From the Guidelines
Pyridostigmine overdose in pediatric patients should be treated with atropine at 0.02-0.05 mg/kg IV/IM (minimum dose 0.1 mg, maximum 2 mg) to counteract cholinergic effects, repeated every 5-10 minutes until secretions are controlled, as recommended by the most recent and highest quality study 1.
Treatment Overview
The treatment of pyridostigmine overdose in pediatric patients involves several key components:
- Administration of atropine to counteract cholinergic effects
- Use of pralidoxime (2-PAM) in severe cases
- Supportive care, including airway management, respiratory support, and cardiac monitoring
- Consideration of activated charcoal administration if the ingestion was recent
Atropine Administration
Atropine should be administered at a dose of 0.02-0.05 mg/kg IV/IM, with a minimum dose of 0.1 mg and a maximum dose of 2 mg, repeated every 5-10 minutes until secretions are controlled 1. This is based on the most recent and highest quality study available.
Pralidoxime (2-PAM) Administration
For severe cases of pyridostigmine overdose, pralidoxime (2-PAM) should be given at 25-50 mg/kg IV over 15-30 minutes, with a maximum dose of 1 gram, which can be repeated in 1-2 hours if needed, then every 6-12 hours 1.
Supportive Care
Supportive care is essential in the treatment of pyridostigmine overdose, including:
- Airway management
- Respiratory support
- Cardiac monitoring
- Fluid resuscitation for hypotension
- Treatment of seizures with benzodiazepines
- Intubation for respiratory compromise
Activated Charcoal Administration
Activated charcoal may be administered at a dose of 1-2 g/kg, with a maximum dose of 50-100g, if the ingestion was recent (within 1 hour) 1.
Importance of Continuous Monitoring
Continuous cardiac monitoring is important in the treatment of pyridostigmine overdose, as dysrhythmias may occur 1.
From the FDA Drug Label
Although failure of patients to show clinical improvement may reflect underdosage, it can also be indicative of overdosage. As is true of all cholinergic drugs, overdosage of pyridostigmine bromide may result in cholinergic crisis, a state characterized by increasing muscle weakness which, through involvement of the muscles of respiration, may lead to death The immediate use of atropine in cholinergic crisis is also recommended
The treatment for pediatric overdose of pyridostigmine is not explicitly stated in the provided drug labels. However, in the event of an overdose, it is crucial to recognize the signs of cholinergic crisis, which may include increasing muscle weakness, and to differentiate it from myasthenic crisis.
- The use of atropine is recommended in the case of cholinergic crisis.
- It is essential to exercise caution when administering atropine, as it can mask signs of overdosage and lead to inadvertent induction of cholinergic crisis 2.
- The provided drug labels do not offer specific guidance on the management of pediatric overdose, and it is critical to consult a healthcare professional for proper evaluation and treatment.
From the Research
Pyridostigmine Pediatric Overdose
- Pyridostigmine is a medication used to treat myasthenia gravis and other conditions, but there is limited information available on pediatric overdose 3, 4, 5.
- A study on acute pyridostigmine overdose in adults reported mild to moderate cholinergic symptoms, such as abdominal cramps, diarrhea, and muscle weakness, with no central nervous system manifestations 4.
- In children, pyridostigmine has been used to treat postural orthostatic tachycardia syndrome, with a reported dose-dependent favorable response and no major adverse effects 5.
- The pharmacokinetics of pyridostigmine in children have been studied, with a reported short half-life of 2.29 hours, suggesting that dosing three times per day may be preferable 5.
- There is no direct evidence on the treatment of pyridostigmine overdose in children, but physostigmine, an antidote for anticholinergic poisoning, may be useful in cases of confirmed anticholinergic poisoning 3.
Symptoms and Treatment
- Symptoms of pyridostigmine overdose may include cholinergic symptoms such as abdominal cramps, diarrhea, and muscle weakness 4.
- Treatment for pyridostigmine overdose may involve gastric emptying, administration of activated charcoal, and atropine in severe cases 4.
- Measurement of serum cholinesterase inhibition may be a reliable and sensitive diagnostic tool in pyridostigmine poisoning 4.
Pharmacokinetics and Dosage
- The pharmacokinetics of pyridostigmine in children have been studied, with a reported short half-life of 2.29 hours 5.
- Dosing three times per day may be preferable due to the short half-life of pyridostigmine 5.
- The dosage of pyridostigmine for children with postural orthostatic tachycardia syndrome has been reported as 45 mg in the morning, 30 mg at lunchtime, and 15 mg at bedtime 5.