Atropine Sulfate - Atropine Sulfate Monohydrate solution/ Drops prescribing information
INDICATIONS AND USAGE
Atropine sulfate ophthalmic solution 1% is indicated for:
Mydriasis
Cycloplegia
Penalization of the healthy eye in the treatment of amblyopia
DOSAGE AND ADMINISTRATION
- In individuals from three (3) months of age or greater 1 drop topically to the cul-de-sac of the conjunctiva, forty minutes prior to the intended maximal dilation time (2.1)
- In individuals 3 years of age or greater, doses may be repeated up to twice daily as needed. (2.2)
In individuals from three (3) months of age or greater, 1 drop topically to the cul-de-sac of the conjunctiva, forty minutes prior to the intended maximal dilation time.
In individuals 3 years of age or greater, doses may be repeated up to twice daily as needed.
DOSAGE FORMS AND STRENGTHS
Ophthalmic solution: 1% atropine sulfate, USP (10mg/mL)
USE IN SPECIFIC POPULATIONS
Pregnancy
Risk Summary
There are no adequate and well-controlled studies with atropine sulfate ophthalmic solution 1% administration in pregnant women to inform a drug-associated risk. Adequate animal development and reproduction studies have not been conducted with atropine sulfate. In humans, 1% atropine sulfate is systemically bioavailable following topical ocular administration [see Clinical Pharmacology (12.3)] . Atropine sulfate ophthalmic solution 1% should only be used during pregnancy if the potential benefit justifies the potential risk to the fetus.
Lactation
There is no information to inform risk regarding the presence of atropine in human milk following ocular administration of atropine sulfate ophthalmic solution 1% to the mother. The effects on breastfed infants and the effects on milk production are also unknown. The developmental and health benefits of breastfeeding should be considered along with the mother's clinical need for atropine sulfate ophthalmic solution 1% and any potential adverse effects on the breastfed child from atropine sulfate ophthalmic solution 1%.
Pediatric Use
Due to the potential for systemic absorption of atropine sulfate ophthalmic solution the use of atropine sulfate ophthalmic solution 1% in children under the age of 3 months is not recommended and the use in children under 3 years of age should be limited to no more than one drop per eye per day. Safety and efficacy in children above the age of 3 months has been established in adequate and well controlled trials.
Geriatric Use
No overall differences in safety or effectiveness have been observed between elderly and adult patients.
CONTRAINDICATIONS
Atropine sulfate ophthalmic solution should not be used in anyone who has demonstrated a previous hypersensitivity or known allergic reaction to any ingredient of the formulation because it may recur.
WARNINGS AND PRECAUTIONS
- Photophobia and blurred vision due to pupil unresponsiveness and cycloplegia may last up to 2 weeks. (5.1)
- Risk of blood pressure increase from systemic absorption (5.2)
- Increased adverse drug reaction susceptibility with certain central nervous system conditions (5.3)
Photophobia and Blurred Vision
Photophobia and blurred vision due to pupil unresponsiveness and cycloplegia may last up to 2 weeks.
Elevation of Blood Pressure
Elevation in blood pressure from systemic absorption has been reported following conjunctival instillation of recommended doses of atropine sulfate ophthalmic solution, 1%.
Increased Adverse Drug Reaction Susceptibility with Certain Central Nervous System Conditions
Individuals with Down syndrome, spastic paralysis, or brain damage are particularly susceptible to central nervous system disturbances, cardiopulmonary, and gastrointestinal toxicity from systemic absorption of atropine.
ADVERSE REACTIONS
The following adverse reactions are described below and elsewhere in the labeling:
- Photophobia and Blurred Vision [see Warnings and Precautions (5.1)]
- Elevation in Blood Pressure [see Warnings and Precautions (5.2)]
- Increased Adverse Drug Reaction Susceptibility with Certain Central Nervous System Conditions [see Warnings and Precautions (5.3)]
The following adverse reactions have been identified following use of atropine sulfate ophthalmic solution. 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.
Ocular Adverse Reactions
Eye pain and stinging occurs upon instillation of atropine sulfate ophthalmic solution. Other commonly occurring adverse reactions include blurred vision, photophobia, superficial keratitis and decreased lacrimation. Allergic reactions such as papillary conjunctivitis, contact dermatitis, and eyelid edema may also occur less commonly.
Systemic Adverse Reactions
Systemic effects of atropine are related to its anti-muscarinic activity. Systemic adverse events reported include dryness of skin, mouth, and throat from decreased secretions from mucus membranes; drowsiness; restlessness, irritability or delirium from stimulation of the central nervous system; tachycardia; flushed skin of the face and neck.
DRUG INTERACTIONS
The use of atropine and monoamine oxidase inhibitors (MAOI) is generally not recommended because of the potential to precipitate hypertensive crisis. (7)
See 17 for PATIENT COUNSELING INFORMATION.
Monoamine Oxidase Inhibitors
The use of atropine and monoamine oxidase inhibitors (MAOI) is generally not recommended because of the potential to precipitate hypertensive crisis.
DESCRIPTION
Atropine sulfate ophthalmic solution, USP 1% is a sterile topical ophthalmic solution. Each mL of atropine sulfate ophthalmic solution, USP 1% contains 10 mg of atropine sulfate monohydrate equivalent to 9.7 mg/mL of atropine sulfate or 8.3 mg of atropine. Atropine sulfate monohydrate is designated chemically as benzeneacetic acid, α-(hydroxymethyl)-,8-methyl-8-aza-bicyclo-[3.2.1]oct-3-yl ester, endo -( + )-, sulfate(2:1) (salt), monohydrate. Its molecular formula is (C 17 H 23 NO 3 ) 2 • H 2 SO 4 • H 2 O and it is represented by the chemical structure:
Atropine sulfate monohydrate is colorless, almost white to white solid and has a molecular weight of 694.83.
Atropine sulfate ophthalmic solution, USP 1% has a pH of 3.5 to 6.0.
Active ingredient: atropine sulfate monohydrate 1%
Preservative: benzalkonium chloride 0.01%
Inactive ingredients: hypromellose, boric acid, sodium hydroxide and/or hydrochloric acid (to adjust pH), water for injection.
CLINICAL PHARMACOLOGY
Mechanism of Action
Atropine acts as a competitive antagonist of the parasympathetic (and sympathetic) acetylcholine muscarinic receptors. Topical atropine on the eye induces mydriasis by inhibiting contraction of the circular pupillary sphincter muscle normally stimulated by acetylcholine. This inhibition allows the countering radial pupillary dilator muscle to contract which results in dilation of the pupil. Additionally, atropine induces cycloplegia by paralysis of the ciliary muscle which controls accommodation while viewing objects.
Pharmacodynamics
The onset of action after administration of atropine sulfate ophthalmic solution 1% generally occurs in minutes with maximal effect seen in hours and the effect can last multiple days [see Clinical Studies (14)].
Pharmacokinetics
In a study of healthy subjects, after topical ocular administration of 30 µL of atropine sulfate ophthalmic solution, 1%, the mean (± SD) systemic bioavailability of l-hyoscyamine was reported to be approximately 64 ± 29% (range 19% to 95%) as compared to intravenous administration of atropine sulfate. The mean (± SD) time to maximum plasma concentration (T max ) was approximately 28 ± 27 minutes (range 3 to 60 minutes), and the mean (±SD) peak plasma concentration (C max ) of l-hyoscyamine was 288 ± 73 pg/mL. The mean (±SD) plasma half-life was reported to be approximately 2.5 ± 0.8 hours.
In a separate study of patients undergoing ocular surgery, after topical ocular administration of 40 µL of atropine sulfate ophthalmic solution, 1%, the mean (± SD) plasma C max of l-hyoscyamine was 860 ± 402 pg/mL.
NONCLINICAL TOXICOLOGY
Carcinogenesis, Mutagenesis, Impairment of Fertility
Atropine sulfate was negative in the Salmonella/microsome mutagenicity test. Studies to evaluate carcinogenicity and impairment of fertility have not been conducted.
CLINICAL STUDIES
Topical administration of atropine sulfate ophthalmic solution 1% results in mydriasis and/or cycloplegia, with efficacy demonstrated in both adults and children. The maximum effect for mydriasis is achieved in about 30–40 minutes after administration, with recovery after approximately 7–10 days. The maximum effect for cycloplegia is achieved within 60–180 minutes after administration, with recovery after approximately 7–12 days.
HOW SUPPLIED/STORAGE AND HANDLING
Atropine sulfate ophthalmic solution, USP 1% is supplied sterile in natural LDPE bottle with natural LDPE nozzle and red HDPE cap as follows:
- 5 mL filled in 10 mL bottles NDC 70069- 716 -01
Storage: Store atropine sulfate ophthalmic solution, USP 1% at 2°–25°C (36°–77°F).
Mechanism of Action
Atropine acts as a competitive antagonist of the parasympathetic (and sympathetic) acetylcholine muscarinic receptors. Topical atropine on the eye induces mydriasis by inhibiting contraction of the circular pupillary sphincter muscle normally stimulated by acetylcholine. This inhibition allows the countering radial pupillary dilator muscle to contract which results in dilation of the pupil. Additionally, atropine induces cycloplegia by paralysis of the ciliary muscle which controls accommodation while viewing objects.
