Neostigmine with glycopyrronium

How it works

Neostigmine inhibits acetylcholinesterase, raising acetylcholine at the neuromuscular junction to overcome competitive non-depolarising block, while glycopyrronium is co-administered to block the muscarinic effects of that excess acetylcholine, chiefly bradycardia and excess secretions.

Prescribing in practice

• Reversal should only be attempted once spontaneous recovery from blockade has begun; giving neostigmine in deep block is ineffective and excess anticholinesterase can paradoxically cause weakness, so neuromuscular monitoring is essential.
• The glycopyrronium component causes tachycardia, dry mouth and may precipitate urinary retention, and is cautioned in glaucoma and obstructive uropathy.
• Neostigmine can provoke bronchospasm, bradycardia and increased secretions, so use with care in asthma and bradyarrhythmias and ensure resuscitation facilities are available.

Monitoring

Monitor neuromuscular recovery with a nerve stimulator together with heart rate and rhythm during and after reversal.

Counselling the patient

• This combination is given at the end of an operation to reverse the muscle-relaxant drugs so normal breathing and strength return.
• A dry mouth and a faster heartbeat for a short time are expected from the glycopyrronium part.
• The team monitors muscle recovery closely to ensure the relaxant has fully worn off.

Evidence & guidelines

Combining neostigmine with an antimuscarinic to counter its muscarinic effects is long-established anaesthetic practice; quantitative neuromuscular monitoring to confirm adequate reversal is recommended by the Association of Anaesthetists.