Siponimod
Severe
Database
Clinical effect not specified
Source: DDInter
Drug reference
pyridostigmine
Reversible acetylcholinesterase inhibitor (quaternary) · Anticholinesterase; Treatment for Myasthenia Gravis; Prophylaxis for Nerve Agent Poisoning
START
60 mg PO every 4–6 h, individualise
TYPICAL MAX
~1500 mg/day (rarely; cholinergic-crisis risk)
STOP IF
Cholinergic crisis (worsening weakness + muscarinic excess)
WATCH
Strength vs cholinergic signs, HR, secretions; distinguish crises
CDSCO approvedATC N07AA02
KDIGO 2024 + manufacturer label
- ONSET
- 24min · absorption
- PEAK
- 1.5h · peak effect
- t½
- 3.5h · t½
- DURATION
- 5h · per dose
EXCRETION
Renal — substantial unchanged
route + CYP
INTERACTIONS
1 major
SEVERE in our sources
PREGNANCY
Used in pregnancy for myasthenia gravis when needed (benefit usually outweighs risk).
FDA category + note
Top interactionssee all 6 →
- SiponimodSevereDatabaseDDInter
Mechanism
Reversibly inhibits acetylcholinesterase, increasing acetylcholine at neuromuscular junctions; quaternary amine with limited CNS penetration — improves muscle strength in myasthenia gravis.
Indications
Myasthenia gravis (symptomatic)Reversal of non-depolarising neuromuscular blockade (with atropine)Pre-treatment against Soman nerve-agent poisoning (military)
Dosing
- Adult
- MG: 60 mg PO every 4–6 h (range 30–120 mg/dose), individualised; sustained-release 180 mg once–twice daily. Max ~1500 mg/day rarely.
- Pediatric
- 7 mg/kg/day in 5–6 divided doses.
- Renal adjustment
- Renally excreted — reduce dose in impairment (prolonged effect).
- Hepatic adjustment
- No specific adjustment.
- Geriatric
- Lower doses; monitor for cholinergic effects.
- Max dose
- ~1500 mg/day (rarely needed; cholinergic crisis risk)
Pharmacokinetics
Onset
~15–30 min (oral)
Peak effect
~1–2 h
Duration
~3–6 h (sustained-release longer)
Half-life
~3–4 h (longer in renal impairment)
Bioavailability
Low (~10–20%, quaternary)
Protein binding
Low
Metabolism
Hepatic + plasma cholinesterase hydrolysis
Excretion
Renal (substantial unchanged)
Contraindications
- Mechanical GI or urinary obstruction
- Hypersensitivity to pyridostigmine/bromides
- Caution: asthma, bradyarrhythmia, peptic ulcer
Side effects
Common
Abdominal cramps/diarrhoeaIncreased salivation/secretionsNauseaSweatingMuscle fasciculationsMiosis
Serious
- Cholinergic crisis (excess dosing — weakness mimicking myasthenic crisis)
- Bradycardia/AV block
- Bronchospasm
- Respiratory failure
Pregnancy & lactation
Pregnancy
Used in pregnancy for myasthenia gravis when needed (benefit usually outweighs risk).
Lactation
Compatible (minimal milk levels; monitor infant).
Drug interactions
Aminoglycosides
Moderate
Database
Neuromuscular blockade worsens MG
Avoid; choose alternative antibiotic
Source: Kimi deep-research + Cla
Anticholinergics
Moderate
Database
Antagonism of muscarinic effects
Use intentionally to limit muscarinic AEs; monitor
Source: Kimi deep-research + Cla
Beta Blockers
Moderate
Database
Additive bradycardia
Monitor HR
Source: Kimi deep-research + Cla
Non Depolarising Neuromuscular Blockers
Moderate
Database
Antagonism (intended for reversal)
Use deliberately for reversal; caution in MG anaesthesia
Source: Kimi deep-research + Cla
Succinylcholine
Moderate
Database
Reduced pseudocholinesterase → prolonged block
Anticipate prolonged succinylcholine effect
Source: Kimi deep-research + Cla
6 additional low-confidence interactions hidden — those rows lack a documented mechanism or management plan in our sources.
Related guidelines
Venous thromboembolism prophylaxis
ASH · Haematology · 2018
Heart failure in diabetes
RSSDI · Cardiology · 2023
Infective endocarditis prevention
NICE · Cardiology / Dentistry · 2008
Infective endocarditis prevention
AHA · Cardiology / Dentistry · 2007
Painful diabetic peripheral neuropathy
AAN · Neurology · 2022
Other Reversible acetylcholinesterase inhibitor (quaternary) drugs
Ask House about pyridostigmine
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Sources: KD Tripathi 7e, Goodman & Gilman 14e·Verified: 2026-05-20 · House clinical team·Cockpit curated: 2026-05-20