Neostigmine (with Glycopyrronium)

How it works

Neostigmine inhibits acetylcholinesterase, raising acetylcholine at the neuromuscular junction to overcome competitive blockade, while glycopyrronium blocks muscarinic receptors to prevent bradycardia and excess secretions.

Prescribing in practice

• Give only once spontaneous neuromuscular recovery has begun (some twitch response present) — administering neostigmine in deep or complete block can deepen weakness and precipitate post-operative residual curarisation.
• The fixed antimuscarinic pairing limits muscarinic effects (bradycardia, bronchospasm, salivation), but watch for tachyarrhythmia from glycopyrronium and have atropine available.
• Use with caution in asthma, peptic ulcer disease and bradyarrhythmias, and note it does not reverse aminosteroid block as predictably or rapidly as a selective binding agent in deep blockade.

Monitoring

Confirm adequacy of reversal with quantitative neuromuscular monitoring (train-of-four) alongside heart rate, respiratory effort and airway secretions before extubation.

Counselling the patient

• This medicine is given by the anaesthetist to wake up your muscles after the operation.
• Report any persistent weakness, double vision or difficulty breathing after surgery.

Evidence & guidelines

Anticholinesterase reversal with a co-administered antimuscarinic is a long-standing, guideline-recognised anaesthetic technique.