (0.35%) patients including 3 patients with bradyasystolic arrests. Ventricular fibrillation occurred in one (0.04%) patient with underlying coronary artery disease. Of the 394 patients with TCA overdose, adverse effects were described in 14 (3.6%). Adverse effects occurred in 7.7% of patients treated with an overdose of an anticholinergic agent compared with 20.6% of patients with non-anticholinergic agents. Five (0.22%) fatalities were identified. Conclusions In conclusion, significant adverse effects associated with the use of physostigmine were infrequently reported. Seizures were self-limited or resolved with benzodiazepines, and all patients recovered neurologically intact. Physostigmine should be avoided in patients with QRS prolongation on EKG, and caution should be used in patients with a history of coronary artery disease and overdoses with QRS prolonging medications. Based upon our review, physostigmine is a safe antidote to treat anticholinergic overdose.

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