From the FDA Drug Label
An anticholinergic agent, e.g., atropine sulfate or glycopyrrolate, should be administered prior to or concomitantly with neostigmine methylsulfate injection. The anticholinergic agent should be administered intravenously using a separate syringe. The recommended dose of neostigmine methylsulfate injection is 0.03 mg/kg to 0.07 mg/kg.
The dosage of atropine is not specified in the label, only that it should be administered prior to or concomitantly with neostigmine. The dosage of neostigmine in neuropathic snake bite is not directly mentioned, but the general recommended dose is 0.03 mg/kg to 0.07 mg/kg 1.
From the Research
For neuroparalytic snake bite management, the recommended dosage is atropine 0.6 mg IV followed by neostigmine 2.5 mg IV, as this combination has been used in recent studies 2. The administration of atropine and neostigmine together is crucial to counteract neuromuscular blockade caused by snake neurotoxins.
- Atropine is given first to prevent cholinergic side effects of neostigmine, such as bradycardia and increased secretions.
- Neostigmine works by inhibiting acetylcholinesterase, which increases acetylcholine at the neuromuscular junction to overcome the competitive blockade caused by snake neurotoxins.
- The combination should be given every 30 minutes as needed, based on clinical response, and treatment may continue for 24-48 hours or until neurological symptoms resolve.
- A recent case report suggests that atropine and neostigmine can be effective in treating neuroparalytic snake bites, even in severe cases 3.
- However, it is essential to note that the effectiveness of neostigmine in reversing neuroparalytic features may vary depending on the type of snake venom and the severity of the bite 2.
- Continuous monitoring of vital signs, respiratory function, and neurological status is essential during treatment.
- In some cases, pyridostigmine may be considered as an adjunctive therapy to promote motor recovery after an allergic reaction to anti-snake venom 4.