Brand names: Isopto Carpine, Pilopine HS
Drug class: Miotics
VA class: OP102
CAS number: 92-13-7

Medically reviewed by Drugs.com on Jul 24, 2023. Written by ASHP.

Introduction

Miotic; direct-acting parasympathomimetic agent.

Uses for Pilocarpine, Pilocarpine Hydrochloride, Pilocarpine Nitrate

Open-angle Glaucoma

Reduction of elevated intraocular pressure (IOP) in patients with primary open-angle (chronic simple, noncongestive) glaucoma.

May use concomitantly with other miotics, sympathomimetic agents, β-adrenergic blocking agents, carbonic anhydrase inhibitors, or hyperosmotic agents.

Angle-closure Glaucoma

Reduction of IOP in the emergency treatment of acute (congestive) angle-closure glaucoma prior to surgery. Because it may preclude successful surgery, do not use for long periods prior to surgical treatment.

Lack of response may be caused by paralysis of the iris sphincter by the extremely high IOP; systemic administration of acetazolamide or hyperosmotic solutions (e.g., glycerin or mannitol) may be required.

Ocular Surgery

Reduction of IOP and protection of the lens by causing miosis prior to goniotomy or iridectomy, including laser iridectomy.

May use to control glaucoma which persists after surgery.

Ophthalmologic Examinations

Production of miosis to counteract mydriatic effects of sympathomimetic agents (e.g., phenylephrine) after ophthalmoscopic examinations in glaucoma patients.

Related/similar drugs

epinephrine ophthalmic, latanoprost ophthalmic, acetazolamide, timolol ophthalmic, pilocarpine ophthalmic, brimonidine ophthalmic, Diamox

Pilocarpine, Pilocarpine Hydrochloride, Pilocarpine Nitrate Dosage and Administration

Administration

Ophthalmic Administration

Avoid contamination of the solution or gel container.

Ophthalmic solutions are preferred when an acute reduction in IOP and/or an intense miotic effect are necessary (e.g., prior to surgery, following ophthalmologic examinations).

Tonometric measurements recommended before and during therapy.

Ophthalmic Solution

Apply topically to the conjunctival sac of affected eye(s) as directed by clinician, usually 3–4 times daily; more frequent administration may be necessary in some patients. Not for injection.

Following topical instillation, apply finger pressure on the lacrimal sac for 1–2 minutes to minimize drainage into nose and throat and reduce risk of absorption and systemic reactions. Remove excess solution around the eye with a tissue and rinse off any medication on hands immediately.

Ophthalmic Gel

Apply topically to the lower conjunctival sac of affected eye(s) once daily at bedtime.

Measure IOP just before next dose following initiation of therapy to ensure adequate control of IOP throughout the 24-hour dosing interval.

If used concomitantly with ophthalmic solutions, instill solutions first and apply gel ≥5 minutes later.

Dosage

Available as pilocarpine hydrochloride; dosage expressed in terms of the salt.

Adjust concentration and frequency of solution instillation according to patient requirements and response, as determined by tonometric readings.

In patients with heavily pigmented irides, higher solution concentrations may be required.

Adjust dosage of ophthalmic gel based on periodic tonometric readings.

Adults

Open-Angle Glaucoma

Ophthalmic

1–2 drops of a 1–4% solution in the eye(s) every 4–12 hours. Solution concentrations >4% are only occasionally more effective than lower concentrations.

Apply a 1.3-cm (0.5-inch) ribbon of a 4% gel into lower conjunctival sac once daily at bedtime.

Acute Angle-Closure Glaucoma

Ophthalmic

1 drop of a 2% solution in the affected eye every 5–10 minutes for 3–6 doses, followed by 1 drop every 1–3 hours until pressure is controlled. To prevent a bilateral attack, 1 drop of a 1–2% solution in the unaffected eye every 6–8 hours.

Ocular Surgery

Iridectomy

Ophthalmic

1 drop of a 2% solution 4 times immediately prior to iridectomy has been used.

Congenital Glaucoma (Goniotomy)

Ophthalmic

1 drop of a 2% solution every 6 hours prior to surgery has been used.

May use a 2% solution to fill the gonioscopic lens prior to goniotomy, or may administer 1 drop of a 2% solution every 6 hours plus 3 times in the 30 minutes immediately preceding goniotomy, with or without concomitant administration of acetazolamide.

Ophthalmologic Examinations

Ophthalmic

1 drop of a 1% solution in the affected eye(s).

Cautions for Pilocarpine, Pilocarpine Hydrochloride, Pilocarpine Nitrate

Contraindications

• Known hypersensitivity to pilocarpine or any ingredient in the formulation.

• Conditions in which pupillary constriction is undesirable (e.g., acute iritis, pupillary block).

Warnings/Precautions

Sensitivity Reactions

Hypersensitivity

Allergic conjunctivitis, dermatitis, or keratitis reported occasionally with miotics; these reactions are usually alleviated by changing to another miotic. In some instances, allergic reactions may be caused by preservatives in the preparations.

General Precautions

Ocular Effects

Retinal detachment reported rarely; use with extreme caution, if at all, in patients with a history or risk of retinal detachment, especially those who are young or aphakic. Carefully examine retinal periphery at least annually to detect an impending detachment.

Use with caution in patients with corneal abrasion to avoid excessive penetration and systemic toxicity.

Possible spasm of accommodation and poor vision in dim light, particularly in geriatric patients and patients with lens opacities. (See Advice to Patients.)

Follicular conjunctival hypertrophy may occur with prolonged therapy.

Possible transient increase in IOP even when the angle is open. In some patients with angle-closure glaucoma receiving miotics, IOP may be increased and acute attacks may be precipitated.

Possible corneal opacities.

Regular slit-lamp examinations recommended; discontinue therapy, at least temporarily, if iris cysts, iritis, synechiae, or lens opacities occur.

Specific Populations

Pregnancy

Category C.

Lactation

Not known whether pilocarpine is distributed into milk. Use with caution.

Pediatric Use

Safety and efficacy not established.

Geriatric Use

Reduced visual acuity in dim light frequently experienced in geriatric patients.

Common Adverse Effects

Ocular irritation (burning or discomfort), lacrimation, temporal or periorbital headache, painful ciliary or accommodative spasm, blurred vision or myopia, conjunctival vascular congestion, superficial keratitis, poor vision in dim light.

Drug Interactions

Specific Drugs

Pilocarpine, Pilocarpine Hydrochloride, Pilocarpine Nitrate Pharmacokinetics

Absorption

Bioavailability

Penetrates cornea rapidly. Application of ophthalmic gel results in increased corneal bioavailability secondary to decreased elimination of pilocarpine from precorneal areas compared with a topically applied solution. IOP reduction and pupillary diameter are similar to values obtained following application of a solution.

Onset

Following topical application of a 1% solution to the conjunctival sac, miosis occurs within 10–30 minutes and is maximal within 30 minutes. Reduction in IOP is detectable within 60 minutes and is maximal within 75 minutes. Spasms of accommodation begin in approximately 15 minutes.

Duration

Following topical application of a 1% solution to the conjunctival sac, miosis usually persists 4–8 hours or rarely up to 20 hours. Reduced IOP persists 4–14 hours, depending on concentration of drug used. Spasms of accommodation persist 2–3 hours.

Application of ophthalmic gel results in an increased duration of ocular effects compared with a topically applied solution. Following topical application of gel, IOP decreases for about 18–24 hours after application.

Distribution

Extent

Bound to serum and ocular tissues.

Not known whether pilocarpine is distributed into milk.

Elimination

Metabolism

Mechanism by which pilocarpine is inactivated in the body is unclear.

Stability

Storage

Ophthalmic

Solution

8–27°C, unless otherwise specified by manufacturer.

Gel

2–27°C. Avoid excessive heat; do not freeze.

Actions

• Directly stimulates cholinergic receptors, resulting in muscarinic and nicotinic effects.

• Contracts the iris sphincter and the ciliary muscle, which produces constriction of the pupil (miosis) and spasm of accommodation, respectively.

• Reduces IOP in normal and glaucomatous eyes.

• Facilitates aqueous humor outflow by contracting the ciliary muscle and widening the trabecular meshwork.

• Decreases activity of extraocular muscles of convergence and causes vasodilation of blood vessels of the conjunctiva, iris, and ciliary body and increased permeability of the blood-aqueous barrier, which may lead to vascular congestion and ocular inflammation.

• Importance of learning and adhering to proper administration techniques to avoid contamination of the solution or gel container.

• Importance of removing soft contact lenses before administration (since pilocarpine may be absorbed by or preservatives in preparations may have a deleterious effect on the lenses).

• Caution advised if driving at night or performing hazardous tasks in dim light.

• Importance of informing clinicians of existing or contemplated concomitant therapy, including prescription and OTC drugs.

• Importance of women informing clinicians if they are or plan to become pregnant or plan to breast-feed.

• Importance of informing patients of other precautionary information. (See Cautions.)

Preparations

Excipients in commercially available drug preparations may have clinically important effects in some individuals; consult specific product labeling for details.

Please refer to the ASHP Drug Shortages Resource Center for information on shortages of one or more of these preparations.

* available from one or more manufacturer, distributor, and/or repackager by generic (nonproprietary) name

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