Do not overexert yourself if you have myasthenia gravis. The amount of medication required to control symptoms of myasthenia gravis varies greatly, and the physician needs this information to adjust the dosage correctly. Record symptoms of myasthenia gravis and effects of drug therapy, especially when drug therapy is initiated and medication doses are being titrated. PATIENT EDUCATION- Wear a medical alert identification device if you are taking long-term cholinergic drug therapy for myasthenia gravis. In addition, the nurse observes neonates of mothers with myasthenia gravis who have received neostigmine for difficulty breathing, swallowing, or sucking. It is necessary to assess for nausea and vomiting, which are common GI effects. He or she assesses for increased secretions, bronchospasm, laryngospasm, and respiratory failure. Assessing for Adverse Effects- The nurse assesses for increased central nervous system (CNS) effects such as convulsions, dizziness, and drowsiness. When neostigmine is given to patients with myasthenia gravis, it is necessary to observe for increased muscle strength decreased difficulty with chewing, swallowing, and speech and decreased or absent ptosis of eyelids. Assessing for Therapeutic Effects- The nurse assesses the patient's response to the medication. CONTRAINDICATION- Patients with lung disease, such as bronchial asthma, or heart disease, such as sick sinus syndrome, should not take the drug Administering the Medication It is important to administer IV neostigmine slowly and have atropine available as an antidote in the event of a cholinergic crisis or hypersensitivity to neostigmine. Atropine sulfate should be readily available whenever cholinergic drugs are given. Toxicity of Neostigmine and Other Acetylcholinesterase Inhibitors- Cholinergic crisis is a drug-induced overstimulation of the parasympathetic nervous system, requiring discontinuation of any anticholinesterase drug that the patient has been receiving. (IV atropine sulfate is the specific antidote for cholinergic agents.) Conditions such as excessive salivation, nausea, emesis, frequent urination, or diarrhea require a reduction in dosage. Other respiratory adverse effects include increased pharyngeal and tracheobronchial secretions, laryngospasm, bronchospasm, bronchiolar constriction, shortness of breath, and respiratory paralysis. Development of respiratory depression indicates cholinergic crisis. Cardiovascular adverse effects of neostigmine are cardiac dysrhythmias, diminished cardiac output, hypotension, syncope, and cardiac arrest. ADVERSE Specific Effects Neostigmine has several adverse effects. These include reversal of skeletal muscle paralysis caused by nondepolarizing muscle relaxants, improvement of muscle strength, and use as an antidote to anticholinergic poisoning. Therefore, renal impairment may result in accumulation and increased adverse effects, Use in Patients With Critical Illness Neostigmine has specific uses in critical illness. ![]() Use in Older Adults Older adults are more likely to experience adverse drug effects Use in Patients With Renal Impairment Neostigmine undergoes tubular excretion in the kidneys. In addition, prescribers order it to reverse the action of nondepolarizing neuromuscular blocking agents, such as tubocurarine, which is used in surgery. In addition, this drug increases tone and contractility of smooth muscle (detrusor) in the urinary bladder and relaxes the sphincter and bronchial smooth muscles USES- The major use of neostigmine is in the diagnosis and treatment of myasthenia gravis. In a patient with myasthenia gravis, specific effects of neostigmine include decreasing the heart rate, increasing the tone of GI smooth muscle, and stimulating the salivary glands to increase secretions. In addition to the cholinergic drug effects described above, the added effect of indirect-acting cholinergic drugs on nicotinic receptors in skeletal muscles results in improved skeletal muscle tone and strength. ACTION- Thus, acetylcholine accumulates in the synapse and enhances the activation of postsynaptic muscarinic as well as nicotinic receptors. Neostigmine decreases the inactivation of acetylcholine in the synapse by the enzyme acetylcholinesterase. ![]() Health care providers use this drug for the long-term treatment of myasthenia gravis and as an antidote for tubocurarine and other nondepolarizing skeletal muscle relaxants used in surgery.
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