pralidoxime

Generic Name: pralidoxime (PRAL i DOX eem)
Brand Name: Protopam Chloride

What is pralidoxime?

Pralidoxime reverses muscle weakness or paralysis caused by a poison or certain drug overdose.

Pralidoxime is used as an antidote to treat poisoning by a chemical or pesticide (insect spray), or by a drug used to treat a muscle disorder.

This medication is not effective as an antidote for all types of pesticide poisonings.

Pralidoxime may also be used for purposes not listed in this medication guide.

What is the most important information I should know about pralidoxime?

If possible, before you receive pralidoxime, tell your doctor if you have kidney disease, or if you are allergic to any drugs.

Also tell your doctor if you are pregnant or breast-feeding.

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In an emergency situation it may not be possible before you are treated to tell your caregivers about your health conditions or if you are pregnant or breast-feeding. Make sure any doctor caring for you afterward knows that you have received this medication.

What should I discuss with my health care provider before receiving pralidoxime?

If possible, before you receive pralidoxime, tell your doctor if you have kidney disease, or if you are allergic to any drugs.

FDA pregnancy category C. It is not known whether pralidoxime is harmful to an unborn baby. Tell your doctor if you are pregnant.

It is not known whether pralidoxime passes into breast milk or if it could harm a nursing baby.

In an emergency situation, it may not be possible before you are treated with pralidoxime to tell your caregivers if you are pregnant or breast-feeding. However, make sure any doctor caring for your pregnancy or your baby knows that you have received this medication.

How is pralidoxime given?

Pralidoxime is usually given as soon as possible after the onset of poisoning or overdose symptoms. You may need to receive pralidoxime for several days.

Pralidoxime is injected into a muscle, under the skin, or into a vein through an IV. A healthcare provider will give you this injection. Pralidoxime must be given slowly. The IV infusion can take up to 30 minutes to complete.

Your breathing, blood pressure, oxygen levels, kidney function, and other vital signs will be watched closely while you are receiving this medication.

After treatment with pralidoxime, you may be watched for up to 72 hours to make sure the medicine has been effective and you no longer have any effects of the poison or drug overdose.

What happens if I miss a dose?

Since pralidoxime is given by a healthcare professional in an emergency setting, you are not likely to miss a dose.

What happens if I overdose?

Since this medication is given by a healthcare professional in a medical setting, an overdose is unlikely to occur.

Overdose symptoms may include some of the side effects listed in this medication guide.

What should I avoid after receiving pralidoxime?

Follow your doctor's instructions about any restrictions on food, beverages, or activity.

Pralidoxime side effects

Some of the side effects of pralidoxime may be similar to the symptoms of poisoning. Your caregivers will watch you closely to determine whether your body is responding well to the medication, or if you are having any serious side effects.

Get emergency medical help if you have any of these signs of an allergic reaction: hives; difficulty breathing; swelling of your face, lips, tongue, or throat.

Tell your caregivers at once if you have a serious side effect such as:

  • fast heart rate;

  • rapid breathing;

  • increased muscle stiffness;

  • a choking feeling;

Less serious side effects may include:

  • pain where the medicine was injected;

  • blurred vision;

  • feeling dizzy or drowsy;

  • headache; or

  • nausea.

This is not a complete list of side effects and others may occur. Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088.

See also: Side effects (in more detail)

Pralidoxime dosing information

Usual Adult Dose for Organophosphate Poisoning:

IV:
Initial dose: 1 to 2 g, preferably as an IV infusion in 100 mL of normal saline, over 15 to 30 minutes; if an infusion is not practical or if pulmonary edema is present, the dose should be given slowly (over at least 5 minutes) by IV injection as a 50 mg/mL solution in Sterile Water for Injection (e.g., 1000 mg in 20 mL)

Second dose: 1 to 2 g may be indicated after about 1 hour if muscle weakness has not been relieved

Additional doses may be given every 10 to 12 hours if muscle weakness persists.

IM:
Mild symptoms:
Initial dose: 600 mg IM; recommend waiting 15 minutes for pralidoxime to take effect
Second dose: 600 mg IM if mild symptoms persist after 15 minutes
Third dose: 600 mg IM (cumulative dose of 1800 mg) if mild symptoms persist after an additional 15 minutes

If severe symptoms develop at any time after the first dose, 2 additional 600 mg IM doses in rapid succession should be administered for a total cumulative dose of 1800 mg.

Severe symptoms: Three 600 mg IM doses in rapid succession should be administered for a total cumulative dose of 1800 mg.

Persistent symptoms: If symptoms persist after administration of the complete 1800 mg regimen, the series may be repeated starting about 1 hour after the administration of the last injection.

Usual Adult Dose for Nerve Agent Poisoning:

IV:
Initial dose: 1 to 2 g, preferably as an IV infusion in 100 mL of normal saline, over 15 to 30 minutes; if an infusion is not practical or if pulmonary edema is present, the dose should be given slowly (over at least 5 minutes) by IV injection as a 50 mg/mL solution in Sterile Water for Injection (e.g., 1000 mg in 20 mL)

Second dose: 1 to 2 g may be indicated after about 1 hour if muscle weakness has not been relieved

Additional doses may be given every 10 to 12 hours if muscle weakness persists.

IM:
Mild symptoms:
Initial dose: 600 mg IM; recommend waiting 15 minutes for pralidoxime to take effect
Second dose: 600 mg IM if mild symptoms persist after 15 minutes
Third dose: 600 mg IM (cumulative dose of 1800 mg) if mild symptoms persist after an additional 15 minutes

If severe symptoms develop at any time after the first dose, 2 additional 600 mg IM doses in rapid succession should be administered for a total cumulative dose of 1800 mg.

Severe symptoms: Three 600 mg IM doses in rapid succession should be administered for a total cumulative dose of 1800 mg.

Persistent symptoms: If symptoms persist after administration of the complete 1800 mg regimen, the series may be repeated starting about 1 hour after the administration of the last injection.

Usual Adult Dose for Anticholinesterase Overdose:

Initial dose: 1 to 2 g IV slowly
Maintenance dose: Increments of 250 mg IV every 5 minutes as needed to control symptoms

Usual Pediatric Dose for Organophosphate Poisoning:

16 years or younger:
IV:
Pralidoxime can be given as a loading dose followed by continuous IV infusion or as intermittent IV infusions, depending upon patient's clinical condition. The specific dose given should depend upon the severity of symptoms.

Loading dose: 20 to 50 mg/kg (not to exceed 2 g/dose) over 15 to 30 minutes followed by continuous infusion
Continuous infusion: 10 to 20 mg/kg/hour following the loading dose

Intermittent infusion:
Initial dose: 20 to 50 mg/kg (not to exceed 2 g/dose) over 15 to 30 minutes
Second dose: 20 to 50 mg/kg may be indicated after about 1 hour if muscle weakness has not been relieved
Repeat dosing: Permissible every 10 to 12 hours as needed.

If administration by continuous or intermittent IV infusion is not practical, or if pulmonary edema is present, the 20 to 50 mg/kg dose should be given slowly (over at least 5 minutes) by IV injection as a 50 mg/mL solution in Sterile Water for Injection. Additional doses may be given every 10 to 12 hours if muscle weakness persists.

IM:
Less than 40 kg:
Mild symptoms:
Initial dose: 15 mg/kg IM; recommend waiting 15 minutes for pralidoxime to take effect
Second dose: 15 mg/kg IM if mild symptoms persist after 15 minutes
Third dose: 15 mg/kg IM (total cumulative dose of 45 mg/kg) if mild symptoms persist after an additional 15 minutes

If severe symptoms develop at any time after the first dose, 2 additional 15 mg/kg IM doses in rapid succession should be administered for a total cumulative dose of 45 mg/kg.

Severe symptoms: Three 15 mg/kg IM doses in rapid succession should be administered for a total cumulative dose of 45 mg/kg.

Persistent symptoms: If symptoms persist after administration of the complete 45 mg/kg regimen, the series may be repeated starting about 1 hour after the administration of the last injection.

40 kg or more:
Mild symptoms:
Initial dose: 600 mg IM; recommend waiting 15 minutes for pralidoxime to take effect
Second dose: 600 mg IM if mild symptoms persist after 15 minutes
Third dose: 600 mg IM (total cumulative dose of 1800 mg) if mild symptoms persist after an additional 15 minutes

If severe symptoms develop at any time after the first dose, 2 additional 600 mg IM doses in rapid succession should be administered for a total cumulative dose of 1800 mg.

Severe symptoms: Three 600 mg IM doses in rapid succession should be administered for a total cumulative dose of 1800 mg.

Persistent symptoms: If symptoms persist after administration of the complete 1800 mg regimen, the series may be repeated starting about 1 hour after the administration of the last injection.

Usual Pediatric Dose for Nerve Agent Poisoning:

16 years or younger:
IV:
Pralidoxime can be given as a loading dose followed by continuous IV infusion or as intermittent IV infusions, depending upon patient's clinical condition. The specific dose given should depend upon the severity of symptoms.

Loading dose: 20 to 50 mg/kg (not to exceed 2 g/dose) over 15 to 30 minutes followed by continuous infusion
Continuous infusion: 10 to 20 mg/kg/hour following the loading dose

Intermittent infusion:
Initial dose: 20 to 50 mg/kg (not to exceed 2 g/dose) over 15 to 30 minutes
Second dose: 20 to 50 mg/kg may be indicated after about 1 hour if muscle weakness has not been relieved
Repeat dosing: Permissible every 10 to 12 hours as needed.

If administration by continuous or intermittent IV infusion is not practical, or if pulmonary edema is present, the 20 to 50 mg/kg dose should be given slowly (over at least 5 minutes) by IV injection as a 50 mg/mL solution in Sterile Water for Injection. Additional doses may be given every 10 to 12 hours if muscle weakness persists.

IM:
Less than 40 kg:
Mild symptoms:
Initial dose: 15 mg/kg IM; recommend waiting 15 minutes for pralidoxime to take effect
Second dose: 15 mg/kg IM if mild symptoms persist after 15 minutes
Third dose: 15 mg/kg IM (total cumulative dose of 45 mg/kg) if mild symptoms persist after an additional 15 minutes

If severe symptoms develop at any time after the first dose, 2 additional 15 mg/kg IM doses in rapid succession should be administered for a total cumulative dose of 45 mg/kg.

Severe symptoms: Three 15 mg/kg IM doses in rapid succession should be administered for a total cumulative dose of 45 mg/kg.

Persistent symptoms: If symptoms persist after administration of the complete 45 mg/kg regimen, the series may be repeated starting about 1 hour after the administration of the last injection.

40 kg or more:
Mild symptoms:
Initial dose: 600 mg IM; recommend waiting 15 minutes for pralidoxime to take effect
Second dose: 600 mg IM if mild symptoms persist after 15 minutes
Third dose: 600 mg IM (total cumulative dose of 1800 mg) if mild symptoms persist after an additional 15 minutes

If severe symptoms develop at any time after the first dose, 2 additional 600 mg IM doses in rapid succession should be administered for a total cumulative dose of 1800 mg.

Severe symptoms: Three 600 mg IM doses in rapid succession should be administered for a total cumulative dose of 1800 mg.

Persistent symptoms: If symptoms persist after administration of the complete 1800 mg regimen, the series may be repeated starting about 1 hour after the administration of the last injection.

What other drugs will affect pralidoxime?

If possible, before you receive this medication, tell your doctor about all other medicines you use, especially:

  • aminophylline (Phyllocontin, Truphylline);

  • atropine (Atreza, Sal-Tropine, and others);

  • morphine (Avinza, Kadian, MS Contin, Oramorph);

  • reserpine;

  • theophylline (Elixophyllin, Theo-24, Uniphyl);

  • a barbiturate such as butabarbital (Butisol), secobarbital (Seconal), pentobarbital (Nembutal), or phenobarbital (Solfoton); or

  • a tranquilizer such as chlorpromazine (Thorazine), fluphenazine (Permitil), perphenazine (Trilafon), prochlorperazine (Compazine), thioridazine (Mellaril), or trifluperazine (Stelazine).

This list is not complete and other drugs may interact with pralidoxime. Tell your doctor about all medications you use. This includes prescription, over-the-counter, vitamin, and herbal products. Do not start a new medication without telling your doctor.

Where can I get more information?

  • Your doctor or pharmacist can provide more information about pralidoxime.
  • Remember, keep this and all other medicines out of the reach of children, never share your medicines with others, and use this medication only for the indication prescribed.
  • Disclaimer: Every effort has been made to ensure that the information provided by Cerner Multum, Inc. ('Multum') is accurate, up-to-date, and complete, but no guarantee is made to that effect. Drug information contained herein may be time sensitive. Multum information has been compiled for use by healthcare practitioners and consumers in the United States and therefore Multum does not warrant that uses outside of the United States are appropriate, unless specifically indicated otherwise. Multum's drug information does not endorse drugs, diagnose patients or recommend therapy. Multum's drug information is an informational resource designed to assist licensed healthcare practitioners in caring for their patients and/or to serve consumers viewing this service as a supplement to, and not a substitute for, the expertise, skill, knowledge and judgment of healthcare practitioners. The absence of a warning for a given drug or drug combination in no way should be construed to indicate that the drug or drug combination is safe, effective or appropriate for any given patient. Multum does not assume any responsibility for any aspect of healthcare administered with the aid of information Multum provides. The information contained herein is not intended to cover all possible uses, directions, precautions, warnings, drug interactions, allergic reactions, or adverse effects. If you have questions about the drugs you are taking, check with your doctor, nurse or pharmacist.

Copyright 1996-2012 Cerner Multum, Inc. Version: 2.02. Revision Date: 2010-12-15, 5:01:39 PM.

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