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Echothiophate: Drug information

Echothiophate: Drug information
(For additional information see "Echothiophate: Patient drug information" and see "Echothiophate: Pediatric drug information")

For abbreviations, symbols, and age group definitions used in Lexicomp (show table)
Brand Names: US
  • Phospholine Iodide
Pharmacologic Category
  • Acetylcholinesterase Inhibitor;
  • Ophthalmic Agent, Antiglaucoma;
  • Ophthalmic Agent, Miotic
Dosing: Adult
Elevated intraocular pressure

Elevated intraocular pressure: Ophthalmic:

Initial: Instill 1 drop in affected eye(s) twice daily (prior to bedtime and in the morning).

Maintenance: Twice-daily dosing is preferred, but some patients have been treated with once-daily or every-other-day dosing (with 1 dose just prior to bedtime).

Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.

Dosing: Kidney Impairment: Adult

There are no dosage adjustments provided in the manufacturer's labeling.

Dosing: Hepatic Impairment: Adult

There are no dosage adjustments provided in the manufacturer's labeling.

Dosing: Older Adult

Refer to adult dosing.

Dosing: Pediatric

(For additional information see "Echothiophate: Pediatric drug information")

Esotropia, accommodative

Esotropia, accommodative: Children and Adolescents: Ophthalmic:

Diagnosis: Instill 1 drop once daily into both eyes at bedtime for 2 to 3 weeks

Treatment: Instill 1 drop every other day in both eyes; gradually lower dose as treatment progresses. Maximum daily dose: 1 drop once daily in both eyes. Note: Use lowest frequency which gives satisfactory response; if necessary, more aggressive therapy may be used for short periods of time.

Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.

Dosing: Kidney Impairment: Pediatric

There are no dosage adjustments provided in the manufacturer's labeling.

Dosing: Hepatic Impairment: Pediatric

There are no dosage adjustments provided in the manufacturer's labeling.

Adverse Reactions

The following adverse drug reactions are derived from product labeling unless otherwise specified.

Postmarketing:

Cardiovascular: Cardiac abnormality (including bradycardia) (Manoguerra 1995)

Dermatologic: Diaphoresis (Alexander 1981)

Gastrointestinal: Abdominal cramps (Manoguerra 1995), diarrhea (Alexander 1981), nausea (Manoguerra 1995), salivation (Manoguerra 1995), vomiting (Manoguerra 1995)

Nervous system: Fatigue (Alexander 1981), headache (Chamberlain 1974), myasthenia (Manoguerra 1995)

Ophthalmic: Angle-closure glaucoma (Jones 1967), cataract (Shaffer 1966), iris cyst (Chamberlain 1974), lacrimation (Manoguerra 1995), miosis (Manoguerra 1995), myopia (Shaffer 1966)

Respiratory: Dyspnea (Manoguerra 1995)

Contraindications

Hypersensitivity to echothiophate or any component of the formulation; most cases of angle-closure glaucoma without iridectomy (due to possibility of increasing angle block); active uveal inflammation

Warnings/Precautions

Concerns related to adverse effects:

• Cardiac irregularities: Temporarily or permanently discontinue if cardiac irregularities occur.

• Cholinergic effects: Discontinue if symptoms of excess cholinergic activity (eg, salivation, sweating, urinary incontinence); overdosage may result in cholinergic crisis, which must be distinguished from myasthenic crisis.

Disease-related concerns:

• Asthma: Not generally recommended for use in patients with asthma.

• Cardiovascular disease: Not generally recommended for use in patients with bradycardia, hypotension or recent MI. In a scientific statement from the American Heart Association, ophthalmic cholinergic agents have been determined to be agents that may exacerbate underlying myocardial dysfunction (magnitude: minor) (AHA [Page 2016]).

• Gastrointestinal disease: Not generally recommended for use in patients with spastic gastrointestinal disturbances or peptic ulcer disease.

• Parkinsonism: Not generally recommended for use in patients with Parkinsonism.

• Seizure disorder: Not generally recommended for use in patients with a history of seizure disorder.

• Vagotonia: Not generally recommended for use in patients with vagotonia.

Other warnings/precautions:

• Appropriate use: Do not use for tonometric glaucoma, or in patients with active or history of uveitis, or history of retinal detachment. Use cautiously prior to ophthalmic surgery due to risk of blood in the anterior chamber. Digital compression of the nasolacrimal ducts for 1 to 2 minutes following instillation to minimize drainage into the nasal chamber is recommended. Wash hands following instillation.

• Exposure to pesticides and insecticides: Use with caution in patients exposed to carbamate- or organophosphate-type insecticides and pesticides; absorption of the pesticide through skin or respiratory tract may result in additive systemic effects; respiratory masks and frequent clothing changes may be necessary during exposure to pesticides in patients receiving echothiophate iodide.

• Tolerance: Patients may develop tolerance after prolonged use; a rest period restores response to the drug.

Dosage Forms: US

Excipient information presented when available (limited, particularly for generics); consult specific product labeling. [DSC] = Discontinued product

Solution Reconstituted, Ophthalmic:

Phospholine Iodide: 0.125% (5 mL [DSC])

Phospholine Iodide: 0.125% (5 mL) [contains chlorobutanol (chlorobutol)]

Generic Equivalent Available: US

No

Pricing: US

Solution (reconstituted) (Phospholine Iodide Ophthalmic)

0.125% (per mL): $611.60

Disclaimer: A representative AWP (Average Wholesale Price) price or price range is provided as reference price only. A range is provided when more than one manufacturer's AWP price is available and uses the low and high price reported by the manufacturers to determine the range. The pricing data should be used for benchmarking purposes only, and as such should not be used alone to set or adjudicate any prices for reimbursement or purchasing functions or considered to be an exact price for a single product and/or manufacturer. Medi-Span expressly disclaims all warranties of any kind or nature, whether express or implied, and assumes no liability with respect to accuracy of price or price range data published in its solutions. In no event shall Medi-Span be liable for special, indirect, incidental, or consequential damages arising from use of price or price range data. Pricing data is updated monthly.

Administration: Adult

Ophthalmic: Proper administration technique is required for maximal benefit. The nasolacrimal duct(s) should be compressed for 1 to 2 minutes after instillation of the drops. Excess fluid around the eye should be blotted with tissue; wash hands after instillation.

Administration: Pediatric

For ophthalmic use only. Proper administration technique is required for maximal benefit. Wash hands prior to use; to avoid contamination, do not allow dispenser tip to touch the eye or any surface; apply gentle pressure to the nasolacrimal duct(s) for 1 to 2 minutes after instillation of the drops to minimize drainage into nose and throat. Excess fluid around the eye should be blotted with tissue; wash hands after instillation.

Use: Labeled Indications

Accommodative esotropia: Concomitant esotropias with a significant accommodative component

Elevated intraocular pressure: Reduction of elevated intraocular pressure

Metabolism/Transport Effects

None known.

Drug Interactions

Note: Interacting drugs may not be individually listed below if they are part of a group interaction (eg, individual drugs within “CYP3A4 Inducers [Strong]” are NOT listed). For a complete list of drug interactions by individual drug name and detailed management recommendations, use the Lexicomp drug interactions program by clicking on the “Launch drug interactions program” link above.

Cyclopentolate: May diminish the therapeutic effect of Echothiophate Iodide. Risk C: Monitor therapy

Mivacurium: Echothiophate Iodide may increase the serum concentration of Mivacurium. Risk C: Monitor therapy

Succinylcholine: Echothiophate Iodide may increase the serum concentration of Succinylcholine. Management: For patients receiving echothiophate iodide eye drops, consider using a neuromuscular-blocking agents other than succinylcholine. If succinylcholine is used, consider a reduced dose, and monitor for enhanced/prolonged effects. Risk D: Consider therapy modification

Tropicamide: May diminish the therapeutic effect of Echothiophate Iodide. Risk C: Monitor therapy

Pregnancy Considerations

Animal reproduction studies have not been conducted.

Breastfeeding Considerations

It is not known if echothiophate is excreted in breast milk. Due to the potential for serious adverse reactions in the breastfed infant, a decision should be made whether to discontinue breastfeeding or to discontinue the drug, taking into account the importance of treatment to the mother.

Monitoring Parameters

Baseline measurement of anterior chamber angle; routine lens examinations (for opacities and during treatment of accommodative esotropia); IOP (at different times of the day)

Mechanism of Action

Long-acting inhibition of cholinesterase enhances activity of endogenous acetylcholine. Reduced degradation of acetylcholine leads to continuous stimulation of the ciliary muscle producing miosis; other effects include potentiation of accommodation and facilitation of aqueous humor outflow, with attendant reduction in intraocular pressure.

Pharmacokinetics (Adult Data Unless Noted)

Onset of action: Miosis: ≤60 minutes

Peak effect: Intraocular pressure decrease: After 24 hours

Duration: Miosis: 1 to 4 weeks; Intraocular pressure: Days to weeks.

Brand Names: International
International Brand Names by Country
For country code abbreviations (show table)

  • (AU) Australia: Phospholine Iodide;
  • (BE) Belgium: Phospholine Iodide;
  • (FI) Finland: Phospholine Iodide;
  • (GB) United Kingdom: Phospholine Iodide;
  • (GR) Greece: Phospholine Iodide;
  • (HU) Hungary: Oftan eco;
  • (IE) Ireland: Phospholine Iodide;
  • (JP) Japan: Phospholine Iodide;
  • (LU) Luxembourg: Phospholine Iodide;
  • (PR) Puerto Rico: Phospholine Iodide;
  • (SE) Sweden: Phospholine Iodide
  1. Abrahamson IA Jr, Abrahamson IA Sr. Prelimary report on 0.06-percent phospholine (echothiophate) iodide in the management of esotropia. Am J Ophthalmol. 1964;57:290-298. [PubMed 14123459]
  2. Alexander WD. Systemic side effects with eye drops. Br Med J (Clin Res Ed). 1981;282(6273):1359. doi:10.1136/bmj.282.6273.1359 [PubMed 6786494]
  3. Birks DA, Prior VJ, Silk E, et al, "Echothiophate Iodide Treatment of Glaucoma in Pregnancy," Arch Ophthalmol, 1968, 79(3):283-5. [PubMed 5640850]
  4. Chamberlain W. Anticholinesterase miotics in the management of accommodative esotropia. Trans Am Ophthalmol Soc. 1974;72:229-241. [PubMed 4462244]
  5. Jones DE, Watson DM. Angle-closure glaucoma precipitated by the use of phospholine iodide for esotropia in a child. Br J Ophthalmol. 1967;51(11):783-785. doi:10.1136/bjo.51.11.783 [PubMed 6060809]
  6. Manoguerra A, Whitney C, Clark RF, Anderson B, Turchen S. Cholinergic toxicity resulting from ocular instillation of echothiophate iodide eye drops. J Toxicol Clin Toxicol. 1995;33(5):463-465. doi:10.3109/15563659509013755 [PubMed 7650771]
  7. Page RL 2nd, O'Bryant CL, Cheng D, et al; American Heart Association Clinical Pharmacology and Heart Failure and Transplantation Committees of the Council on Clinical Cardiology; Council on Cardiovascular Surgery and Anesthesia; Council on Cardiovascular and Stroke Nursing; and Council on Quality of Care and Outcomes Research. Drugs That May Cause or Exacerbate Heart Failure: A Scientific Statement From the American Heart Association [published correction appears in Circulation. 2016;134(12):e261]. Circulation. 2016;134(6):e32-e69. [PubMed 27400984]
  8. Phospholine iodide (echothiophate) [prescribing information]. Locust Valley, NY: Fera Pharmaceuticals LLC; August 2021.
  9. Shaffer RN, Hetherington J Jr. Anticholinesterase drugs and cataracts. Trans Am Ophthalmol Soc. 1966;64:204-216. [PubMed 6007355]
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