From the Guidelines
Neostigmine administration is contraindicated in patients with a heart rate of less than 60 beats per minute, which is defined as bradycardia, according to the 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care 1. Key contraindications for neostigmine include:
- Bradycardia (heart rate <60 bpm)
- AV block
- Severe asthma or COPD
- Intestinal or urinary obstruction When administering neostigmine:
- Typical dose: 0.03-0.07 mg/kg IV
- Always co-administer with an anticholinergic (e.g., glycopyrrolate 0.01 mg/kg or atropine 0.02 mg/kg) to counteract muscarinic side effects
- Monitor heart rate and ECG closely during administration Neostigmine is an acetylcholinesterase inhibitor that increases acetylcholine levels at the neuromuscular junction, reversing non-depolarizing neuromuscular blockade. However, it also affects the parasympathetic nervous system, potentially causing bradycardia and bronchospasm. The heart rate threshold of 60 bpm and contraindications are set to prevent dangerous exacerbation of these effects in vulnerable patients, as noted in the guidelines 1. The definition of bradycardia as a heart rate of <60 beats per minute is crucial in determining the safety of neostigmine administration, and a heart rate above 60 bpm is generally considered acceptable for neostigmine administration.
From the FDA Drug Label
Neostigmine methylsulfate injection is contraindicated in patients with: • known hypersensitivity to neostigmine methylsulfate (known hypersensitivity reactions have included urticaria, angioedema, erythema multiforme, generalized rash, facial swelling, peripheral edema, pyrexia, flushing, hypotension, bronchospasm, bradycardia and anaphylaxis). • peritonitis or mechanical obstruction of the intestinal or urinary tract.
A contraindication to Neostigmine administration is known hypersensitivity to neostigmine methylsulfate or peritonitis or mechanical obstruction of the intestinal or urinary tract. The FDA drug label does not specify a particular heart rate that indicates Bradycardia. 2 2 2
From the Research
Contraindications to Neostigmine Administration
- Bradycardia (heart rate <60/min) is a contraindication to neostigmine administration, as it can worsen bradycardia 3
- Hypotension (systolic blood pressure <90 mm Hg) is also a contraindication to neostigmine administration 3
- Active bronchospasm, clinical or radiographic evidence of perforation, history of partial colonic resection, active gastrointestinal bleeding, pregnancy, or serum creatinine >3 mg/dL are additional contraindications to neostigmine administration 3