Pralidoxime
2-PAM
What it isOxime reactivating acetylcholinesterase; organophosphate poisoning.
Why this oneIt reverses nicotinic weakness, including respiratory muscle paralysis, which atropine cannot touch.
What limits itGive it before the enzyme ages; it supplements atropine and is generally not useful in carbamate poisoning.
FDA-approved for
- organophosphate poisoning (~1964)
FDA label
Read the full label on DailyMed ↗
| FDA dosing | Population | Start | Target | Max |
|---|---|---|---|---|
| Organophosphate poisoning (IV, with atropine) | Adults | 20–50 mg/kg IV over 15–30 min (max 2000 mg/dose) | Repeat / continuous infusion as needed | Infusion rate ≤200 mg/min |
| Organophosphate poisoning (IM auto-injector) | Adults | 600 mg IM for mild symptoms | Repeat q15min PRN | 1800 mg (3×600 mg) for severe |
| Organophosphate poisoning (IM) | Peds <40 kg | 15 mg/kg IM per injection | Repeat PRN | 45 mg/kg (3-injection course) |
| Anticholinesterase overdose in myasthenia gravis | Adults | 1000–2000 mg IV | Then 250 mg q5min |
Renal Undefined
Hepatic Undefined
Additional doses may be needed q3–8 h if signs of poisoning recur; observe patient 48–72 h
Instructions
- Administer slowly, preferably by IV infusion; use IM or SC if IV not feasible
- Combine with atropinization, decontamination, and supportive care
- Give as early as possible; little benefit if given >36 h after exposure
Available strengths
- inj 1 g
Cautions
- Reduce dose in renal impairment (excreted renally)
- May cause blurred vision, dizziness, headache, tachycardia, hypertension, muscular weakness when given parenterally
- Signs of atropinization may appear earlier when used with atropine
- Transient elevations in AST/ALT and CPK
Adverse reactions
- Injection-site pain (IM)
- Blurred vision, diplopia, impaired accommodation
- Dizziness, headache, drowsiness
- Nausea
- Tachycardia, increased blood pressure
- Hyperventilation
- Muscular weakness
Pregnancy No animal studies; give only if clearly needed
Lactation Undefined
Cost
Pralidoxime (2-PAM)
| Strength | #/mo | generic $/unit | CostPlus | |
|---|---|---|---|---|
| 1 g | inj | per unit | not offered |
NADAC is a voluntary CMS survey of what retail community pharmacies pay for the drugs they stock. Pralidoxime is administered under clinical supervision and dispensed outside retail pharmacies, so it rarely appears on surveyed invoices.
NO BOXED WARNINGS
Principal riskUseless once the enzyme has aged, and in carbamates
Classes and tags
Clinical profile
Legacy pregnancy categoryC
Defining liabilityRapid-infusion cardiopulmonary toxicity