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Safety of Physostigmine for Pediatric Antimuscarinic Poisoning

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A Correction to this article was published on 28 May 2024

This article has been updated

Abstract

Introduction

Physostigmine fell out of widespread use in the 1980s due to safety concerns; however, more recent research has demonstrated that its safety profile is better than previously thought. These studies have mainly included adults. We theorized that improved safety data may lead to more acceptance. Our objectives, therefore, were to characterize current frequency of use of physostigmine in pediatric patients as well as to study adverse effect rates in a national pediatric patient population.

Methods

The National Poison Data System was queried for cases of patients aged 0–18 years that involved single-substance exposures to antimuscarinic xenobiotics that were reported to a poison center between January 1, 2000, and December 31, 2020. Cases were stratified into groups by therapy received: benzodiazepines alone, benzodiazepines and physostigmine, physostigmine alone, or no physostigmine or benzodiazepines. Patient demographics, clinical effects, and medical outcomes were analyzed.

Results

A total of 694,132 cases were reviewed, and 150,075 were included for analysis. Nearly 5% (7562/150,075) of patients received specific pharmacological therapy with benzodiazepines, physostigmine, or both. A benzodiazepine as a single agent was the most frequently used pharmacologic therapy (92% of 7562). Among patients receiving any pharmacological therapy, only 8.3% (n = 627) of patients received physostigmine. Frequency of serious outcomes significantly increased across the study period among patients receiving benzodiazepines alone or with physostigmine. There was no increase in serious outcomes among patients receiving only physostigmine.

Conclusions

Physostigmine frequency of use was low overall, but when used, was associated with less severe outcomes when compared to benzodiazepines.

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Acknowledgements

The authors are very grateful for the support of and guidance in statistical methodology from George Eckert, MAS, Biostatistician Supervisor in the Department of Biostatistics at the Indiana University School of Medicine and Richard M. Fairbanks School of Public Health.

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Authors and Affiliations

  1. Indiana University School of Medicine, Indianapolis, IN, USA

    Sarah Huber, Robert Avera, Adam Overberg & Kristine Nañagas

  2. IU Health Methodist Hospital, 1701 North Senate Blvd. B412b, Indianapolis, IN, 46234, USA

    Sarah Huber, Robert Avera, Shannon Penfound, Adam Overberg & Kristine Nañagas

  3. Indiana University Health – Academic Health Center, Indianapolis, IN, USA

    Robert Avera, Adam Overberg & Kristine Nañagas

  4. Indiana Poison Center, Indianapolis, IN, USA

    Robert Avera, Shannon Penfound, Adam Overberg & Kristine Nañagas

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Contributions

All authors contributed to the study conception and design. Material preparation, data collection, and analysis were performed by SH, RA, AO, and SP. The first draft of the manuscript was written by SH, RA, AO, and KN, and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

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Correspondence to Kristine Nañagas.

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There were no external sources of funding for this study.

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Supervising Editor: Howard Greller, MD.

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The original version of this article was revised: Table 1 contained typographical errors as originally published and has been updated, and a sentence in the 2nd paragraph of the Results section has been updated to reflect the corrected values in Table 1.

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Huber, S., Avera, R., Penfound, S. et al. Safety of Physostigmine for Pediatric Antimuscarinic Poisoning. J. Med. Toxicol. (2024). https://doi.org/10.1007/s13181-024-00988-0

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