Drug Interactions between chlorpheniramine / guaifenesin / phenylephrine and demecarium bromide ophthalmic

Alcohol can increase the nervous system side effects of chlorpheniramine such as dizziness, drowsiness, and difficulty concentrating. Some people may also experience impairment in thinking and judgment. You should avoid or limit the use of alcohol while being treated with chlorpheniramine. Do not use more than the recommended dose of chlorpheniramine, and avoid activities requiring mental alertness such as driving or operating hazardous machinery until you know how the medication affects you. Talk to your doctor or pharmacist if you have any questions or concerns.

Both phenylephrine and caffeine can increase blood pressure and heart rate, and combining them may enhance these effects. Talk to your doctor before using these medications, especially if you have a history of high blood pressure or heart disease. You may need a dose adjustment or more frequent monitoring by your doctor to safely use both medications. Contact your doctor if your condition changes or you experience increased side effects. It is important to tell your doctor about all other medications you use, including vitamins and herbs. Do not stop using any medications without first talking to your doctor.

The use of miotic agents may occasionally cause retinal detachment due to drug-induced ciliary or accommodative spasm, which causes the lens and vitreous to move forward and create a retinal tear. Therapy with miotic agents should be administered with extreme caution, if at all, in patients with risk factors for retinal detachment, such as old age, retinal degenerative changes or other retinal disorders, aphakia, prior cataract extraction, or a history of severe myopia or retinal detachment.

Sympathomimetic agents may cause adverse cardiovascular effects, particularly when used in high dosages and/or in susceptible patients. In cardiac tissues, these agents may produce positive chronotropic and inotropic effects via stimulation of beta- 1 adrenergic receptors. Cardiac output, oxygen consumption, and the work of the heart may be increased. In the peripheral vasculature, vasoconstriction may occur via stimulation of alpha-1 adrenergic receptors. Palpitations, tachycardia, arrhythmia, hypertension, reflex bradycardia, coronary occlusion, cerebral vasculitis, myocardial infarction, cardiac arrest, and death have been reported. Some of these agents, particularly ephedra alkaloids (ephedrine, ma huang, phenylpropanolamine), may also predispose patients to hemorrhagic and ischemic stroke. Therapy with sympathomimetic agents should generally be avoided or administered cautiously in patients with sensitivity to sympathomimetic amines, hyperthyroidism, or underlying cardiovascular or cerebrovascular disorders. These agents should not be used in patients with severe coronary artery disease or severe/uncontrolled hypertension.

Sympathomimetic agents may cause adverse cardiovascular effects, particularly when used in high dosages and/or in susceptible patients. In cardiac tissues, these agents may produce positive chronotropic and inotropic effects via stimulation of beta- 1 adrenergic receptors. Cardiac output, oxygen consumption, and the work of the heart may be increased. In the peripheral vasculature, vasoconstriction may occur via stimulation of alpha-1 adrenergic receptors. Palpitations, tachycardia, arrhythmia, hypertension, reflex bradycardia, coronary occlusion, cerebral vasculitis, myocardial infarction, cardiac arrest, and death have been reported. Some of these agents, particularly ephedra alkaloids (ephedrine, ma huang, phenylpropanolamine), may also predispose patients to hemorrhagic and ischemic stroke. Therapy with sympathomimetic agents should generally be avoided or administered cautiously in patients with sensitivity to sympathomimetic amines, hyperthyroidism, or underlying cardiovascular or cerebrovascular disorders. These agents should not be used in patients with severe coronary artery disease or severe/uncontrolled hypertension.

Miotic agents may cause a paradoxical transient increase in intraocular pressure, which can precipitate an acute attack in patients with angle-closure (narrow-angle) glaucoma or anatomically narrow angles. The risk is much higher with long-acting cholinesterase inhibitors (e.g., demecarium and echothiophate), since these agents can cause pupillary block and increase angle closure. Therapy with long-acting cholinesterase inhibitors should be administered cautiously, or avoided, in patients with chronic angle-closure glaucoma or in patients with anatomically narrow angles. The use of echothiophate iodide is specifically contraindicated in most cases of angle-closure glaucoma. Because chronic use of long-acting cholinesterase inhibitors may cause dilation of blood vessels and increased permeability, these agents should be avoided for at least 2 weeks prior to ophthalmic surgery so as to minimize the risk of hyphema. Miotic agents in general should not be used in patients with glaucoma secondary to unrelieved pupillary block.

Sympathomimetic agents may cause adverse cardiovascular effects, particularly when used in high dosages and/or in susceptible patients. In cardiac tissues, these agents may produce positive chronotropic and inotropic effects via stimulation of beta- 1 adrenergic receptors. Cardiac output, oxygen consumption, and the work of the heart may be increased. In the peripheral vasculature, vasoconstriction may occur via stimulation of alpha-1 adrenergic receptors. Palpitations, tachycardia, arrhythmia, hypertension, reflex bradycardia, coronary occlusion, cerebral vasculitis, myocardial infarction, cardiac arrest, and death have been reported. Some of these agents, particularly ephedra alkaloids (ephedrine, ma huang, phenylpropanolamine), may also predispose patients to hemorrhagic and ischemic stroke. Therapy with sympathomimetic agents should generally be avoided or administered cautiously in patients with sensitivity to sympathomimetic amines, hyperthyroidism, or underlying cardiovascular or cerebrovascular disorders. These agents should not be used in patients with severe coronary artery disease or severe/uncontrolled hypertension.

The use of miotic agents may occasionally cause retinal detachment due to drug-induced ciliary or accommodative spasm, which causes the lens and vitreous to move forward and create a retinal tear. Therapy with miotic agents should be administered with extreme caution, if at all, in patients with risk factors for retinal detachment, such as old age, retinal degenerative changes or other retinal disorders, aphakia, prior cataract extraction, or a history of severe myopia or retinal detachment.

Sympathomimetic agents may cause adverse cardiovascular effects, particularly when used in high dosages and/or in susceptible patients. In cardiac tissues, these agents may produce positive chronotropic and inotropic effects via stimulation of beta- 1 adrenergic receptors. Cardiac output, oxygen consumption, and the work of the heart may be increased. In the peripheral vasculature, vasoconstriction may occur via stimulation of alpha-1 adrenergic receptors. Palpitations, tachycardia, arrhythmia, hypertension, reflex bradycardia, coronary occlusion, cerebral vasculitis, myocardial infarction, cardiac arrest, and death have been reported. Some of these agents, particularly ephedra alkaloids (ephedrine, ma huang, phenylpropanolamine), may also predispose patients to hemorrhagic and ischemic stroke. Therapy with sympathomimetic agents should generally be avoided or administered cautiously in patients with sensitivity to sympathomimetic amines, hyperthyroidism, or underlying cardiovascular or cerebrovascular disorders. These agents should not be used in patients with severe coronary artery disease or severe/uncontrolled hypertension.

The use of miotic agents may occasionally cause retinal detachment due to drug-induced ciliary or accommodative spasm, which causes the lens and vitreous to move forward and create a retinal tear. Therapy with miotic agents should be administered with extreme caution, if at all, in patients with risk factors for retinal detachment, such as old age, retinal degenerative changes or other retinal disorders, aphakia, prior cataract extraction, or a history of severe myopia or retinal detachment.

The use of miotic agents is contraindicated in patients with active anterior uveitis and/or glaucoma associated with iridocyclitis. Pupillary constriction produced by these agents may aggravate the inflammation and predispose these patients to the development of posterior synechiae.

Topically applied cholinergic agents are systemically absorbed, with the potential for producing rare but clinically significant systemic effects, including urinary incontinence, tightness of the bladder, increased gastric contractility and acid secretion, bradycardia, severe hypotension, bronchospasm, seizures, and coma. Increases in blood pressure may occur rarely due to a nicotinic effect on sympathetic ganglia. Therapy with ophthalmic cholinergic agents, particularly the long-acting cholinesterase inhibitors (e.g., demecarium and echothiophate), should be administered cautiously in patients with corneal abrasion (which may increase drug penetration), bronchospastic diseases, spastic gastrointestinal disturbances, urinary tract obstruction, peptic ulcer, pronounced bradycardia and hypotension, vascular hypertension, acute cardiac failure, recent myocardial infarction, epilepsy, parkinsonism, and other conditions that may respond adversely to vagotonic effects. The usual precautions should be followed to minimize the risk of systemic toxicity, including digital compression of the nasolacrimal ducts (1 to 2 minutes) following instillation to limit drainage into the nasal chamber, where extensive absorption may occur, and washing hands after use to prevent skin absorption. Excessive cholinergic effects may be reversed with parenterally administered atropine.

Topically applied cholinergic agents are systemically absorbed, with the potential for producing rare but clinically significant systemic effects, including urinary incontinence, tightness of the bladder, increased gastric contractility and acid secretion, bradycardia, severe hypotension, bronchospasm, seizures, and coma. Increases in blood pressure may occur rarely due to a nicotinic effect on sympathetic ganglia. Therapy with ophthalmic cholinergic agents, particularly the long-acting cholinesterase inhibitors (e.g., demecarium and echothiophate), should be administered cautiously in patients with corneal abrasion (which may increase drug penetration), bronchospastic diseases, spastic gastrointestinal disturbances, urinary tract obstruction, peptic ulcer, pronounced bradycardia and hypotension, vascular hypertension, acute cardiac failure, recent myocardial infarction, epilepsy, parkinsonism, and other conditions that may respond adversely to vagotonic effects. The usual precautions should be followed to minimize the risk of systemic toxicity, including digital compression of the nasolacrimal ducts (1 to 2 minutes) following instillation to limit drainage into the nasal chamber, where extensive absorption may occur, and washing hands after use to prevent skin absorption. Excessive cholinergic effects may be reversed with parenterally administered atropine.

It has been suggested that the anticholinergic effect of antihistamines may reduce the volume and cause thickening of bronchial secretions, resulting in obstruction of respiratory tract. Some manufacturers and clinicians recommend that therapy with antihistamines be administered cautiously in patients with asthma or chronic obstructive pulmonary disease.

Sympathomimetic agents may cause or worsen urinary difficulty in patients with prostate enlargement due to smooth muscle contraction in the bladder neck via stimulation of alpha-1 adrenergic receptors. Therapy with sympathomimetic agents should be administered cautiously in patients with hypertrophy or neoplasm of the prostate.

Antihistamines may infrequently cause cardiovascular adverse effects related to their anticholinergic and local anesthetic (quinidine-like) activities. Tachycardia, palpitation, ECG changes, arrhythmias, hypotension, and hypertension have been reported. Although these effects are uncommon and usually limited to overdosage situations, the manufacturers and some clinicians recommend that therapy with antihistamines be administered cautiously in patients with cardiovascular disease, hypertension, and/or hyperthyroidism.

The use of miotic agents has been associated with the development of lens opacities characterized by the appearance of anterior subcapsular vacuoles. The incidence of cataracts appears to be highest in patients treated with long-acting cholinesterase inhibitors (e.g., demecarium and echothiophate) and may also be related to age (higher in patients > 60 years of age), drug concentration, frequency of use, and duration of therapy (>= 6 months). Lens opacities usually regress if miotic therapy is withdrawn early in their development but often become progressive once they are established. Therapy with miotic agents should be administered cautiously in patients with or predisposed to cataracts. Slit-lamp examinations should be performed regularly, and miotic therapy discontinued if necessary.

Topically applied cholinergic agents are systemically absorbed, with the potential for producing rare but clinically significant systemic effects, including urinary incontinence, tightness of the bladder, increased gastric contractility and acid secretion, bradycardia, severe hypotension, bronchospasm, seizures, and coma. Increases in blood pressure may occur rarely due to a nicotinic effect on sympathetic ganglia. Therapy with ophthalmic cholinergic agents, particularly the long-acting cholinesterase inhibitors (e.g., demecarium and echothiophate), should be administered cautiously in patients with corneal abrasion (which may increase drug penetration), bronchospastic diseases, spastic gastrointestinal disturbances, urinary tract obstruction, peptic ulcer, pronounced bradycardia and hypotension, vascular hypertension, acute cardiac failure, recent myocardial infarction, epilepsy, parkinsonism, and other conditions that may respond adversely to vagotonic effects. The usual precautions should be followed to minimize the risk of systemic toxicity, including digital compression of the nasolacrimal ducts (1 to 2 minutes) following instillation to limit drainage into the nasal chamber, where extensive absorption may occur, and washing hands after use to prevent skin absorption. Excessive cholinergic effects may be reversed with parenterally administered atropine.

It has been suggested that the anticholinergic effect of antihistamines may reduce the volume and cause thickening of bronchial secretions, resulting in obstruction of respiratory tract. Some manufacturers and clinicians recommend that therapy with antihistamines be administered cautiously in patients with asthma or chronic obstructive pulmonary disease.

Topically applied cholinergic agents are systemically absorbed, with the potential for producing rare but clinically significant systemic effects, including urinary incontinence, tightness of the bladder, increased gastric contractility and acid secretion, bradycardia, severe hypotension, bronchospasm, seizures, and coma. Increases in blood pressure may occur rarely due to a nicotinic effect on sympathetic ganglia. Therapy with ophthalmic cholinergic agents, particularly the long-acting cholinesterase inhibitors (e.g., demecarium and echothiophate), should be administered cautiously in patients with corneal abrasion (which may increase drug penetration), bronchospastic diseases, spastic gastrointestinal disturbances, urinary tract obstruction, peptic ulcer, pronounced bradycardia and hypotension, vascular hypertension, acute cardiac failure, recent myocardial infarction, epilepsy, parkinsonism, and other conditions that may respond adversely to vagotonic effects. The usual precautions should be followed to minimize the risk of systemic toxicity, including digital compression of the nasolacrimal ducts (1 to 2 minutes) following instillation to limit drainage into the nasal chamber, where extensive absorption may occur, and washing hands after use to prevent skin absorption. Excessive cholinergic effects may be reversed with parenterally administered atropine.

Topically applied cholinergic agents are systemically absorbed, with the potential for producing rare but clinically significant systemic effects, including urinary incontinence, tightness of the bladder, increased gastric contractility and acid secretion, bradycardia, severe hypotension, bronchospasm, seizures, and coma. Increases in blood pressure may occur rarely due to a nicotinic effect on sympathetic ganglia. Therapy with ophthalmic cholinergic agents, particularly the long-acting cholinesterase inhibitors (e.g., demecarium and echothiophate), should be administered cautiously in patients with corneal abrasion (which may increase drug penetration), bronchospastic diseases, spastic gastrointestinal disturbances, urinary tract obstruction, peptic ulcer, pronounced bradycardia and hypotension, vascular hypertension, acute cardiac failure, recent myocardial infarction, epilepsy, parkinsonism, and other conditions that may respond adversely to vagotonic effects. The usual precautions should be followed to minimize the risk of systemic toxicity, including digital compression of the nasolacrimal ducts (1 to 2 minutes) following instillation to limit drainage into the nasal chamber, where extensive absorption may occur, and washing hands after use to prevent skin absorption. Excessive cholinergic effects may be reversed with parenterally administered atropine.

Sympathomimetic agents may cause increases in blood glucose concentrations. These effects are usually transient and slight but may be significant with dosages higher than those normally recommended. Therapy with sympathomimetic agents should be administered cautiously in patients with diabetes mellitus. Closer monitoring of blood glucose concentrations may be appropriate.

Topically applied cholinesterase inhibitors are systemically absorbed, with the potential for producing rare but clinically significant systemic effects, including central nervous system disturbances such as confusion and seizures. Children with Down's syndrome may be particularly susceptible to the CNS effects of these drugs. Echothiophate, specifically, has also been reported to cause hyperactivity in these children. Therapy with ophthalmic cholinesterase inhibitors, particularly the long-acting ones (e.g., demecarium and echothiophate), should be administered cautiously in children with Down's syndrome.

Topically applied cholinergic agents are systemically absorbed, with the potential for producing rare but clinically significant systemic effects, including urinary incontinence, tightness of the bladder, increased gastric contractility and acid secretion, bradycardia, severe hypotension, bronchospasm, seizures, and coma. Increases in blood pressure may occur rarely due to a nicotinic effect on sympathetic ganglia. Therapy with ophthalmic cholinergic agents, particularly the long-acting cholinesterase inhibitors (e.g., demecarium and echothiophate), should be administered cautiously in patients with corneal abrasion (which may increase drug penetration), bronchospastic diseases, spastic gastrointestinal disturbances, urinary tract obstruction, peptic ulcer, pronounced bradycardia and hypotension, vascular hypertension, acute cardiac failure, recent myocardial infarction, epilepsy, parkinsonism, and other conditions that may respond adversely to vagotonic effects. The usual precautions should be followed to minimize the risk of systemic toxicity, including digital compression of the nasolacrimal ducts (1 to 2 minutes) following instillation to limit drainage into the nasal chamber, where extensive absorption may occur, and washing hands after use to prevent skin absorption. Excessive cholinergic effects may be reversed with parenterally administered atropine.

Antihistamines often have anticholinergic activity, to which elderly patients are particularly sensitive. Therapy with antihistamines should be administered cautiously, if at all, in patients with preexisting conditions that are likely to be exacerbated by anticholinergic activity, such as urinary retention or obstruction; angle-closure glaucoma, untreated intraocular hypertension, or uncontrolled primary open-angle glaucoma; and gastrointestinal obstructive disorders. Conventional, first-generation antihistamines such as the ethanolamines (bromodiphenhydramine, carbinoxamine, clemastine, dimenhydrinate, diphenhydramine, doxylamine, phenyltoloxamine) tend to exhibit substantial anticholinergic effects. In contrast, the newer, relatively nonsedating antihistamines (e.g., cetirizine, fexofenadine, loratadine) reportedly have low to minimal anticholinergic activity at normally recommended dosages and may be appropriate alternatives.

Antihistamines often have anticholinergic activity, to which elderly patients are particularly sensitive. Therapy with antihistamines should be administered cautiously, if at all, in patients with preexisting conditions that are likely to be exacerbated by anticholinergic activity, such as urinary retention or obstruction; angle-closure glaucoma, untreated intraocular hypertension, or uncontrolled primary open-angle glaucoma; and gastrointestinal obstructive disorders. Conventional, first-generation antihistamines such as the ethanolamines (bromodiphenhydramine, carbinoxamine, clemastine, dimenhydrinate, diphenhydramine, doxylamine, phenyltoloxamine) tend to exhibit substantial anticholinergic effects. In contrast, the newer, relatively nonsedating antihistamines (e.g., cetirizine, fexofenadine, loratadine) reportedly have low to minimal anticholinergic activity at normally recommended dosages and may be appropriate alternatives.

Sympathomimetic agents can induce transient mydriasis via stimulation of alpha-1 adrenergic receptors. In patients with anatomically narrow angles or narrow-angle glaucoma, pupillary dilation can provoke an acute attack. In patients with other forms of glaucoma, mydriasis may occasionally increase intraocular pressure. Therapy with sympathomimetic agents should be administered cautiously in patients with or predisposed to glaucoma, particularly narrow-angle glaucoma.

Topically applied cholinergic agents are systemically absorbed, with the potential for producing rare but clinically significant systemic effects, including urinary incontinence, tightness of the bladder, increased gastric contractility and acid secretion, bradycardia, severe hypotension, bronchospasm, seizures, and coma. Increases in blood pressure may occur rarely due to a nicotinic effect on sympathetic ganglia. Therapy with ophthalmic cholinergic agents, particularly the long-acting cholinesterase inhibitors (e.g., demecarium and echothiophate), should be administered cautiously in patients with corneal abrasion (which may increase drug penetration), bronchospastic diseases, spastic gastrointestinal disturbances, urinary tract obstruction, peptic ulcer, pronounced bradycardia and hypotension, vascular hypertension, acute cardiac failure, recent myocardial infarction, epilepsy, parkinsonism, and other conditions that may respond adversely to vagotonic effects. The usual precautions should be followed to minimize the risk of systemic toxicity, including digital compression of the nasolacrimal ducts (1 to 2 minutes) following instillation to limit drainage into the nasal chamber, where extensive absorption may occur, and washing hands after use to prevent skin absorption. Excessive cholinergic effects may be reversed with parenterally administered atropine.

Antihistamines may infrequently cause cardiovascular adverse effects related to their anticholinergic and local anesthetic (quinidine-like) activities. Tachycardia, palpitation, ECG changes, arrhythmias, hypotension, and hypertension have been reported. Although these effects are uncommon and usually limited to overdosage situations, the manufacturers and some clinicians recommend that therapy with antihistamines be administered cautiously in patients with cardiovascular disease, hypertension, and/or hyperthyroidism.

Topically applied cholinergic agents are systemically absorbed, with the potential for producing rare but clinically significant systemic effects, including urinary incontinence, tightness of the bladder, increased gastric contractility and acid secretion, bradycardia, severe hypotension, bronchospasm, seizures, and coma. Increases in blood pressure may occur rarely due to a nicotinic effect on sympathetic ganglia. Therapy with ophthalmic cholinergic agents, particularly the long-acting cholinesterase inhibitors (e.g., demecarium and echothiophate), should be administered cautiously in patients with corneal abrasion (which may increase drug penetration), bronchospastic diseases, spastic gastrointestinal disturbances, urinary tract obstruction, peptic ulcer, pronounced bradycardia and hypotension, vascular hypertension, acute cardiac failure, recent myocardial infarction, epilepsy, parkinsonism, and other conditions that may respond adversely to vagotonic effects. The usual precautions should be followed to minimize the risk of systemic toxicity, including digital compression of the nasolacrimal ducts (1 to 2 minutes) following instillation to limit drainage into the nasal chamber, where extensive absorption may occur, and washing hands after use to prevent skin absorption. Excessive cholinergic effects may be reversed with parenterally administered atropine.

Antihistamines may infrequently cause cardiovascular adverse effects related to their anticholinergic and local anesthetic (quinidine-like) activities. Tachycardia, palpitation, ECG changes, arrhythmias, hypotension, and hypertension have been reported. Although these effects are uncommon and usually limited to overdosage situations, the manufacturers and some clinicians recommend that therapy with antihistamines be administered cautiously in patients with cardiovascular disease, hypertension, and/or hyperthyroidism.

Topically applied cholinergic agents are systemically absorbed, with the potential for producing rare but clinically significant systemic effects, including urinary incontinence, tightness of the bladder, increased gastric contractility and acid secretion, bradycardia, severe hypotension, bronchospasm, seizures, and coma. Increases in blood pressure may occur rarely due to a nicotinic effect on sympathetic ganglia. Therapy with ophthalmic cholinergic agents, particularly the long-acting cholinesterase inhibitors (e.g., demecarium and echothiophate), should be administered cautiously in patients with corneal abrasion (which may increase drug penetration), bronchospastic diseases, spastic gastrointestinal disturbances, urinary tract obstruction, peptic ulcer, pronounced bradycardia and hypotension, vascular hypertension, acute cardiac failure, recent myocardial infarction, epilepsy, parkinsonism, and other conditions that may respond adversely to vagotonic effects. The usual precautions should be followed to minimize the risk of systemic toxicity, including digital compression of the nasolacrimal ducts (1 to 2 minutes) following instillation to limit drainage into the nasal chamber, where extensive absorption may occur, and washing hands after use to prevent skin absorption. Excessive cholinergic effects may be reversed with parenterally administered atropine.

Limited pharmacokinetic data are available for the older, first-generation antihistamines. Many appear to be primarily metabolized by the liver, and both parent drugs and metabolites are excreted in the urine. Patients with renal and/or liver disease may be at greater risk for adverse effects from antihistamines due to drug and metabolite accumulation. Therapy with antihistamines should be administered cautiously in such patients. Lower initial dosages may be appropriate.

Topically applied cholinergic agents are systemically absorbed, with the potential for producing rare but clinically significant systemic effects, including urinary incontinence, tightness of the bladder, increased gastric contractility and acid secretion, bradycardia, severe hypotension, bronchospasm, seizures, and coma. Increases in blood pressure may occur rarely due to a nicotinic effect on sympathetic ganglia. Therapy with ophthalmic cholinergic agents, particularly the long-acting cholinesterase inhibitors (e.g., demecarium and echothiophate), should be administered cautiously in patients with corneal abrasion (which may increase drug penetration), bronchospastic diseases, spastic gastrointestinal disturbances, urinary tract obstruction, peptic ulcer, pronounced bradycardia and hypotension, vascular hypertension, acute cardiac failure, recent myocardial infarction, epilepsy, parkinsonism, and other conditions that may respond adversely to vagotonic effects. The usual precautions should be followed to minimize the risk of systemic toxicity, including digital compression of the nasolacrimal ducts (1 to 2 minutes) following instillation to limit drainage into the nasal chamber, where extensive absorption may occur, and washing hands after use to prevent skin absorption. Excessive cholinergic effects may be reversed with parenterally administered atropine.

Topically applied cholinergic agents are systemically absorbed, with the potential for producing rare but clinically significant systemic effects, including urinary incontinence, tightness of the bladder, increased gastric contractility and acid secretion, bradycardia, severe hypotension, bronchospasm, seizures, and coma. Increases in blood pressure may occur rarely due to a nicotinic effect on sympathetic ganglia. Therapy with ophthalmic cholinergic agents, particularly the long-acting cholinesterase inhibitors (e.g., demecarium and echothiophate), should be administered cautiously in patients with corneal abrasion (which may increase drug penetration), bronchospastic diseases, spastic gastrointestinal disturbances, urinary tract obstruction, peptic ulcer, pronounced bradycardia and hypotension, vascular hypertension, acute cardiac failure, recent myocardial infarction, epilepsy, parkinsonism, and other conditions that may respond adversely to vagotonic effects. The usual precautions should be followed to minimize the risk of systemic toxicity, including digital compression of the nasolacrimal ducts (1 to 2 minutes) following instillation to limit drainage into the nasal chamber, where extensive absorption may occur, and washing hands after use to prevent skin absorption. Excessive cholinergic effects may be reversed with parenterally administered atropine.

Topically applied cholinergic agents are systemically absorbed, with the potential for producing rare but clinically significant systemic effects, including urinary incontinence, tightness of the bladder, increased gastric contractility and acid secretion, bradycardia, severe hypotension, bronchospasm, seizures, and coma. Increases in blood pressure may occur rarely due to a nicotinic effect on sympathetic ganglia. Therapy with ophthalmic cholinergic agents, particularly the long-acting cholinesterase inhibitors (e.g., demecarium and echothiophate), should be administered cautiously in patients with corneal abrasion (which may increase drug penetration), bronchospastic diseases, spastic gastrointestinal disturbances, urinary tract obstruction, peptic ulcer, pronounced bradycardia and hypotension, vascular hypertension, acute cardiac failure, recent myocardial infarction, epilepsy, parkinsonism, and other conditions that may respond adversely to vagotonic effects. The usual precautions should be followed to minimize the risk of systemic toxicity, including digital compression of the nasolacrimal ducts (1 to 2 minutes) following instillation to limit drainage into the nasal chamber, where extensive absorption may occur, and washing hands after use to prevent skin absorption. Excessive cholinergic effects may be reversed with parenterally administered atropine.

Topically applied cholinergic agents are systemically absorbed, with the potential for producing rare but clinically significant systemic effects, including urinary incontinence, tightness of the bladder, increased gastric contractility and acid secretion, bradycardia, severe hypotension, bronchospasm, seizures, and coma. Increases in blood pressure may occur rarely due to a nicotinic effect on sympathetic ganglia. Therapy with ophthalmic cholinergic agents, particularly the long-acting cholinesterase inhibitors (e.g., demecarium and echothiophate), should be administered cautiously in patients with corneal abrasion (which may increase drug penetration), bronchospastic diseases, spastic gastrointestinal disturbances, urinary tract obstruction, peptic ulcer, pronounced bradycardia and hypotension, vascular hypertension, acute cardiac failure, recent myocardial infarction, epilepsy, parkinsonism, and other conditions that may respond adversely to vagotonic effects. The usual precautions should be followed to minimize the risk of systemic toxicity, including digital compression of the nasolacrimal ducts (1 to 2 minutes) following instillation to limit drainage into the nasal chamber, where extensive absorption may occur, and washing hands after use to prevent skin absorption. Excessive cholinergic effects may be reversed with parenterally administered atropine.

Sympathomimetic agents may cause or worsen urinary difficulty in patients with prostate enlargement due to smooth muscle contraction in the bladder neck via stimulation of alpha-1 adrenergic receptors. Therapy with sympathomimetic agents should be administered cautiously in patients with hypertrophy or neoplasm of the prostate.

Limited pharmacokinetic data are available for the older, first-generation antihistamines. Many appear to be primarily metabolized by the liver, and both parent drugs and metabolites are excreted in the urine. Patients with renal and/or liver disease may be at greater risk for adverse effects from antihistamines due to drug and metabolite accumulation. Therapy with antihistamines should be administered cautiously in such patients. Lower initial dosages may be appropriate.

Topically applied cholinergic agents are systemically absorbed, with the potential for producing rare but clinically significant systemic effects, including urinary incontinence, tightness of the bladder, increased gastric contractility and acid secretion, bradycardia, severe hypotension, bronchospasm, seizures, and coma. Increases in blood pressure may occur rarely due to a nicotinic effect on sympathetic ganglia. Therapy with ophthalmic cholinergic agents, particularly the long-acting cholinesterase inhibitors (e.g., demecarium and echothiophate), should be administered cautiously in patients with corneal abrasion (which may increase drug penetration), bronchospastic diseases, spastic gastrointestinal disturbances, urinary tract obstruction, peptic ulcer, pronounced bradycardia and hypotension, vascular hypertension, acute cardiac failure, recent myocardial infarction, epilepsy, parkinsonism, and other conditions that may respond adversely to vagotonic effects. The usual precautions should be followed to minimize the risk of systemic toxicity, including digital compression of the nasolacrimal ducts (1 to 2 minutes) following instillation to limit drainage into the nasal chamber, where extensive absorption may occur, and washing hands after use to prevent skin absorption. Excessive cholinergic effects may be reversed with parenterally administered atropine.

Topically applied cholinergic agents are systemically absorbed, with the potential for producing rare but clinically significant systemic effects, including urinary incontinence, tightness of the bladder, increased gastric contractility and acid secretion, bradycardia, severe hypotension, bronchospasm, seizures, and coma. Increases in blood pressure may occur rarely due to a nicotinic effect on sympathetic ganglia. Therapy with ophthalmic cholinergic agents, particularly the long-acting cholinesterase inhibitors (e.g., demecarium and echothiophate), should be administered cautiously in patients with corneal abrasion (which may increase drug penetration), bronchospastic diseases, spastic gastrointestinal disturbances, urinary tract obstruction, peptic ulcer, pronounced bradycardia and hypotension, vascular hypertension, acute cardiac failure, recent myocardial infarction, epilepsy, parkinsonism, and other conditions that may respond adversely to vagotonic effects. The usual precautions should be followed to minimize the risk of systemic toxicity, including digital compression of the nasolacrimal ducts (1 to 2 minutes) following instillation to limit drainage into the nasal chamber, where extensive absorption may occur, and washing hands after use to prevent skin absorption. Excessive cholinergic effects may be reversed with parenterally administered atropine.

Antihistamines often have anticholinergic activity, to which elderly patients are particularly sensitive. Therapy with antihistamines should be administered cautiously, if at all, in patients with preexisting conditions that are likely to be exacerbated by anticholinergic activity, such as urinary retention or obstruction; angle-closure glaucoma, untreated intraocular hypertension, or uncontrolled primary open-angle glaucoma; and gastrointestinal obstructive disorders. Conventional, first-generation antihistamines such as the ethanolamines (bromodiphenhydramine, carbinoxamine, clemastine, dimenhydrinate, diphenhydramine, doxylamine, phenyltoloxamine) tend to exhibit substantial anticholinergic effects. In contrast, the newer, relatively nonsedating antihistamines (e.g., cetirizine, fexofenadine, loratadine) reportedly have low to minimal anticholinergic activity at normally recommended dosages and may be appropriate alternatives.

Topically applied cholinergic agents are systemically absorbed, with the potential for producing rare but clinically significant systemic effects, including urinary incontinence, tightness of the bladder, increased gastric contractility and acid secretion, bradycardia, severe hypotension, bronchospasm, seizures, and coma. Increases in blood pressure may occur rarely due to a nicotinic effect on sympathetic ganglia. Therapy with ophthalmic cholinergic agents, particularly the long-acting cholinesterase inhibitors (e.g., demecarium and echothiophate), should be administered cautiously in patients with corneal abrasion (which may increase drug penetration), bronchospastic diseases, spastic gastrointestinal disturbances, urinary tract obstruction, peptic ulcer, pronounced bradycardia and hypotension, vascular hypertension, acute cardiac failure, recent myocardial infarction, epilepsy, parkinsonism, and other conditions that may respond adversely to vagotonic effects. The usual precautions should be followed to minimize the risk of systemic toxicity, including digital compression of the nasolacrimal ducts (1 to 2 minutes) following instillation to limit drainage into the nasal chamber, where extensive absorption may occur, and washing hands after use to prevent skin absorption. Excessive cholinergic effects may be reversed with parenterally administered atropine.