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Atropine (Systemic)

Medically reviewed by Drugs.com. Last updated on Jun 9, 2020.

Pronunciation

(A troe peen)

Index Terms

  • Atropine Sulfate

Dosage Forms

Excipient information presented when available (limited, particularly for generics); consult specific product labeling. [DSC] = Discontinued product

Solution, Injection, as sulfate:

Generic: 8 mg/20 mL (20 mL)

Solution, Injection, as sulfate [preservative free]:

Generic: 0.4 mg/0.5 mL (0.5 mL [DSC]); 0.4 mg/mL (1 mL); 1 mg/mL (1 mL)

Solution Auto-injector, Intramuscular, as sulfate:

AtroPen: 0.5 mg/0.7 mL (0.7 mL); 1 mg/0.7 mL (0.7 mL); 2 mg/0.7 mL (0.7 mL) [pyrogen free; contains phenol]

Solution Auto-injector, Intramuscular, as sulfate [preservative free]:

AtroPen: 0.25 mg/0.3 mL (0.3 mL) [pyrogen free]

Solution Prefilled Syringe, Injection, as sulfate:

Generic: 1 mg/10 mL (10 mL)

Solution Prefilled Syringe, Injection, as sulfate [preservative free]:

Generic: 0.25 mg/5 mL (5 mL); 0.5 mg/5 mL (5 mL); 1 mg/10 mL (10 mL)

Brand Names: U.S.

  • AtroPen

Pharmacologic Category

  • Anticholinergic Agent
  • Antidote
  • Antispasmodic Agent, Gastrointestinal

Pharmacology

Blocks the action of acetylcholine at parasympathetic sites in smooth muscle, secretory glands, and the CNS; increases cardiac output, dries secretions. Atropine reverses the muscarinic effects of cholinergic poisoning due to agents with acetylcholinesterase inhibitor activity by acting as a competitive antagonist of acetylcholine at muscarinic receptors. The primary goal in cholinergic poisonings is reversal of bronchorrhea and bronchoconstriction. Atropine has no effect on the nicotinic receptors responsible for muscle weakness, fasciculations, and paralysis.

Absorption

Rapid and well absorbed from all dosage forms

Distribution

Widely distributes throughout the body; crosses the blood-brain barrier

Metabolism

Hepatic via enzymatic hydrolysis

Excretion

Urine (13% to 50% as unchanged drug and metabolites)

Onset of Action

Inhibition of salivation: IM: Within 30 minutes; maximum effect: 30 to 60 minutes (Mirakhur 1980; Volz-Zang 1995)

Increased heart rate:

IM: Within 15 to 30 minutes (Kentala 1990; Volz-Zang 1995); maximum effect: 45 to 60 minutes (Mirakhur 1980; Volz-Zang 1995)

IV: Immediate; maximum effect: 0.7 to 4 minutes (Lonnerholm 1975; Santini 1999)

Time to Peak

IM: 30 minutes; IM autoinjector: 3 minutes

Duration of Action

Inhibition of salivation: IM: ≤4 hours

Half-Life Elimination

Children <2 years: 6.9 ± 3 hours; Children >2 years: 2.5 ± 1.2 hours; Adults: 3 ± 0.9 hours; Elderly 65 to 75 years of age: 10 ± 7.3 hours

Protein Binding

14% to 44%

Special Populations: Elderly

Elimination half-life is more than doubled.

Use: Labeled Indications

Bradycardia during neuromuscular blockade reversal: Adjuvant use during neuromuscular blockade reversal with anticholinesterases (eg, edrophonium, neostigmine) to manage bradycardia.

Bradycardia, symptomatic: Treatment of symptomatic sinus bradycardia.

Inhibition of salivation and secretions (preanesthesia): Preoperative/preanesthetic medication to inhibit salivation and secretions.

Muscarine-containing mushroom poisoning: Treatment of symptoms from muscarine-containing mushroom poisoning.

Organophosphate or carbamate insecticide or nerve agent poisoning: Antidote for anticholinesterase poisoning (carbamate insecticides, nerve agents, organophosphate insecticides).

Off Label Uses

Stress echocardiography (adjunct chronotropic agent)

Data from a number of clinical studies evaluating the use of atropine to increase heart rate as an adjunctive agent during dobutamine stress echocardiography support the use of atropine when at least 85% of the age-predicted maximal target heart rate is not achieved with dobutamine alone [Bholasingh 2003], [Fioretti 1994], [McNeill 1992], [Picano 1994].

Based on the American Society of Nuclear Cardiology imaging guidelines for single-photon emission CT nuclear cardiology procedures, atropine may be administered as an adjunctive agent to increase heart rate in patients who do not achieve target heart rate with dobutamine alone [ASNC [Henzlova 2016]].

Contraindications

There are no contraindications listed in the manufacturer’s labeling.

Dosing: Adult

Note: IV doses <0.5 mg have been associated with paradoxical bradycardia (Boudet 1991; Lonnerholm 1975). Restrict total dose to 0.03 to 0.04 mg/kg in patients with ischemic heart disease.

Bradycardia during neuromuscular blockade reversal: IV: 5 to 7 mcg/kg when administered with edrophonium or 15 to 20 mcg/kg when administered with neostigmine (Cronnelly 1982; Miller 2015; Mirakhur 1981; Naguib 1989).

Bradycardia, symptomatic:

Note: Atropine is ineffective in heart transplant patients due to lack of vagal innervation and likely not effective for type II second-degree or third-degree atrioventricular node block (AHA [Hazinski 2015]).

IV, IM: 0.5 to 1 mg every 3 to 5 minutes; maximum total dose: 3 mg.

Endotracheal: 1 to 2 mg every 3 to 5 minutes.

Inhibition of salivation and secretions (preanesthesia): IM, IV, SubQ: 0.5 to 1 mg 30 to 60 minutes preoperatively; repeat every 4 to 6 hours as needed; maximum total dose: 3 mg.

Muscarine-containing mushroom poisoning (off-label dose): IV: 1 to 2 mg; titrate and repeat as needed to reverse symptoms (ie, titrate to achieve decreased bronchial secretions) (Goldfrank 2018).

Organophosphate or carbamate insecticide or nerve agent poisoning:

Note: The dose of atropine required varies considerably with the severity of poisoning. The total amount of atropine used for carbamate poisoning is usually less than with organophosphate insecticide or nerve agent poisoning. Severely poisoned patients may exhibit significant tolerance to atropine; ≥2 times the suggested doses may be needed. Titrate to pulmonary status (decreased bronchial secretions); consider administration of atropine via continuous IV infusion in patients requiring large doses of atropine (King 2015). Once patient is stable for a period of time, the dose/dosing frequency may be decreased. Pralidoxime is a component of the management of organophosphate insecticide and nerve agent toxicity; refer to Pralidoxime monograph for the specific route and dose.

IV:

Mild to moderate symptoms: Initial: 1 to 2 mg bolus (Howland 2018); repeat by doubling the dose every 3 to 5 minutes if previous dose did not induce a response (Eddleston 2004b; Roberts 2007; Thiermann 2013). Maintain atropinization by administering repeat doses as needed for ≥2 to 12 hours based on recurrence of symptoms (Reigart 1999). After the desired response is achieved with bolus dosing, consider starting an IV continuous infusion for improved clinical outcomes (Abedin 2012; Eddleston 2004b; Roberts 2007).

Severe symptoms: Initial: 3 to 5 mg bolus (Howland 2018); repeat by doubling the dose every 3 to 5 minutes if previous dose did not induce a response (Eddleston 2004b; Roberts 2007; Thiermann 2013). Maintain atropinization by administering repeat doses as needed for ≥2 to 12 hours based on recurrence of symptoms (Reigart 1999). After the desired response is achieved with bolus dosing, consider starting an IV continuous infusion for improved clinical outcomes (Abedin 2012; Eddleston 2004b; Roberts 2007).

IV continuous infusion: After desired response is achieved with IV boluses, administer 10% to 20% of the total cumulative IV bolus dose as an IV continuous infusion per hour (eg, if 18 mg given by IV bolus is required to achieve the desired response, start an IV continuous infusion of 1.8 mg per hour); adjust infusion rate as needed to maintain adequate response without causing atropine toxicity (Abedin 2012; Eddleston 2004b; Roberts 2007).

IM (AtroPen):

Mild symptoms (≥2 mild symptoms): Administer 2 mg as soon as an exposure is known or strongly suspected. If severe symptoms develop after the first dose, 2 additional doses should be repeated in rapid succession 10 minutes after the first dose; do not administer more than 3 doses. If profound anticholinergic effects occur in the absence of excessive bronchial secretions, further doses of atropine should be withheld.

Severe symptoms (≥1 severe symptoms): Immediately administer three 2 mg doses in rapid succession.

Symptoms of insecticide or nerve agent poisoning, as provided by manufacturer in the AtroPen product labeling, to guide therapy:

Mild symptoms: Blurred vision, bradycardia, breathing difficulties, chest tightness, coughing, drooling, miosis, muscular twitching, nausea, runny nose, salivation increased, stomach cramps, tachycardia, teary eyes, tremor, vomiting, or wheezing.

Severe symptoms: Breathing difficulties (severe), confused/strange behavior, defecation (involuntary), muscular twitching/generalized weakness (severe), respiratory secretions (severe), seizure, unconsciousness, urination (involuntary).

Endotracheal: Usual dose: 2 to 2.5 times IV dose diluted in 5 to 10 mL of 0.9% sodium chloride or sterile water (Howland 2018).

Stress echocardiography (adjunct chronotropic agent) (off-label use): IV: 0.25 to 0.5 mg up to a total dose of 1 to 2 mg until 85% of target heart rate is achieved (ASNC [Henzlova 2016]).

Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.

Dosing: Geriatric

Refer to adult dosing.

Dosing: Pediatric

Bradycardia: Infants, Children, and Adolescents:

IV, Intraosseous: 0.02 mg/kg/dose; minimum dose: 0.1 mg/dose, maximum dose: 0.5 mg/dose; may repeat once in 5 minutes; reserve use for those patients unresponsive to improved oxygenation and epinephrine (PALS [de Caen 2015]; PALS [Kleinman 2010]); some have suggested the minimum dose should not be used in patients <5 kg (Barrington 2011; Prakash 2017).

Endotracheal: 0.04 to 0.06 mg/kg/dose; may repeat once if needed (PALS [de Caen 2015]; PALS [Kleinman 2010])

Inhibit salivation and secretions (preoperative/intraoperative):

Infants and Children <12 years: IM, IV, SubQ: 0.02 mg/kg/dose; maximum dose: 0.5 mg/dose; administer first dose 30 to 60 minutes preoperatively and then repeat every 4 to 6 hours as needed; maximum total dose: 1 mg/procedure.

Children ≥12 years and Adolescents: IM, IV, SubQ: 0.02 mg/kg/dose; maximum dose: 1 mg/dose; administer first dose 30 to 60 minutes preoperatively and then repeat every 4 to 6 hours as needed; maximum total dose: 2 mg/procedure.

Intubation; emergent (premedication): Note: Routine use not recommended for preintubation in infants and children; atropine may be considered in situations with a high-risk of bradycardia (eg, succinylcholine use) (PALS [de Caen 2015]) or septic shock (Brierley 2009).

Infants and Children: IV: 0.02 mg/kg/dose with no minimum dose; maximum dose: 0.5 mg/dose (PALS [de Caen 2015]).

Muscarine-containing mushroom poisoning: Limited data available: Infants, Children, and Adolescents: IV: 0.02 mg/kg/dose; minimum dose: 0.1 mg. Titrate and repeat as needed (Goldfrank 2015)

Organophosphate or carbamate insecticide or nerve agent poisoning: Note: If exposure is known or suspected, antidotal therapy should be given as soon as symptoms appear; do not wait for confirmation. The dose of atropine required varies considerably with the severity of poisoning. The total amount of atropine used for carbamate poisoning is usually less than with organophosphate insecticide or nerve agent poisoning. Severely poisoned patients may exhibit significant tolerance to atropine; ≥2 times the suggested doses may be needed. Titrate to pulmonary status (decreased bronchial secretions); consider administration of atropine via continuous IV infusion in patients requiring large doses of atropine. Once patient is stable for a period of time, the dose/dosing frequency may be decreased. Pralidoxime is a component of the management of organophosphate insecticide and nerve agent toxicity; refer to pralidoxime for the specific route and dose.

IV, IM, Intraosseous:

Infants and Children: Initial: 0.05 to 0.1 mg/kg; repeat every 5 to 10 minutes as needed, doubling the dose if previous dose does not induce atropinization (AAP [Roberts 2012]; Hegenbarth 2008; Roberts 2013; Rotenberg 2003). Maintain atropinization by administering repeat doses as needed for ≥2 to 12 hours based on recurrence of symptoms (Roberts 2013).

Adolescents: Initial: 1 to 3 mg/dose; repeat every 3 to 5 minutes as needed, doubling the dose if previous dose does not induce atropinization. Maintain atropinization by administering repeat doses as needed for ≥2 to 12 hours based on recurrence of symptoms (Roberts 2013).

Continuous IV infusion: Infants, Children, and Adolescents: Following atropinization, administer 10% to 20% of the total loading dose required to induce atropinization as a continuous IV infusion per hour; adjust as needed to maintain adequate atropinization without atropine toxicity (Eddleston 2004; Roberts 2007; Roberts 2013).

IM (AtroPen): Infants, Children, and Adolescents: Number of doses dependent upon symptom severity:

Weight-directed dosing:

<7 kg (<15 lb): 0.25 mg/dose (yellow pen)

7 to 18 kg (15 to 40 lb): 0.5 mg/dose (blue pen)

>18 to 41 kg (>40 to 90 lb): 1 mg/dose (dark red pen)

>41 kg (>90 lb): 2 mg/dose (green pen)

Mild symptoms (≥2 mild symptoms): Administer the weight-directed dose listed above as soon as an exposure is known or strongly suspected. If severe symptoms develop after the first dose, 2 additional doses should be repeated in rapid succession 10 minutes after the first dose; do not administer more than 3 doses. If profound anticholinergic effects occur in the absence of excessive bronchial secretions, further doses of atropine should be withheld. Mild symptoms of insecticide or nerve agent poisoning, as provided by manufacturer in the AtroPen product labeling to guide therapy, include: Blurred vision, bradycardia, breathing difficulties, chest tightness, coughing, drooling, miosis, muscular twitching, nausea, runny nose, salivation increased, stomach cramps, tachycardia, teary eyes, tremor, vomiting, or wheezing.

Severe symptoms (≥1 severe symptom): Immediately administer three weight-directed doses in rapid succession. Severe symptoms of insecticide or nerve agent poisoning, as provided by manufacturer in the AtroPen product labeling to guide therapy, include: Breathing difficulties (severe), confused/strange behavior, defecation (involuntary), muscular twitching/generalized weakness (severe), respiratory secretions (severe), seizure, unconsciousness, urination (involuntary); Note: Infants may become drowsy or unconscious with muscle floppiness as opposed to muscle twitching.

Endotracheal: Infants, Children, and Adolescents: Increase the dose by 2 to 3 times the usual IV dose. Mix with 3 to 5 mL of normal saline and administer. Flush with 3 to 5 mL of NS and follow with 5 assisted manual ventilations (Rotenberg 2003).

Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.

Reconstitution

Parenteral: Mass chemical terrorism: Preparation of bulk atropine solution: Add atropine sulfate powder to 100 mL of NS in polyvinyl chloride bags to yield a final concentration of 1 mg/mL (Dix 2003).

Administration

IM: AtroPen: Administer to the outer thigh. Firmly grasp the autoinjector with the green tip (0.5 mg, 1 mg, and 2 mg autoinjector) or black tip (0.25 mg autoinjector) pointed down; remove the yellow safety release (0.5 mg, 1 mg, and 2 mg autoinjector) or gray safety release (0.25 autoinjector). Jab the green tip at a 90° angle against the outer thigh; may be administered through clothing as long as pockets at the injection site are empty. In thin patients, bunch up the thigh prior to injection. Hold the autoinjector in place for 10 seconds following the injection; remove the autoinjector and massage the injection site. After administration, the needle will be visible; if the needle is not visible, repeat the above steps. After use, bend the needle against a hard surface (needle does not retract) to avoid accidental injury.

IV: Administer undiluted by rapid IV injection; slow injection may result in paradoxical bradycardia. In bradycardia, atropine administration should not delay treatment with external pacing.

Intraosseous (IO): May administer intraosseous if needed.

Endotracheal: Dilute in ≤10 mL NS or sterile water. Absorption may be greater with sterile water. Stop compressions (if using for cardiac arrest), spray the drug quickly down the tube. Follow immediately with several quick insufflations and continue chest compressions.

SubQ: May administer subcutaneous if needed.

Storage

Store injection at room temperature; avoid freezing. After initial use of multiple-dose vial, discard within 24 hours. In addition, AtroPen should be protected from light. Preparation of bulk atropine solution for mass chemical terrorism at a concentration of 1 mg/mL is stable for 72 hours at 4°C to 8°C (39°F to 46°F); 20°C to 25°C (68°F to 77°F); 32°C to 36°C (90°F to 97°F) (Dix 2003).

Drug Interactions

Acetylcholinesterase Inhibitors: Anticholinergic Agents may diminish the therapeutic effect of Acetylcholinesterase Inhibitors. Acetylcholinesterase Inhibitors may diminish the therapeutic effect of Anticholinergic Agents. Monitor therapy

Aclidinium: May enhance the anticholinergic effect of Anticholinergic Agents. Avoid combination

Amantadine: May enhance the anticholinergic effect of Anticholinergic Agents. Monitor therapy

Amezinium: Atropine (Systemic) may enhance the stimulatory effect of Amezinium. Monitor therapy

Anticholinergic Agents: May enhance the adverse/toxic effect of other Anticholinergic Agents. Monitor therapy

Botulinum Toxin-Containing Products: May enhance the anticholinergic effect of Anticholinergic Agents. Monitor therapy

Cannabinoid-Containing Products: Anticholinergic Agents may enhance the tachycardic effect of Cannabinoid-Containing Products. Exceptions: Cannabidiol. Monitor therapy

Chloral Betaine: May enhance the adverse/toxic effect of Anticholinergic Agents. Monitor therapy

Cimetropium: Anticholinergic Agents may enhance the anticholinergic effect of Cimetropium. Avoid combination

CloZAPine: Anticholinergic Agents may enhance the constipating effect of CloZAPine. Management: Consider alternatives to this combination whenever possible. If combined, monitor closely for signs and symptoms of gastrointestinal hypomotility and consider prophylactic laxative treatment. Consider therapy modification

Eluxadoline: Anticholinergic Agents may enhance the constipating effect of Eluxadoline. Avoid combination

EPHEDrine (Systemic): Atropine (Systemic) may enhance the therapeutic effect of EPHEDrine (Systemic). Monitor therapy

Gastrointestinal Agents (Prokinetic): Anticholinergic Agents may diminish the therapeutic effect of Gastrointestinal Agents (Prokinetic). Monitor therapy

Glucagon: Anticholinergic Agents may enhance the adverse/toxic effect of Glucagon. Specifically, the risk of gastrointestinal adverse effects may be increased. Monitor therapy

Glycopyrrolate (Oral Inhalation): Anticholinergic Agents may enhance the anticholinergic effect of Glycopyrrolate (Oral Inhalation). Avoid combination

Glycopyrronium (Topical): May enhance the anticholinergic effect of Anticholinergic Agents. Avoid combination

Ipratropium (Oral Inhalation): May enhance the anticholinergic effect of Anticholinergic Agents. Avoid combination

Itopride: Anticholinergic Agents may diminish the therapeutic effect of Itopride. Monitor therapy

Levosulpiride: Anticholinergic Agents may diminish the therapeutic effect of Levosulpiride. Avoid combination

Macimorelin: Atropine (Systemic) may diminish the diagnostic effect of Macimorelin. Avoid combination

Mianserin: May enhance the anticholinergic effect of Anticholinergic Agents. Monitor therapy

Mirabegron: Anticholinergic Agents may enhance the adverse/toxic effect of Mirabegron. Monitor therapy

Nitroglycerin: Anticholinergic Agents may decrease the absorption of Nitroglycerin. Specifically, anticholinergic agents may decrease the dissolution of sublingual nitroglycerin tablets, possibly impairing or slowing nitroglycerin absorption. Monitor therapy

Opioid Agonists: Anticholinergic Agents may enhance the adverse/toxic effect of Opioid Agonists. Specifically, the risk for constipation and urinary retention may be increased with this combination. Monitor therapy

Oxatomide: May enhance the anticholinergic effect of Anticholinergic Agents. Avoid combination

Potassium Chloride: Anticholinergic Agents may enhance the ulcerogenic effect of Potassium Chloride. Management: Patients on drugs with substantial anticholinergic effects should avoid using any solid oral dosage form of potassium chloride. Avoid combination

Potassium Citrate: Anticholinergic Agents may enhance the ulcerogenic effect of Potassium Citrate. Avoid combination

Pramlintide: May enhance the anticholinergic effect of Anticholinergic Agents. These effects are specific to the GI tract. Avoid combination

Ramosetron: Anticholinergic Agents may enhance the constipating effect of Ramosetron. Monitor therapy

Revefenacin: Anticholinergic Agents may enhance the anticholinergic effect of Revefenacin. Avoid combination

Ritodrine: Atropine (Systemic) may enhance the adverse/toxic effect of Ritodrine. Monitor therapy

Secretin: Anticholinergic Agents may diminish the therapeutic effect of Secretin. Management: Avoid concomitant use of anticholinergic agents and secretin. Discontinue anticholinergic agents at least 5 half-lives prior to administration of secretin. Consider therapy modification

Sincalide: Drugs that Affect Gallbladder Function may diminish the therapeutic effect of Sincalide. Management: Consider discontinuing drugs that may affect gallbladder motility prior to the use of sincalide to stimulate gallbladder contraction. Consider therapy modification

Thiazide and Thiazide-Like Diuretics: Anticholinergic Agents may increase the serum concentration of Thiazide and Thiazide-Like Diuretics. Monitor therapy

Tiotropium: Anticholinergic Agents may enhance the anticholinergic effect of Tiotropium. Avoid combination

Topiramate: Anticholinergic Agents may enhance the adverse/toxic effect of Topiramate. Monitor therapy

Umeclidinium: May enhance the anticholinergic effect of Anticholinergic Agents. Avoid combination

Adverse Reactions

Frequency not always defined. Severity and frequency of adverse reactions are dose related.

Cardiovascular: Asystole, atrial arrhythmia, atrial fibrillation, atrioventricular dissociation (transient), bigeminy, bradycardia, chest pain, decreased blood pressure, ECG changes (prolonged P wave, shortened PR segment, R on T phenomenon, shortened RT duration, prolonged QT interval, widening of QRS Complex, flattened T wave, repolarization abnormalities, ST segment elevation, retrograde conduction), ectopic beats (atrial), extrasystoles (nodal, ventricular, supraventricular), flushing, increased blood pressure, left heart failure, myocardial infarction, nodal arrhythmia (no P wave on ECG), palpitations, sinus tachycardia, supraventricular tachycardia (including junctional tachycardia), tachycardia, trigeminy, ventricular arrhythmia (including flutter), ventricular fibrillation, ventricular flutter, ventricular premature contractions, ventricular tachycardia, weak pulse (or impalpable peripheral pulses)

Central nervous system: Abnormal electroencephalogram (runs of alpha waves, increase in photic stimulation, and signs of drowsiness), agitation (children), amnesia, anxiety, ataxia, behavioral changes, coma, confusion, decreased deep tendon reflex, delirium, dizziness, drowsiness, dysarthria, dysmetria, emotional disturbance, excitement, feeling hot, hallucination (visual or aural), headache, hyperpyrexia, hyperreflexia, hypertonia, insomnia, intoxicated feeling, irritability (children), lack of concentration, lethargy (children), mania, myoclonus, neurologic abnormality, nocturnal enuresis, opisthotonus, paranoia, positive Babinski sign, restlessness, seizure (generally tonic-clonic), stupor, vertigo

Dermatologic: Anhidrosis, cold skin, dermatitis, dry and hot skin, erythematous rash, hyperhidrosis, macular eruption, maculopapular rash, papular rash, scarlatiniform rash, skin rash

Endocrine & metabolic: Dehydration, hyperglycemia, hypoglycemia, hypokalemia, hyponatremia, increased thirst, loss of libido

Gastrointestinal: Abdominal and bladder distension, abdominal pain, constipation, delayed gastric emptying, diminished bowel sounds, dry mucous membranes, dysphagia, malabsorption, nausea, oral lesion, paralytic ileus, salivation, vomiting, xerostomia

Genitourinary: Difficulty in micturition, impotence, urinary hesitancy, urinary retention, urinary urgency

Hematologic & oncologic: Abnormal erythrocytes (increased), decreased hemoglobin, increased hemoglobin, leukocytosis, petechiae

Hypersensitivity: Hypersensitivity reaction

Local: Injection site reaction

Neuromuscular & skeletal: Laryngospasm, muscle twitching, weakness

Ophthalmic: Abnormal eye movements (cyclophoria and heterophoria), angle-closure glaucoma (acute), blepharitis, blindness, blurred vision, conjunctivitis, crusted of eyelid, cycloplegia, decreased accommodation, decreased visual acuity, dry eye syndrome, eye irritation, keratoconjunctivitis sicca, lacrimation, mydriasis, photophobia, strabismus

Renal: Increased blood urea nitrogen

Respiratory: Bradypnea, changes in respiration (labored respiration), cyanosis, dyspnea, laryngitis, pulmonary edema, respiratory failure, stridor (inspiratory), tachypnea

Miscellaneous: Failure to thrive, fever (secondary to decreased sweat gland activity), swelling (children)

Warnings/Precautions

Concerns related to adverse effects:

• Anaphylaxis: May occur.

• Hyperthermia: In the presence of a high environmental temperature, heat prostration can occur.

• Psychosis: Can occur in sensitive individuals or following use of excessive doses.

Disease-related concerns:

• Arrhythmias: Avoid relying on atropine for effective treatment of type II second-degree or third-degree AV block (with or without a new wide QRS complex). Asystole or bradycardic PEA: Although no evidence exists for significant detrimental effects, routine use is unlikely to have a therapeutic benefit and is no longer recommended (ACLS 2010).

• Autonomic neuropathy: Use with caution in patients with autonomic neuropathy.

• Cardiovascular disease: Use with caution in patients with myocardial ischemia, heart failure, tachyarrhythmias (including sinus tachycardia), and/or hypertension; treatment-related blood pressure increases and tachycardia may lead to ischemia, precipitate an MI, or increase arrhythmogenic potential.

• Gastrointestinal disease: Use may convert partial organic pyloric stenosis into complete obstruction. Avoid use in patients with paralytic ileus, intestinal atony of the elderly or debilitated patient, severe ulcerative colitis, and toxic megacolon complicating ulcerative colitis.

• Glaucoma: Use may precipitate acute glaucoma.

• Hepatic impairment: Use with caution in patients with hepatic impairment; effects of atropine may be prolonged in severe hepatic impairment.

• Hiatal hernia: Use with caution in patients with hiatal hernia associated with reflux esophagitis.

• Hyperthyroidism: Use with caution in patients with hyperthyroidism.

• Myasthenia gravis: Use with extreme caution when used to treat side effects of acetylcholinesterase inhibition or avoid; may precipitate a myasthenic crisis.

• Renal impairment: Use with caution in patients with renal impairment; effects of atropine may be prolonged in severe renal impairment.

• Respiratory impairment: Use may cause thickening of bronchial secretions and formation of viscid plugs in patients with chronic lung disease.

• Urinary retention: Use may lead to complete urinary retention in patients with prostatic hypertrophy. Avoid use if possible in patients with obstructive uropathy or in other conditions resulting in urinary retention

Special populations:

• Heart transplant recipients: Atropine will likely be ineffective in treatment of bradycardia due to lack of vagal innervation of the transplanted heart. Cholinergic reinnervation may occur over time (years), so atropine may be used cautiously; however, some may experience paradoxical slowing of the heart rate and high-degree AV block upon administration (ACLS 2010; Bernheim 2004).

• Pediatric: Children may be more sensitive to the anticholinergic effects of atropine. Use with caution in children with spastic paralysis.

Dosage form specific issues:

• Benzyl alcohol and derivatives: Some dosage forms may contain benzyl alcohol and/or sodium benzoate/benzoic acid; benzoic acid (benzoate) is a metabolite of benzyl alcohol; large amounts of benzyl alcohol (≥99 mg/kg/day) have been associated with a potentially fatal toxicity (“gasping syndrome”) in neonates; the “gasping syndrome” consists of metabolic acidosis, respiratory distress, gasping respirations, CNS dysfunction (including convulsions, intracranial hemorrhage), hypotension, and cardiovascular collapse (AAP ["Inactive" 1997]; CDC 1982); some data suggest that benzoate displaces bilirubin from protein binding sites (Ahlfors 2001); avoid or use dosage forms containing benzyl alcohol and/or benzyl alcohol derivative with caution in neonates. See manufacturer's labeling.

Other warnings/precautions:

• Appropriate use: Anticholinesterase poisoning: Atropine reverses the muscarinic but not the nicotinic effects associated with anticholinesterase toxicity. Clinical symptoms consistent with highly-suspected organophosphate or carbamate insecticides or nerve agent poisoning should be treated with antidote immediately; administration should not be delayed for confirmatory laboratory tests. Signs of atropinization include flushing, mydriasis, tachycardia, and dryness of the mouth or nose. Monitor effects closely when administering subsequent injections as necessary. The presence of these effects is not indicative of the success of therapy; inappropriate use of mydriasis as an indicator of successful treatment has resulted in atropine toxicity. Reversal of bronchial secretions is the preferred indicator of success. Adjunct treatment with a cholinesterase reactivator (eg, pralidoxime) may be required in patients with toxicity secondary to organophosphorus insecticides or nerve agents. Treatment should always include proper evacuation and decontamination procedures; medical personnel should protect themselves from inadvertent contamination. Antidotal administration is intended only for initial management; definitive and more extensive medical care is required following administration. Individuals should not rely solely on antidote for treatment, as other supportive measures (eg, artificial respiration) may still be required.

Monitoring Parameters

Heart rate, blood pressure, pulse, mental status; intravenous administration requires a cardiac monitor

Organophosphate or carbamate insecticide or nerve agent poisoning: Heart rate, blood pressure, respiratory status, oxygenation secretions. Maintain atropinization with repeated dosing as indicated by clinical status. Crackles in lung bases, or continuation of cholinergic signs, may be signs of inadequate dosing. Pulmonary improvement may not parallel other signs of atropinization. Monitor for signs and symptoms of atropine toxicity (eg, fever, muscle fasciculations, delirium); if toxicity occurs, discontinue atropine and monitor closely.

Consult individual institutional policies and procedures.

Pregnancy Considerations

Atropine has been found to cross the human placenta (Kanto 1981). In general, medications used as antidotes should take into consideration the health and prognosis of the mother; antidotes should be administered to pregnant women if there is a clear indication for use and should not be withheld because of fears of teratogenicity (Bailey 2003). Medications used for the treatment of cardiac arrest in pregnancy are the same as in the non-pregnant woman. Doses and indications should follow current Advanced Cardiovascular Life Support guidelines. Appropriate medications should not be withheld due to concerns of fetal teratogenicity (Jeejeebhoy [AHA] 2015).

Patient Education

What is this drug used for?

• It is used to treat some poisonings.

• In surgery, it is used to lower secretions such as saliva.

• It is used to treat muscle spasms of the GI (gastrointestinal) tract, gallbladder system, or urinary system.

• It is used when the heart is not beating.

All drugs may cause side effects. However, many people have no side effects or only have minor side effects. Call your doctor or get medical help if any of these side effects or any other side effects bother you or do not go away:

• Blurred vision

• Sensitivity to light

• Constipation

• Dry mouth

• Nasal dryness

• Flushing

• Headache

• Enlarged pupils

• Injection site pain

• Nausea

• Vomiting

WARNING/CAUTION: Even though it may be rare, some people may have very bad and sometimes deadly side effects when taking a drug. Tell your doctor or get medical help right away if you have any of the following signs or symptoms that may be related to a very bad side effect:

• Unable to pass urine

• Change in amount of urine passed

• Fast heartbeat

• Abnormal heartbeat

• Severe dizziness

• Passing out

• Trouble breathing

• Slow breathing

• Shallow breathing

• Confusion

• Change in balance

• Sensing things that seem real but are not

• Severe loss of strength and energy

• Agitation

• Tremors

• Abdominal swelling

• Sexual dysfunction

• Decreased sex drive

• Vision changes

• Eye pain

• Severe eye irritation

• Lack of sweating

• Depression

• Signs of an allergic reaction, like rash; hives; itching; red, swollen, blistered, or peeling skin with or without fever; wheezing; tightness in the chest or throat; trouble breathing, swallowing, or talking; unusual hoarseness; or swelling of the mouth, face, lips, tongue, or throat.

Note: This is not a comprehensive list of all side effects. Talk to your doctor if you have questions.

Consumer Information Use and Disclaimer: This information should not be used to decide whether or not to take this medicine or any other medicine. Only the healthcare provider has the knowledge and training to decide which medicines are right for a specific patient. This information does not endorse any medicine as safe, effective, or approved for treating any patient or health condition. This is only a limited summary of general information about the medicine's uses from the patient education leaflet and is not intended to be comprehensive. This limited summary does NOT include all information available about the possible uses, directions, warnings, precautions, interactions, adverse effects, or risks that may apply to this medicine. This information is not intended to provide medical advice, diagnosis or treatment and does not replace information you receive from the healthcare provider. For a more detailed summary of information about the risks and benefits of using this medicine, please speak with your healthcare provider and review the entire patient education leaflet.

Further information

Always consult your healthcare provider to ensure the information displayed on this page applies to your personal circumstances.