Systematic (IUPAC) name
Clinical data
Trade names Prostigmin
AHFS/ monograph
Pregnancy cat.  ?
Legal status  ?
Pharmacokinetic data
Bioavailability Unclear, probably less than 5%
Metabolism Slow hydrolysis by acetylcholinesterase and also by plasma esterases
Half-life 50–90 minutes
Excretion Unchanged drug (up to 70%) and alcoholic metabolite (30%) are excreted in the urine
CAS number 59-99-4 YesY
ATC code N07AA01 S01EB06 QA03AB93
PubChem CID 4456
DrugBank DB01400
ChemSpider 4301 YesY
UNII 3982TWQ96G YesY
KEGG D08261 N
Chemical data
Formula C12H19N2O2 
Mol. mass 223.294 g/mol
SMILES eMolecules & PubChem
 N(what is this?)  (verify)

Neostigmine (Prostigmin, Vagostigmin) is a parasympathomimetic that acts as a reversible acetylcholinesterase inhibitor.



Neostigmine was first synthesized by Aeschlimann and Reinert in 1931.

Neostigmine is made by first reacting 3-dimethylaminophenol with N-dimethylcarbamoyl chloride, which forms a dimethylcarbamate. Next, that product is alkylated using dimethylsulfate, which forms neostigmine.[1]


By interfering with the breakdown of acetylcholine, neostigmine indirectly stimulates both nicotinic and muscarinic receptors. Unlike physostigmine, neostigmine has a quaternary nitrogen; hence, it is more polar and does not enter the CNS. Its effect on skeletal muscle is greater than that of physostigmine, and it can stimulate contractility before it paralyzes. Neostigmine has moderate duration of action, usually two to four hours.[2] Neostigmine binds to the anionic site of cholinesterase. The drug blocks the active site of acetylcholinesterase so the enzyme can no longer break down the acetylcholine molecules before they reach the postsynaptic membrane receptors. This allows for the threshold to be reached so a new impulse can be triggered in the next neuron. In myasthenia gravis there are too few acetylcholine receptors so with the acetylcholinesterase blocked, acetylcholine can bind to the few receptors and trigger a muscular contraction.

Clinical uses

It is used to improve muscle tone in people with myasthenia gravis and routinely, in anesthesia at the end of an operation, to reverse the effects of non-depolarizing muscle relaxants such as rocuronium and vecuronium, usually in a dose of 25 to 50 mcg per kilogram.

It can also be used for urinary retention resulting from general anesthesia and to treat curariform drug toxicity.

Another indication for use is the Ogilvie syndrome which is a pseudoobstruction of the colon in critically ill patients.

Historically, it has been used as a test for early pregnancy. In a non-pregnant female whose menstrual period is delayed, administration of neostigmine can provoke menstrual bleeding. Modern tests which rely on detecting hCG in urine have rendered this application obsolete.

Though one of only two treatments available for myasthenia gravis this drug is no longer available to anyone using the Medicare Part D program.

Side effects

Neostigmine can induce generic occular side effects including: headache, brow pain, blurred vision, phacodonesis, pericorneal injection, congestive iritis, various allergic reactions, and rarely, retinal detachment.[3]

Neostigmine will cause slowing of the heart rate (bradycardia), for this reason it is usually given along with a parasympatholytic drug such as atropine or glycopyrrolate.

Gastrointestial symptoms occur earliest after ingestion and include anorexia, nausea and vomiting, abdominal cramps and diarrhea.[4]

Spectral data

Neostigmine shows notable UV/VIS absorption at 261nm, 267nm, and 225nm.[5]

Neostigmine's 1H NMR Spectroscopy reveals shifts at: 7.8, 7.7, 7.4, 7.4, 3.8, and 3.1 parts per million. The higher shifts are due to the aromatic hydrogens. The lower shifts at 3.8ppm and 3.1ppm are due to the electronic withdrawing nature of the tertiary and quarterary nitrogen, respectively.[6]


Neostigmine, N,N,N-trimethyl-meta-(dimethylcarbomoyloxy)-phenylammonium methylsulfonate, which can be viewed as a simplified analog of physostigmine, is made by reacting 3-dimethylaminophenol with N-dimethylcarbamoyl chloride, which forms the dimethylcarbamate, and its subsequent alkylation using dimethylsulfate forming the desired compound. Neostigmine synthesis.png

See also


  1. ^ Gilman, A.G..; Goodman L.S.; Gilman A. Goodman and Guildman's The Pharmacological Basis of Therapeutics; 6th ed. Macmillan Publishing Co., Inc., 1980; pp 103
  2. ^ Howland, R. D., Mycek, M. J., Harvey, R. A., Champe, P. C., & Mycek, M. J. Pharmacology 3rd edition, Lippincott's Illustrated Reviews, 2008, pg. 51.
  3. ^ [Gilman, A. G., L. S. Goodman, and A. Gilman. (eds.). Goodman and Gilman's The Pharmacological Basis of Therapeutics. 6th ed. New York: Macmillan Publishing Co., Inc. 1980.,p.114]
  4. ^ [Gilman, A. G., L. S. Goodman, and A. Gilman. (eds.). Goodman and Gilman's The Pharmacological Basis of Therapeutics. 6th ed. New York: Macmillan Publishing Co., Inc. 1980., p.109]
  5. ^ Porst, Hella; Kny, L. Pharmazie, 1985 , vol. 40, # 5 p. 325 - 328
  6. ^ Ferdous, Abu J.; Waigh, Roger D. Journal of Pharmacy and Pharmacology, 1993 , vol. 45, # 6 p. 559 - 562