What IV medication can be used to treat severe ileus?

From the Guidelines

Neostigmine is not mentioned in the provided evidence, however, based on the context of treating severe ileus, it is the primary IV medication used for this condition. The typical dosage is 2-2.5 mg administered intravenously over 3-5 minutes, with atropine 0.4-0.6 mg given simultaneously to counteract cholinergic side effects.

Key Considerations

• Before administration, patients should have a nasogastric tube in place to decompress the stomach, and cardiac monitoring is essential as neostigmine can cause bradycardia.
• This medication is contraindicated in patients with mechanical obstruction, so imaging should confirm the diagnosis of ileus before treatment.
• Alternative medications include metoclopramide (10 mg IV every 6 hours) and erythromycin (250 mg IV every 6 hours), though these are generally less effective than neostigmine for severe cases.
• Treatment should be accompanied by correction of electrolyte abnormalities, particularly potassium and magnesium, as these deficiencies can worsen ileus.

Additional Context from Provided Evidence

• The provided evidence 1 discusses the treatment of Clostridium difficile infection, which can cause ileus, but does not provide guidance on the primary treatment of severe ileus.
• It does mention the use of intravenous metronidazole as an adjunctive therapy for ileus or severe/complicated CDI, typically with oral and/or rectal vancomycin, but notes that there are no randomized trials supporting this practice.
• However, the primary focus of the evidence is on the treatment of CDI, not severe ileus, and neostigmine is the established treatment for severe ileus based on general medical knowledge.

From the FDA Drug Label

NEOSTIGMINE METHYLSULFATE injection, for intravenous use ... CONTRAINDICATIONS Hypersensitivity to neostigmine ( 4) Peritonitis or mechanical obstruction of the intestinal or urinary tract ( 4)

The neostigmine (IV) medication is contraindicated in patients with peritonitis or mechanical obstruction of the intestinal tract, which may be related to severe ileus. However, there is no direct information in the label that supports the use of neostigmine (IV) for the treatment of severe ileus. Neostigmine (IV) is indicated for the reversal of the effects of non-depolarizing neuromuscular blocking agents (NMBAs) after surgery 2. Therefore, neostigmine (IV) can be considered for the treatment of severe ileus, but only if it is related to neuromuscular blockade and with caution, as it is not the primary indication.

From the Research

IV Medication for Severe Ileus

• Neostigmine is a parasympathomimetic drug that can be used to treat severe ileus, as it acts as a reversible acetylcholinesterase inhibitor 3, 4, 5, 6, 7.
• The medication has been shown to be effective in patients with acute colonic pseudo-obstruction, postoperative ileus, and drug-induced ileus 3, 4, 6, 7.
• Neostigmine can be administered intravenously, with a typical dose of 2 mg, and has been shown to lead to prompt evacuation of flatus or stool and a reduction in abdominal distention 3, 7.
• The median time to response has been reported to be 4 minutes, with a range of 3 to 30 minutes 7.
• Common side effects of neostigmine include abdominal pain, excess salivation, and vomiting, while symptomatic bradycardia is a less common but potentially serious side effect 3, 7.

Administration and Efficacy

• Neostigmine can be administered as a bolus or infusion, with both methods shown to be effective in treating severe ileus 3.
• The medication has been shown to be effective in promoting defecation in ICU patients with colonic ileus, with 79% of patients passing stools after treatment with neostigmine 5.
• Neostigmine has also been shown to be effective in treating postoperative ileus in orthopedic spinal patients, with 6 out of 7 patients experiencing prompt colonic decompression 6.