Atropine Schedule (India)

Schedule H

Atropine Routes

Intravenous (IV), Intramuscular (IM), Subcutaneous (SC), Endotracheal (ET), Ophthalmic (Topical)

Atropine Formulations

Injection: 0.6 mg/mL (1 mL ampoule), 1 mg/mL (1 mL ampoule)

Ophthalmic solution: 1% w/v eye drops (5 mL, 10 mL bottles)

Note: Paediatric oral drops and prefilled syringes are NOT routinely available in India.

Atropine Adult indications

INDICATIONS + DOSING — FOR CLINICIAN USE ONLY

Primary Indications (Approved / Standard in India)

Symptomatic Bradycardia (Haemodynamically Unstable)

Parameter Recommendation

Starting dose 0.5–1 mg IV bolus

Titration Repeat 0.5–1 mg IV every 3–5 minutes until adequate heart rate achieved

Usual maintenance dose Not applicable (acute use only)

Maximum dose 3 mg total (vagolytic effect complete at this dose)

Key Clinical Notes:

First-line agent for symptomatic sinus bradycardia and high-grade AV block

Doses <0.5 mg may cause paradoxical bradycardia — avoid underdosing in adults

Ineffective in denervated hearts (cardiac transplant) and infranodal blocks

Not effective for hypothermic bradycardia — focus on rewarming

Onset: 1–2 minutes IV

Organophosphate / Carbamate Poisoning

Parameter Recommendation

Starting dose 2–5 mg IV bolus (severe cases may need higher initial dose)

Titration Double the dose every 5–10 minutes until muscarinic symptoms controlled

Usual maintenance dose Continuous IV infusion 0.5–2 mg/hour (10–20% of total loading dose per hour)

Maximum dose No fixed maximum — titrate to clinical endpoints

Clinical Endpoints for Atropinisation:

Drying of bronchial secretions (primary endpoint)

Heart rate >80/min

Systolic BP >80 mmHg

Pupils no longer pinpoint (but do NOT use pupil size as primary titration target)

Key Clinical Notes:

Administer with pralidoxime (PAM) for organophosphate poisoning

Very large cumulative doses (100+ mg over 24–48 hours) may be required in severe poisoning

Continue infusion until patient can maintain atropinisation without redosing for 24 hours

Do not delay atropine for poisoning — it is life-saving

Pre-anaesthetic Medication (Reduction of Secretions and Vagal Bradycardia Prevention)

Parameter Recommendation

Starting dose 0.3–0.6 mg IM or SC

Titration Not applicable

Usual maintenance dose Single pre-operative dose

Maximum dose 0.6 mg

Key Clinical Notes:

Administer 30–60 minutes before anaesthesia induction (IM/SC)

Less commonly used in modern anaesthesia practice — glycopyrrolate often preferred (less CNS effects, longer duration)

Use with caution in elderly and patients with coronary artery disease

Mydriasis and Cycloplegia (Ophthalmic Use)

Parameter Recommendation

Starting dose 1 drop of 1% solution in affected eye(s)

Titration Not applicable

Usual maintenance dose 1–2 drops once or twice daily

Maximum dose As per ophthalmology protocol

Key Clinical Notes:

Produces prolonged mydriasis (7–10 days) and cycloplegia (up to 14 days)

Used for cycloplegic refraction in children, uveitis treatment, and pre/post-operative mydriasis

NOT suitable for routine fundoscopy where shorter-acting mydriatics (tropicamide) are preferred

Compress lacrimal sac for 1–2 minutes after instillation to reduce systemic absorption

Secondary Indications – Adults Only (Off-label)

Asystole / Pulseless Electrical Activity (PEA) — NO LONGER RECOMMENDED

Atropine is NO LONGER part of standard ACLS protocols for asystole or PEA

Historical use has been discontinued based on lack of survival benefit

Focus on high-quality CPR, adrenaline, and reversible cause identification

Reversal of Neuromuscular Blockade (with Neostigmine) — OFF-LABEL (but common practice)

Starting dose: 0.6–1.2 mg IV (given with neostigmine 2.5–5 mg)

Titration: Not applicable

Usual maintenance dose: Single dose

Maximum dose: 1.2 mg

Specialist only (Anaesthesiology)

Evidence: Standard anaesthesia practice; prevents muscarinic side effects of neostigmine

Atropine Paediatric indications

PAEDIATRIC DOSING (Specialist Only)

Primary Indications (Approved / Standard in India)

Symptomatic Bradycardia (Paediatric Advanced Life Support)

Age/Weight Starting Dose Route Maximum Single Dose Maximum Total Dose

Neonates 0.02 mg/kg IV/IO Minimum 0.1 mg 0.04 mg/kg

Infants (<1 year) 0.02 mg/kg IV/IO 0.5 mg 1 mg

Children (1–12 years) 0.02 mg/kg IV/IO 0.5 mg 1 mg

Adolescents (>12 years) 0.02 mg/kg IV/IO 1 mg 2 mg

Parameter Recommendation

Starting dose 0.02 mg/kg IV/IO

Titration Repeat every 3–5 minutes if bradycardia persists

Usual maintenance dose Not applicable (acute use)

Maximum dose Child: 1 mg total; Adolescent: 2 mg total

Endotracheal (ET) Route (if IV/IO not available):

Dose: 0.04–0.06 mg/kg ET

Dilute in 3–5 mL normal saline before administration

Absorption is unpredictable — establish IV/IO access as soon as possible

Organophosphate / Carbamate Poisoning

Parameter Recommendation

Starting dose 0.02–0.05 mg/kg IV (minimum 0.1 mg)

Titration Repeat every 5–10 minutes until secretions dry

Usual maintenance dose Continuous infusion may be needed — 0.02–0.08 mg/kg/hour

Maximum dose No fixed maximum — titrate to clinical response

Key Clinical Notes:

Administer with pralidoxime

Endpoint: Drying of secretions (NOT pupil size or heart rate alone)

Specialist only (Paediatric Emergency/ICU)

Cycloplegic Refraction / Uveitis (Ophthalmic)

Age Dose Frequency

3 months – 3 years 1 drop of 0.5% solution Once daily for 1–3 days before examination

3 years 1 drop of 1% solution Once daily for 1–3 days

Key Clinical Notes:

Compress lacrimal punctum after instillation to minimize systemic absorption

Monitor for systemic anticholinergic effects (flushing, fever, tachycardia)

Not recommended below 3 months of age except under specialist ophthalmology supervision

Secondary Indications – Paediatric Doses (Off-label)

Pre-anaesthetic Use — OFF-LABEL (less common in modern practice)

Starting dose: 0.01–0.02 mg/kg IM

Titration: Not applicable

Usual maintenance dose: Single dose

Maximum dose: 0.4 mg

Duration: 30–60 minutes before induction

Specialist only (Paediatric Anaesthesiology)

Evidence: Standard paediatric anaesthesia texts; glycopyrrolate often preferred

Safety Monitoring (All Paediatric Use):

Heart rate and rhythm monitoring

Blood pressure

Respiratory status (especially in poisoning)

Temperature monitoring (risk of hyperthermia)

Mental status assessment for anticholinergic toxicity

Minimum dose of 0.1 mg per dose recommended in neonates and infants to avoid paradoxical bradycardia.

Atropine Renal Adjustments

No dosage adjustment required

Atropine is primarily metabolized hepatically with minimal renal excretion of unchanged drug

Safe to use in renal impairment including dialysis patients

Atropine Hepatic adjustment

Mild impairment: No dosage adjustment required

Moderate impairment: Use with caution; standard doses generally tolerated

Severe impairment (Child-Pugh C): Use with caution; may have increased sensitivity to anticholinergic effects due to reduced hepatic metabolism; monitor for excessive anticholinergic effects

Atropine Contraindications

Known hypersensitivity to atropine or belladonna alkaloids

Narrow-angle glaucoma (ophthalmic use contraindicated; systemic use with extreme caution)

Obstructive gastrointestinal disease (pyloric stenosis, paralytic ileus, toxic megacolon)

Obstructive uropathy with urinary retention

Myasthenia gravis (may worsen weakness by blocking compensatory muscarinic effects)

Severe ulcerative colitis or toxic megacolon

Note: In life-threatening emergencies (bradycardia, poisoning), relative contraindications should not delay treatment.

Atropine Cautions

Elderly patients — increased sensitivity to CNS effects (confusion, delirium)

Cardiovascular disease — may precipitate tachyarrhythmias or myocardial ischaemia

Hyperthyroidism — exaggerated tachycardic response

Fever or high ambient temperature — risk of hyperthermia (inhibits sweating)

Chronic pulmonary disease — thickened secretions may worsen airway obstruction

Prostatic hypertrophy — risk of acute urinary retention

Down syndrome — increased sensitivity to anticholinergic effects

Autonomic neuropathy

Gastro-oesophageal reflux disease

Hiatus hernia

Atropine Pregnancy

Parameter Recommendation

Risk category No formal Indian classification; generally considered relatively safe in emergencies

Placental transfer Crosses placenta; may cause fetal tachycardia

Preferred alternatives None in emergency situations — use atropine when indicated

When may be used Life-threatening bradycardia, poisoning, anaesthesia adjunct

Monitoring Continuous fetal heart rate monitoring when used intrapartum; maternal heart rate and rhythm

Atropine Lactation

Parameter Recommendation

Compatibility Compatible with breastfeeding (single/emergency doses)

Expected drug levels in milk Low; minimal amounts excreted

Preferred alternatives Not applicable in emergency settings

What to monitor in infant Dry mouth, feeding difficulty, constipation, irritability, decreased urine output (with repeated maternal doses)

Note: May reduce milk production with repeated doses due to anticholinergic effects.

Atropine Elderly

Starting dose: 0.3–0.5 mg IV for bradycardia (lower end of adult range)

Titration: Slower titration with longer intervals between doses

Extra risks:

Pronounced CNS effects (confusion, agitation, hallucinations, delirium)

Increased risk of urinary retention

Tachyarrhythmias and myocardial ischaemia

Constipation and faecal impaction

Heat intolerance and hyperthermia

Falls (due to confusion, visual disturbance)

Avoid ophthalmic use unless essential — prolonged cycloplegia increases fall risk

Atropine Major drug interactions

Interacting Drug Effect Mechanism Management

Cholinesterase inhibitors (neostigmine, pyridostigmine, donepezil, rivastigmine) Antagonistic effect Opposing actions at muscarinic receptors Expected when atropine used to counter muscarinic side effects; avoid in myasthenia gravis treatment

Other anticholinergics (antihistamines, tricyclic antidepressants, antipsychotics, oxybutynin) Additive anticholinergic toxicity Cumulative muscarinic blockade Avoid combination; if necessary, monitor for anticholinergic syndrome

Potassium chloride (slow-release oral preparations) Increased risk of GI ulceration Delayed GI transit prolongs contact time Avoid slow-release potassium during atropine use; use liquid preparations if needed

Atropine Moderate drug interactions

Interacting Drug Effect Management

Beta-blockers Atropine may be needed to counteract bradycardia; concurrent use may cause unpredictable heart rate response Monitor heart rate closely

Digoxin Atropine may increase digoxin absorption (reduced GI motility) Monitor for digoxin toxicity if atropine used repeatedly

Amantadine Additive anticholinergic effects Monitor for confusion and urinary retention

Nitrates May have additive hypotensive effects initially followed by tachycardia Monitor blood pressure and heart rate

Opioids Additive constipation and urinary retention Prophylactic bowel regimen; monitor voiding

Topical ophthalmic beta-blockers Systemic beta-blockade may be antagonized by atropine Monitor for desired ophthalmic effect

Atropine Common Adverse effects

Dry mouth (xerostomia)

Blurred vision and photophobia

Tachycardia and palpitations

Urinary hesitancy or retention

Constipation and reduced gastrointestinal motility

Flushing and warm dry skin

Mydriasis (even with systemic use)

Decreased sweating

Mild confusion or restlessness (especially elderly)

Atropine Serious Adverse effects

Anticholinergic toxicity/syndrome: Hyperthermia, severe agitation, hallucinations, seizures, coma — requires supportive care; consider physostigmine in severe cases

Acute angle-closure glaucoma: Especially with ophthalmic use in predisposed individuals — requires immediate ophthalmology referral

Severe tachyarrhythmias: Atrial fibrillation, supraventricular tachycardia, ventricular arrhythmias — more common in cardiac disease

Hyperthermia/heat stroke: Due to inhibition of sweating — especially in hot environments or with fever

Complete urinary retention: Especially in elderly men with prostatic hypertrophy

Paralytic ileus: With repeated high doses

Anaphylaxis: Rare

Atropine Monitoring requirements

Baseline:

Heart rate and rhythm (ECG if available)

Blood pressure

Respiratory rate and pattern (in poisoning)

Pupil size (in poisoning — but not primary titration target)

Level of consciousness

After Administration:

Heart rate every 5 minutes during acute use

Blood pressure monitoring

Respiratory secretions (in OP poisoning — primary endpoint)

Mental status (especially elderly)

Temperature (risk of hyperthermia)

For Ophthalmic Use:

Intraocular pressure in susceptible patients

Systemic absorption signs (especially children): flushing, fever, tachycardia, dry skin

Long-term:

Not typically applicable — atropine is used acutely

In OP poisoning, continue monitoring for 24–48 hours after stopping infusion

Atropine Brands in India

Injection:

Atropine Sulphate IP (generic — multiple manufacturers)

Tropine (Neon)

Atropin (Samarth)

Atrosulf (Sun Pharma)

Ophthalmic:

Atropine Eye Drops 1% (generic — multiple manufacturers)

Atropt (Alcon)

Atrosulph (FDC)

Tropicacyl-A (combination with tropicamide — limited use)

Atropine Price range (INR)

Injection 0.6 mg/mL (1 mL ampoule): ₹3–₹12

Injection 1 mg/mL (1 mL ampoule): ₹5–₹15

Eye drops 1% (5 mL): ₹20–₹50

Eye drops 1% (10 mL): ₹35–₹80

Included in NLEM 2022

Available in government hospital supplies (essential for poisoning management and emergency care)

Atropine Clinical pearls

Avoid underdosing in bradycardia: Doses <0.5 mg in adults may cause paradoxical bradycardia due to central vagal stimulation — always use at least 0.5 mg per dose

OP poisoning endpoint is secretion drying, NOT pupil dilation: Pupils may remain constricted despite adequate atropinisation; titrate to clear lung sounds and dry bronchial secretions

Do not delay atropine in severe OP poisoning: Large doses are often required — some patients need hundreds of milligrams over several days; underdosing leads to treatment failure

Glycopyrrolate preferred for pre-anaesthetic use: Does not cross blood-brain barrier (fewer CNS effects) and has longer duration; atropine reserved for specific indications

Shorter-acting mydriatics preferred for routine eye exams: Tropicamide (onset 20–30 minutes, duration 4–6 hours) is preferred over atropine (duration 7–14 days) for routine fundoscopy

Anticholinergic toxicity in elderly: "Blind as a bat, dry as a bone, red as a beet, mad as a hatter, hot as a hare" — recognize this syndrome early and provide supportive care

Atropine Tags

atropine; anticholinergic; bradycardia; organophosphate poisoning; carbamate poisoning; emergency medicine; mydriatic; NLEM India; parasympatholytic; resuscitation

Atropine Version

RxIndia v1.0 — 08 Apr 2025

Atropine Reference

CDSCO approved prescribing information

Indian Pharmacopoeia 2018

National List of Essential Medicines (NLEM) India 2022

API Textbook of Medicine

AIIMS Emergency Medicine Protocols

ICMR Guidelines on Pesticide Poisoning Management

IAP Paediatric Advanced Life Support Guidelines

Goodman & Gilman's The Pharmacological Basis of Therapeutics

RxIndia

The Drug Registry

Atropine