What is the recommended dosing for Robinul (glycopyrrolate)?

Robinul (Glycopyrrolate) Dosing

The recommended dosing for glycopyrrolate varies significantly by indication, with FDA-approved adult doses ranging from 0.1-0.2 mg IV every 4 hours for peptic ulcer to 0.004 mg/kg IM for preanesthetic medication, while pediatric dosing follows similar weight-based calculations with specific adjustments for age. 1

Adult Dosing by Indication

Preanesthetic Medication

• 0.004 mg/kg IM, administered 30-60 minutes prior to induction of anesthesia 1
• May be given at the time preanesthetic narcotic/sedative is administered 1

Intraoperative Use (Bradycardia/Arrhythmias)

• 0.1 mg IV as single dose, repeated as needed at 2-3 minute intervals 1
• Used to counteract drug-induced or vagal reflexes during surgery 1

Reversal of Neuromuscular Blockade

• 0.2 mg glycopyrrolate for each 1.0 mg neostigmine (or 5.0 mg pyridostigmine) 1
• Can be administered simultaneously by IV injection and mixed in the same syringe 1
• This 0.2:1.0 ratio (glycopyrrolate:neostigmine) demonstrates greatest efficacy with lowest adverse effects 2
• The 10 mcg/kg dose of glycopyrrolate mixed with neostigmine provides the most stable heart rates 3

Peptic Ulcer

• 0.1 mg IV or IM at 4-hour intervals, 3-4 times daily 1
• May increase to 0.2 mg if more profound effect required 1
• Maximum four times daily 1

Palliative Care Applications

Excessive Secretions/Death Rattle

• 0.2-0.4 mg IV or subcutaneous every 4 hours as needed 4, 5
• Alternative: 0.4 mg subcutaneous every 4 hours PRN 4
• Used to reduce excessive respiratory secretions in dying patients 4

Diarrhea Management

• 0.2-0.4 mg IV every 4 hours PRN as anticholinergic agent 4, 5
• Consider for persistent Grade 2-4 diarrhea when other interventions fail 4

Pediatric Dosing by Indication

Preanesthetic Medication

• 0.004 mg/kg IM, given 30-60 minutes prior to induction 1
• Infants (1 month to 2 years): May require up to 0.009 mg/kg 1

Intraoperative Use

• 0.004 mg/kg IV, not to exceed 0.1 mg single dose 1
• May be repeated as needed at 2-3 minute intervals 1
• Rarely needed if used as preanesthetic medication due to long duration of action 1

Reversal of Neuromuscular Blockade

• 0.2 mg for each 1.0 mg neostigmine (or 5.0 mg pyridostigmine) 1
• Same ratio as adults; can be mixed in same syringe 1

Adjunct to Ketamine (Prevent Hypersalivation)

• Atropine or glycopyrrolate may be used to prevent increased salivation during ketamine sedation 4
• Specific pediatric emergency dosing not explicitly stated in guidelines 4

Chronic Drooling (Off-Label, FDA-Approved for Ages 3-16)

• Starting dose: 0.02 mg/kg PO three times daily (maximum 3 mg per dose) 6
• Titrate over 4-week period based on response 6
• Effective dose range varies widely: 0.01-0.82 mg/kg/day in clinical practice 7
• Mean effective dose approximately 0.11 mg/kg 6
• For children under 3 years: Median starting dose 0.065 mg/kg/day divided three times daily (range 0.02-0.21 mg/kg/day) showed 94% response rate 8

Important Clinical Considerations

Administration Routes

• May be given IM, IV, or subcutaneous without dilution 1
• For IV push, administer undiluted 1

Monitoring and Adverse Effects

• Common side effects: Dry mouth (9-41%), constipation (9-39%), behavioral changes in children (18-36%) 6
• Monitor heart rate when used with neostigmine; glycopyrrolate provides more stable heart rates than atropine 3
• Contains benzyl alcohol; use caution in neonates 1

Compatibility

• Compatible diluents: D5W, D10W, NS, D5 0.45% NS, Ringer's injection 1
• Incompatible: Lactated Ringer's solution 1
• Compatible for mixing with multiple anesthetic agents including atropine, morphine, fentanyl, neostigmine, and others 1

Key Dosing Pitfalls

• Avoid underdosing in neuromuscular blockade reversal: The 5 mcg/kg glycopyrrolate or 10 mcg/kg atropine doses are inadequate and associated with unacceptable bradycardia 3
• Pediatric drooling requires individualized titration: The effective dose range is extremely broad (0.01-0.82 mg/kg/day), necessitating careful upward titration 7
• Not recommended for peptic ulcer in pediatric patients per FDA labeling 1
• Side effects increase with higher doses; 28% discontinuation rate in drooling studies due to adverse effects 7