These Highlights Do Not Include All The Information Needed To Use Atropine Sulfate Injection Safely And Effectively. See Full Prescribing Information For Atropine Sulfate Injection.

Excessive dosing may cause palpitation, dilated pupils, difficulty in swallowing, hot dry skin, thirst,

dizziness, restlessness, tremor, fatigue and ataxia. Toxic doses lead to restlessness and excitement,

hallucinations, delirium and coma. Depression and circulatory collapse occur only with severe

intoxication. In such cases, blood pressure declines and death due to respiratory failure may ensue

following paralysis and coma.

The fatal adult dose of atropine is not known. In pediatric populations, 10 mg or less may be fatal.

In the event of toxic overdosage, a short acting barbiturate or diazepam may be given as needed to control

marked excitement and convulsions. Large doses for sedation should be avoided because central

depressant action may coincide with the depression occurring late in atropine poisoning. Central

stimulants are not recommended.

Physostigmine, given as an atropine antidote by slow intravenous injection of 1 to 4 mg (0.5 to 1 mg in

pediatric populations), rapidly abolishes delirium and coma caused by large doses of atropine. Since

physostigmine is rapidly destroyed, the patient may again lapse into coma after one to two hours, and

repeated doses may be required.

Artificial respiration with oxygen may be necessary. Ice bags and alcohol sponges help to reduce fever,

especially in pediatric populations.

Atropine is not removed by dialysis

Atropine Sulfate Injection, USP is a sterile, nonpyrogenic isotonic solution of atropine sulfate

monohydrate in water for injection with sodium chloride sufficient to render the solution isotonic. It is

administered parenterally by intravenous injection.

Each milliliter (mL) contains 0.1 mg (adult strength) or 0.05 mg (pediatric strength) of atropine sulfate

monohydrate equivalent to 0.083 mg (adult strength) or 0.042 mg (pediatric strength) of atropine, and

sodium chloride, 9 mg. May contain sodium hydroxide and/or sulfuric acid for pH adjustment

0.308 mOsmol/mL (calc.). pH 3.0 to 6.5.

Sodium chloride added to render the solution isotonic for injection of the active ingredient is present in

amounts insufficient to affect serum electrolyte balance of sodium (Na+

) and chloride (Cl-

) ions.

The solution contains no bacteriostat, antimicrobial agent or added buffer (except for pH adjustment) and

is intended for use only as a single-dose injection. When smaller doses are required the unused portion

should be discarded.

Atropine Sulfate, USP is chemically designated 1α H, 5α H-Tropan-3-α-ol (±)-tropate (ester), sulfate (2:1)

(salt) monohydrate, (C₁₇H₂₃NO₃)₂ H₂SO₄ H₂O, colorless crystals or white crystalline powder very

soluble in water. It has the following structural formula:

Atropine, a naturally occurring belladonna alkaloid, is a racemic mixture of equal parts of d- and

1-hyocyamine, whose activity is due almost entirely to the levo isomer of the drug.

Sodium Chloride, USP is chemically designated NaCl, a white crystalline powder freely soluble in water.

The Ansyr® syringe is molded from a specially formulated polypropylene. Water permeates from inside

the container at an extremely slow rate which will have an insignificant effect on solution concentration

over the expected shelf life. Solutions in contact with the plastic container may leach out certain chemical

components from the plastic in very small amounts; however, biological testing was supportive of the

safety of the syringe material

None.

The following adverse reactions have been identified during post-approval use of atropine sulfate.

Because these reactions are reported voluntarily from a population of uncertain size, it is not always

possible to reliably estimate their frequency or establish a causal relationship to drug exposure.

Most of the side effects of atropine are directly related to its antimuscarinic action. Dryness of the mouth,

blurred vision, photophobia and tachycardia commonly occur. Anhidrosis can produce heat intolerance.

Constipation and difficulty in micturition may occur in elderly patients. Occasional hypersensitivity

reactions have been observed, especially skin rashes which in some instances progressed to exfoliation.

7.1 Mexiletine

Atropine Sulfate Injection decreased the rate of mexiletine absorption without altering the relative oral

bioavailability; this delay in mexiletine absorption was reversed by the combination of atropine and

intravenous metoclopramide during pretreatment for anesthesia.

Atropine Sulfate Injection is indicated for temporary blockade of severe or life-threatening muscarinic

effects, e.g., as an antisialagogue, an antivagal agent, an antidote for organophosphorus or muscarinic

mushroom poisoning, and to treat bradyasystolic cardiac arrest.

12.1 Mechanism of Action

Atropine is an antimuscarinic agent since it antagonizes the muscarine-like actions of acetylcholine and

other choline esters.

Atropine inhibits the muscarinic actions of acetylcholine on structures innervated by postganglionic

cholinergic nerves, and on smooth muscles which respond to endogenous acetylcholine but are not so

innervated. As with other antimuscarinic agents, the major action of atropine is a competitive or

surmountable antagonism which can be overcome by increasing the concentration of acetylcholine at

receptor sites of the effector organ (e.g., by using anticholinesterase agents which inhibit the enzymatic

destruction of acetylcholine). The receptors antagonized by atropine are the peripheral structures that are

stimulated or inhibited by muscarine (i.e., exocrine glands and smooth and cardiac muscle). Responses to

postganglionic cholinergic nerve stimulation also may be inhibited by atropine but this occurs less readily

than with responses to injected (exogenous) choline esters.

12.2 Pharmacodynamics

Atropine-induced parasympathetic inhibition may be preceded by a transient phase of stimulation,

especially on the heart where small doses first slow the rate before characteristic tachycardia develops due

to paralysis of vagal control. Atropine exerts a more potent and prolonged effect on heart, intestine and

bronchial muscle than scopolamine, but its action on the iris, ciliary body and certain secretory glands is

weaker than that of scopolamine. Unlike the latter, atropine in clinical doses does not depress the central

nervous system but may stimulate the medulla and higher cerebral centers. Although mild vagal excitation

occurs, the increased respiratory rate and (sometimes) increased depth of respiration produced by atropine

are more probably the result of bronchiolar dilatation. Accordingly, atropine is an unreliable respiratory

stimulant and large or repeated doses may depress respiration.

Adequate doses of atropine abolish various types of reflex vagal cardiac slowing or asystole. The drug

also prevents or abolishes bradycardia or asystole produced by injection of choline esters,

anticholinesterase agents or other parasympathomimetic drugs, and cardiac arrest produced by stimulation

of the vagus. Atropine also may lessen the degree of partial heart block when vagal activity is an etiologic

factor. In some patients with complete heart block, the idioventricular rate may be accelerated by atropine;

in others, the rate is stabilized. Occasionally a large dose may cause atrioventricular (A-V) block and

nodal rhythm.

Atropine Sulfate Injection in clinical doses counteracts the peripheral dilatation and abrupt decrease in

blood pressure produced by choline esters. However, when given by itself, atropine does not exert a

striking or uniform effect on blood vessels or blood pressure. Systemic doses slightly raise systolic and

lower diastolic pressures and can produce significant postural hypotension. Such doses also slightly

increase cardiac output and decrease central venous pressure. Occasionally, therapeutic doses dilate

cutaneous blood vessels, particularly in the “blush” area (atropine flush) and may cause atropine “fever”

due to suppression of sweat gland activity in infants and small children.

The effects of intravenous atropine on heart rate (maximum heart rate) and saliva flow (minimum flow)

after intravenous administration (rapid, constant infusion over 3 min.) are delayed by 7 to 8 minutes after

drug administration and both effects are non-linearly related to the amount of drug in the peripheral

compartment. Changes in plasma atropine levels following intramuscular administration (0.5 to

4 mg doses) and heart rate are closely overlapped but the time course of the changes in atropine levels and

behavioral impairment indicates that pharmacokinetics is not the primary rate-limiting mechanism for the

central nervous system effect of atropine.

12.3 Pharmacokinetics

Atropine disappears rapidly from the blood following injection and is distributed throughout the body.

Exercise, both prior to and immediately following intramuscular administration of atropine, significantly

increases the absorption of atropine due to increased perfusion in the muscle and significantly decreases

the clearance of atropine. The pharmacokinetics of atropine is nonlinear after intravenous administration

of 0.5 to 4 mg. Atropine’s plasma protein binding is about 44% and saturable in the 2-20 μg/mL

concentration range. Atropine readily crosses the placental barrier and enters the fetal circulation, but is

not found in amniotic fluid. Much of the drug is destroyed by enzymatic hydrolysis, particularly in the

liver; from 13 to 50% is excreted unchanged in the urine. Traces are found in various secretions, including

milk. The major metabolites of atropine are noratropine, atropin-n-oxide, tropine, and tropic acid. The

metabolism of atropine is inhibited by organophosphate pesticides.

Specific Populations

The elimination half-life of atropine is more than doubled in children under two years and the elderly

(>65 years old) compared to other age groups. There is no gender effect on the pharmacokinetics and

pharmacodynamics (heart rate changes) of atropine.

13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility

Studies have not been performed to evaluate the carcinogenic or mutagenic potential of atropine or its

potential to affect fertility adversely.

5.1 Tachycardia

When the recurrent use of atropine is essential in patients with coronary artery disease, the total dose

should be restricted to 2 to 3 mg (maximum 0.03 to 0.04 mg/kg) to avoid the detrimental effects of

atropine-induced tachycardia on myocardial oxygen demand.

5.2 Acute Glaucoma

Atropine may precipitate acute glaucoma.

5.3 Pyloric Obstruction

Atropine may convert partial organic pyloric stenosis into complete obstruction.

5.4 Complete Urinary Retention

Atropine may lead to complete urinary retention in patients with prostatic hypertrophy.

5.5 Viscid Plugs

Atropine may cause inspissation of bronchial secretions and formation of viscid plugs in patients with

chronic lung disease.

2.1 General Administration

Parenteral drug products should be inspected visually for particulate matter and discoloration prior to

administration, whenever solution and container permit. Do not administer unless solution is clear and

seal is intact. Each syringe is intended for single dose only. Discard unused portion.

For intravenous administration.

Titrate based on heart rate, PR interval, blood pressure and symptoms.

2.2 Adult Dosage

2.3 Pediatric Dosage

Dosing in pediatric populations has not been well studied. Usual initial dose is 0.01 to 0.03 mg/kg.

2.4 Dosing in Patients with Coronary Artery Disease

Limit the total dose of atropine sulfate to 0.03 mg/kg to 0.04 mg/kg [see Warnings and Precautions (5.1)]

Injection: 0.05 mg/mL and 0.1 mg/mL in Ansyr® Plastic Syringe.

Injection: 0.1 mg/mL in LifeShield® Abboject® Glass Syringe.

Injection: 0.1 mg/mL in Abboject® Syringe with Male Luer Lock Adapter.

8.1 Pregnancy

Animal reproduction studies have not been conducted with atropine. It also is not known whether atropine

can cause fetal harm when given to a pregnant woman or can affect reproduction capacity.

8.3 Nursing Mothers

Trace amounts of atropine was found in breast milk. The clinical impact of this is not known.

8.4 Pediatric Use

Recommendations for use in pediatric patients are not based on clinical trials.

8.5 Geriatric Use

An evaluation of current literature revealed no clinical experience identifying differences in response

between elderly and younger patients. In general, dose selection for an elderly patient should be cautious,

usually starting at the low end of the dosing range, reflecting the greater frequency of decreased hepatic,

renal, or cardiac function, and of concomitant disease or other drug therapy.

Atropine Sulfate Injection, USP is supplied in single-dose syringes as follows:

Store at 20°C to 25°C (68°F to 77°F); excursions permitted between 15°C and 30°C (59°F and 86°F).

[See USP Controlled Room Temperature.]

Distributed by Hospira, Inc., Lake Forest, IL 60045 USA

Abboject® is a trademark of Abbott Laboratories.

LifeShield® is the trademark of ICU Medical, Inc. and is used under license.

LAB-1041-4.2

Excessive dosing may cause palpitation, dilated pupils, difficulty in swallowing, hot dry skin, thirst,

dizziness, restlessness, tremor, fatigue and ataxia. Toxic doses lead to restlessness and excitement,

hallucinations, delirium and coma. Depression and circulatory collapse occur only with severe

intoxication. In such cases, blood pressure declines and death due to respiratory failure may ensue

following paralysis and coma.

The fatal adult dose of atropine is not known. In pediatric populations, 10 mg or less may be fatal.

In the event of toxic overdosage, a short acting barbiturate or diazepam may be given as needed to control

marked excitement and convulsions. Large doses for sedation should be avoided because central

depressant action may coincide with the depression occurring late in atropine poisoning. Central

stimulants are not recommended.

Physostigmine, given as an atropine antidote by slow intravenous injection of 1 to 4 mg (0.5 to 1 mg in

pediatric populations), rapidly abolishes delirium and coma caused by large doses of atropine. Since

physostigmine is rapidly destroyed, the patient may again lapse into coma after one to two hours, and

repeated doses may be required.

Artificial respiration with oxygen may be necessary. Ice bags and alcohol sponges help to reduce fever,

especially in pediatric populations.

Atropine is not removed by dialysis

Atropine Sulfate Injection, USP is a sterile, nonpyrogenic isotonic solution of atropine sulfate

monohydrate in water for injection with sodium chloride sufficient to render the solution isotonic. It is

administered parenterally by intravenous injection.

Each milliliter (mL) contains 0.1 mg (adult strength) or 0.05 mg (pediatric strength) of atropine sulfate

monohydrate equivalent to 0.083 mg (adult strength) or 0.042 mg (pediatric strength) of atropine, and

sodium chloride, 9 mg. May contain sodium hydroxide and/or sulfuric acid for pH adjustment

0.308 mOsmol/mL (calc.). pH 3.0 to 6.5.

Sodium chloride added to render the solution isotonic for injection of the active ingredient is present in

amounts insufficient to affect serum electrolyte balance of sodium (Na+

) and chloride (Cl-

) ions.

The solution contains no bacteriostat, antimicrobial agent or added buffer (except for pH adjustment) and

is intended for use only as a single-dose injection. When smaller doses are required the unused portion

should be discarded.

Atropine Sulfate, USP is chemically designated 1α H, 5α H-Tropan-3-α-ol (±)-tropate (ester), sulfate (2:1)

(salt) monohydrate, (C₁₇H₂₃NO₃)₂ H₂SO₄ H₂O, colorless crystals or white crystalline powder very

soluble in water. It has the following structural formula:

Atropine, a naturally occurring belladonna alkaloid, is a racemic mixture of equal parts of d- and

1-hyocyamine, whose activity is due almost entirely to the levo isomer of the drug.

Sodium Chloride, USP is chemically designated NaCl, a white crystalline powder freely soluble in water.

The Ansyr® syringe is molded from a specially formulated polypropylene. Water permeates from inside

the container at an extremely slow rate which will have an insignificant effect on solution concentration

over the expected shelf life. Solutions in contact with the plastic container may leach out certain chemical

components from the plastic in very small amounts; however, biological testing was supportive of the

safety of the syringe material

None.

The following adverse reactions have been identified during post-approval use of atropine sulfate.

Because these reactions are reported voluntarily from a population of uncertain size, it is not always

possible to reliably estimate their frequency or establish a causal relationship to drug exposure.

Most of the side effects of atropine are directly related to its antimuscarinic action. Dryness of the mouth,

blurred vision, photophobia and tachycardia commonly occur. Anhidrosis can produce heat intolerance.

Constipation and difficulty in micturition may occur in elderly patients. Occasional hypersensitivity

reactions have been observed, especially skin rashes which in some instances progressed to exfoliation.

7.1 Mexiletine

Atropine Sulfate Injection decreased the rate of mexiletine absorption without altering the relative oral

bioavailability; this delay in mexiletine absorption was reversed by the combination of atropine and

intravenous metoclopramide during pretreatment for anesthesia.

Atropine Sulfate Injection is indicated for temporary blockade of severe or life-threatening muscarinic

effects, e.g., as an antisialagogue, an antivagal agent, an antidote for organophosphorus or muscarinic

mushroom poisoning, and to treat bradyasystolic cardiac arrest.

12.1 Mechanism of Action

Atropine is an antimuscarinic agent since it antagonizes the muscarine-like actions of acetylcholine and

other choline esters.

Atropine inhibits the muscarinic actions of acetylcholine on structures innervated by postganglionic

cholinergic nerves, and on smooth muscles which respond to endogenous acetylcholine but are not so

innervated. As with other antimuscarinic agents, the major action of atropine is a competitive or

surmountable antagonism which can be overcome by increasing the concentration of acetylcholine at

receptor sites of the effector organ (e.g., by using anticholinesterase agents which inhibit the enzymatic

destruction of acetylcholine). The receptors antagonized by atropine are the peripheral structures that are

stimulated or inhibited by muscarine (i.e., exocrine glands and smooth and cardiac muscle). Responses to

postganglionic cholinergic nerve stimulation also may be inhibited by atropine but this occurs less readily

than with responses to injected (exogenous) choline esters.

12.2 Pharmacodynamics

Atropine-induced parasympathetic inhibition may be preceded by a transient phase of stimulation,

especially on the heart where small doses first slow the rate before characteristic tachycardia develops due

to paralysis of vagal control. Atropine exerts a more potent and prolonged effect on heart, intestine and

bronchial muscle than scopolamine, but its action on the iris, ciliary body and certain secretory glands is

weaker than that of scopolamine. Unlike the latter, atropine in clinical doses does not depress the central

nervous system but may stimulate the medulla and higher cerebral centers. Although mild vagal excitation

occurs, the increased respiratory rate and (sometimes) increased depth of respiration produced by atropine

are more probably the result of bronchiolar dilatation. Accordingly, atropine is an unreliable respiratory

stimulant and large or repeated doses may depress respiration.

Adequate doses of atropine abolish various types of reflex vagal cardiac slowing or asystole. The drug

also prevents or abolishes bradycardia or asystole produced by injection of choline esters,

anticholinesterase agents or other parasympathomimetic drugs, and cardiac arrest produced by stimulation

of the vagus. Atropine also may lessen the degree of partial heart block when vagal activity is an etiologic

factor. In some patients with complete heart block, the idioventricular rate may be accelerated by atropine;

in others, the rate is stabilized. Occasionally a large dose may cause atrioventricular (A-V) block and

nodal rhythm.

Atropine Sulfate Injection in clinical doses counteracts the peripheral dilatation and abrupt decrease in

blood pressure produced by choline esters. However, when given by itself, atropine does not exert a

striking or uniform effect on blood vessels or blood pressure. Systemic doses slightly raise systolic and

lower diastolic pressures and can produce significant postural hypotension. Such doses also slightly

increase cardiac output and decrease central venous pressure. Occasionally, therapeutic doses dilate

cutaneous blood vessels, particularly in the “blush” area (atropine flush) and may cause atropine “fever”

due to suppression of sweat gland activity in infants and small children.

The effects of intravenous atropine on heart rate (maximum heart rate) and saliva flow (minimum flow)

after intravenous administration (rapid, constant infusion over 3 min.) are delayed by 7 to 8 minutes after

drug administration and both effects are non-linearly related to the amount of drug in the peripheral

compartment. Changes in plasma atropine levels following intramuscular administration (0.5 to

4 mg doses) and heart rate are closely overlapped but the time course of the changes in atropine levels and

behavioral impairment indicates that pharmacokinetics is not the primary rate-limiting mechanism for the

central nervous system effect of atropine.

12.3 Pharmacokinetics

Atropine disappears rapidly from the blood following injection and is distributed throughout the body.

Exercise, both prior to and immediately following intramuscular administration of atropine, significantly

increases the absorption of atropine due to increased perfusion in the muscle and significantly decreases

the clearance of atropine. The pharmacokinetics of atropine is nonlinear after intravenous administration

of 0.5 to 4 mg. Atropine’s plasma protein binding is about 44% and saturable in the 2-20 μg/mL

concentration range. Atropine readily crosses the placental barrier and enters the fetal circulation, but is

not found in amniotic fluid. Much of the drug is destroyed by enzymatic hydrolysis, particularly in the

liver; from 13 to 50% is excreted unchanged in the urine. Traces are found in various secretions, including

milk. The major metabolites of atropine are noratropine, atropin-n-oxide, tropine, and tropic acid. The

metabolism of atropine is inhibited by organophosphate pesticides.

Specific Populations

The elimination half-life of atropine is more than doubled in children under two years and the elderly

(>65 years old) compared to other age groups. There is no gender effect on the pharmacokinetics and

pharmacodynamics (heart rate changes) of atropine.

13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility

Studies have not been performed to evaluate the carcinogenic or mutagenic potential of atropine or its

potential to affect fertility adversely.

5.1 Tachycardia

When the recurrent use of atropine is essential in patients with coronary artery disease, the total dose

should be restricted to 2 to 3 mg (maximum 0.03 to 0.04 mg/kg) to avoid the detrimental effects of

atropine-induced tachycardia on myocardial oxygen demand.

5.2 Acute Glaucoma

Atropine may precipitate acute glaucoma.

5.3 Pyloric Obstruction

Atropine may convert partial organic pyloric stenosis into complete obstruction.

5.4 Complete Urinary Retention

Atropine may lead to complete urinary retention in patients with prostatic hypertrophy.

5.5 Viscid Plugs

Atropine may cause inspissation of bronchial secretions and formation of viscid plugs in patients with

chronic lung disease.

2.1 General Administration

Parenteral drug products should be inspected visually for particulate matter and discoloration prior to

administration, whenever solution and container permit. Do not administer unless solution is clear and

seal is intact. Each syringe is intended for single dose only. Discard unused portion.

For intravenous administration.

Titrate based on heart rate, PR interval, blood pressure and symptoms.

2.2 Adult Dosage

2.3 Pediatric Dosage

Dosing in pediatric populations has not been well studied. Usual initial dose is 0.01 to 0.03 mg/kg.

2.4 Dosing in Patients with Coronary Artery Disease

Limit the total dose of atropine sulfate to 0.03 mg/kg to 0.04 mg/kg [see Warnings and Precautions (5.1)]

Injection: 0.05 mg/mL and 0.1 mg/mL in Ansyr® Plastic Syringe.

Injection: 0.1 mg/mL in LifeShield® Abboject® Glass Syringe.

Injection: 0.1 mg/mL in Abboject® Syringe with Male Luer Lock Adapter.

8.1 Pregnancy

Animal reproduction studies have not been conducted with atropine. It also is not known whether atropine

can cause fetal harm when given to a pregnant woman or can affect reproduction capacity.

8.3 Nursing Mothers

Trace amounts of atropine was found in breast milk. The clinical impact of this is not known.

8.4 Pediatric Use

Recommendations for use in pediatric patients are not based on clinical trials.

8.5 Geriatric Use

An evaluation of current literature revealed no clinical experience identifying differences in response

between elderly and younger patients. In general, dose selection for an elderly patient should be cautious,

usually starting at the low end of the dosing range, reflecting the greater frequency of decreased hepatic,

renal, or cardiac function, and of concomitant disease or other drug therapy.

Atropine Sulfate Injection, USP is supplied in single-dose syringes as follows:

Store at 20°C to 25°C (68°F to 77°F); excursions permitted between 15°C and 30°C (59°F and 86°F).

[See USP Controlled Room Temperature.]

Distributed by Hospira, Inc., Lake Forest, IL 60045 USA

Abboject® is a trademark of Abbott Laboratories.

LifeShield® is the trademark of ICU Medical, Inc. and is used under license.

LAB-1041-4.2