Paweł Radkowski, Joanna Monika Najbar, Aleksandra Antonina Skórka

Neostigmine: A declining role in anesthesiology. Emerging indications in contemporary clinical practice

2025-12-30

Background. In clinical practice, neostigmine remains an indispensable pharmacological agent. As an acetylcholinesterase inhibitor, it plays a pivotal role in medicine by increasing acetylcholine concentrations at neuromuscular junctions. This mechanism enables effective reversal of neuromuscular blockade induced by non-depolarizing neuromuscular blocking agents. Beyond this established use, neostigmine exhibits a broad therapeutic profile with multiple clinical applications.

The aim. This review aims to consolidate current knowledge regarding neostigmine, with a particular focus on recent advances and emerging directions in its clinical development. These include novel delivery systems, potential expanded therapeutic indications, and the evaluation of its efficacy and safety across diverse (pediatric, geriatric, and pregnant) patient populations.

Materials and methods. A comprehensive literature review was conducted using PubMed and Google Scholar databases. Search terms included combinations of keywords such as „neostigmine”, „neostigmine geriatric”, „neostigmine pediatric”, „neostigmine dosing”, „neostigmine side effects”, „neostigmine off-label”, „neostigmine anesthesia”, „neostigmine myasthenia gravis” and „neuromuscular blockade treatment”. The analysis encompassed literature published between 1977 and 2025, including randomized controlled trials, meta-analyses, and case reports.

Results. Neostigmine remains the most commonly used agent for reversing neuromuscular blockade, with a broad spectrum of action and relative affordability. However, it has several limitations, including reduced efficacy in reversing deep blockade, the risk of muscle weakness, and potential adverse cardiovascular effects. Data remain limited regarding its use in geriatric and pediatric populations. Novel applications, such as in the treatment of gastrointestinal dysmotility or modulation of inflammatory responses, highlight new avenues for clinical exploration. Neuromuscular monitoring during neostigmine administration is essential to ensure therapeutic efficacy and patient safety.

Conclusions. Neostigmine remains a clinically relevant drug due to its low cost and broad-ranging pharmacodynamic effects. Nonetheless, its role in anesthesiology may gradually decline with the emergence of newer agents such as sugammadex. Expanding indications, particularly in gastroenterology and neurology, offer promising directions for future research but require validation in larger, controlled clinical trials. The use of neostigmine necessitates individualized risk assessment, especially in pediatric and elderly patients. In the era of rapidly evolving pharmacotherapy, its future role will depend on the outcomes of ongoing studies and possible updates to clinical practice guidelines.

Keywords: neostigmine, neuromuscular blockade, acetylcholinesterase inhibitor, intensive care units.

© Farm Pol, 2025, 81(6): 379–388