N/A

Cardiovascular Risks Cardiovascular adverse reactions reported in the literature for atropine include, but are not limited to, sinus tachycardia, palpitations, premature ventricular contractions, atrial flutter, atrial fibrillation, ventricular flutter, ventricular fibrillation, cardiac syncope, asystole, and myocardial infarction [see Adverse Reactions (6)]. In patients with a recent myocardial infarction and/or severe coronary artery disease, there is a possibility that atropine-induced tachycardia may cause ischemia, extend or initiate myocardial infarcts, and stimulate ventricular ectopy and fibrillation. Atropine should be used with caution in patients with known cardiovascular disease or cardiac conduction problems. Heat Injury Atropine may inhibit sweating which, in a warm environment or with excessive exercise, can lead to hyperthermia and heat injury. To the extent feasible, avoid excessive exercise and heat exposure [see Adverse Reactions (6)]. Acute Glaucoma Atropine may cause acute glaucoma and should be administered with caution in patients at risk for acute glaucoma or who have severe narrow angle glaucoma. Monitor for signs and symptoms of intraocular pressure, as appropriate. Urinary Retention Atropine may cause urinary retention and should be administered with caution to patients with clinically significant bladder outflow obstruction. Pyloric Stenosis Atropine may cause complete pyloric obstruction in patients with partial pyloric stenosis. These patients should be monitored for gastrointestinal symptoms following administration of Atropine. Exacerbation of Chronic Lung Disease Atropine may cause thickening of bronchial secretions and formation of dangerous viscid plugs in individuals with chronic lung disease. Respiratory status should be monitored in individuals with chronic lung disease following administration of Atropine. Hypersensitivity Atropine can cause hypersensitivity reactions, including anaphylactic reactions [see Adverse Reactions (6)]. Medical supervision is necessary in patients who have had previous anaphylactic reactions to atropine and require treatment for organophosphorus or nerve agent poisoning. Cardiovascular (CV) Risks : Tachycardia, palpitations, premature ventricular contractions, flutter, fibrillation, etc. Use caution in patients with known CV disease or conduction problems. (5.1) Heat Injury: May inhibit sweating and lead to hyperthermia; avoid excessive exercising and heat exposure. (5.2) Acute Glaucoma : May precipitate in susceptible individuals. (5.3) Urinary Retention : Administer with caution in patient with bladder outflow obstruction. (5.4) Pyloric Stenosis : May convert into complete obstruction. (5.5) Exacerbation of Chronic Lung Disease : Atropine may cause inspiration of bronchial secretions and formation of dangerous viscid plugs in individuals with chronic lung disease; monitor respiratory status. (5.6) Hypersensitivity : Atropine may cause hypersensitivity reactions, including anaphylaxis (5.7)

The following serious adverse reactions are described elsewhere in the labeling: Cardiovascular Risks [ see Warnings and Precautions ( 5.1) ] Heat Injury [ see Warnings and Precautions ( 5.2) ] Acute Glaucoma [ see Warnings and Precautions ( 5.3) ] Urinary Retention [ see Warnings and Precautions ( 5.4) ] Pyloric Stenosis [ see Warnings and Precautions ( 5.5) ] Exacerbation of Chronic Lung Disease [ see Warnings and Precautions ( 5.6) ] Hypersensitivity [ see Warnings and Precautions (5.7) ] The following adverse reactions associated with the use of atropine were identified in the literature. 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. Injection Site Reactions Mild to moderate pain may be experienced at the site of injection. Adverse Reactions at Recommended Dosages The major and most common side effects of atropine can be attributed to its antimuscarinic action. These include dryness of the mouth, blurred vision, dry eyes, photophobia, confusion, headache, dizziness, fatigue, tachycardia, palpitations, flushing, urinary hesitance or retention, constipation, abdominal pain, abdominal distention, nausea, vomiting, loss of libido, and impotency. Anhidrosis may produce heat intolerance and impairment of temperature regulation especially in a hot environment. Hypersensitivity Hypersensitivity reactions will occasionally occur with atropine; these are usually seen as skin rashes, on occasion progressing to exfoliation. Anaphylactic reactions have occurred. Additional Adverse Reactions to Atropine by Organ System The following adverse reactions were reported in published literature for atropine in both adults and pediatric patients: Cardiovascular : Sinus tachycardia, supraventricular tachycardia, junctional tachycardia, ventricular tachycardia, bradycardia, palpitations, ventricular arrhythmia, ventricular flutter, ventricular fibrillation, atrial arrhythmia, atrial fibrillation, atrial ectopic beats, ventricular premature contractions, bigeminal beats, trigeminal beats, nodal extrasystole, ventricular extrasystole, supraventricular extrasystole, asystole, cardiac syncope, prolongation of sinus node recovery time, cardiac dilation, left ventricular failure, myocardial infarction, intermittent nodal rhythm (no P wave), prolonged P wave, shortened PR segment, R on T phenomenon, shortened RT duration, widening and flattening of QRS complex, prolonged QT interval, flattening of T wave, repolarization abnormalities, altered ST-T waves, retrograde conduction, transient AV dissociation, increased blood pressure, decreased blood pressure, labile blood pressure, weak or impalpable peripheral pulses. Eye : Mydriasis, pupils poorly reactive to light, decreased contrast sensitivity, decreased visual acuity, decreased accommodation, cycloplegia, strabismus, heterophoria, cyclophoria, acute angle closure glaucoma, conjunctivitis, keratoconjunctivitis sicca, blindness, tearing, dry conjunctiva, irritated eyes, crusting of eyelid, blepharitis. Gastrointestinal : Paralytic ileus, decreased bowel sounds, delayed gastric emptying, decreased food absorption, dysphagia. General : Hyperpyrexia, lethargy, somnolence, chest pain, excessive thirst, weakness, syncope, insomnia, tongue chewing, dehydration, feeling hot. Special Investigations : Leukocytosis, hyponatremia, elevated BUN, elevated hemoglobin, elevated erythrocytes, low hemoglobin, hypoglycemia, hyperglycemia, hypokalemia, increase in photic stimulation on EEG, signs of drowsiness on EEG, runs of alpha waves on EEG, alpha waves (EEG) blocked upon opening eyes. Metabolic : Failure to feed. Central Nervous System : Ataxia, hallucinations (visual or aural), seizures (generally tonic-clonic), abnormal movements, coma, stupor, amnesia, diminished tendon reflexes, hyperreflexia, muscle twitching, opisthotnos, Babinski's reflex/Chaddock's reflex, hypertonia, dysmetria, muscle clonus, sensation of intoxication, difficulty concentrating, vertigo, dysarthria. Psychiatric : Agitation, restlessness, delirium, paranoia, anxiety, mental disorders, mania, withdrawn behavior, behavior changes. Genitourinary : Difficulty in micturation, urine urgency, distended urinary bladder, bed-wetting. Pulmonary : Tachypnea, slow respirations, shallow respirations, breathing difficulty, labored respirations, inspiratory stridor, laryngitis, laryngospasm, pulmonary edema, respiratory failure, subcostal recession. Dermatologic : Dry mucous membranes, dry warm skin, oral lesions, dermatitis, petechiae, rash, macular rash, papular rash, maculopapular rash, scarlatiniform rash, erythematous rash, sweating/moist skin, cold skin, cyanosed skin, salivation. Adverse Reactions Caused by Inadvertent Injection Administering additional 2 mg Atropine autoinjectors by mistake in the absence of actual nerve agent or insecticide poisoning may cause an overdose of atropine which could result in temporary incapacitation (inability to walk properly, see clearly or think clearly for several or more hours). Patients with cardiac disease may be at risk for serious adverse events, including death. Adverse Reactions Observed in Pediatric Patients after Inappropriate Administration of Atropine Amitai et al. (JAMA 1990) evaluated the safety of an atropine autoinjector in a case series of 240 children who received the atropine inappropriately (i.e., no nerve agent exposure) during the 1990 Gulf War Period. Overall, severity of atropinization followed a nonlinear correlation with dose. Estimated doses up to 0.045 mg/kg produced no signs of atropinization. Estimated doses between 0.045 mg/kg to 0.175 mg/kg and even greater than 0.175 mg/kg were associated with mild and severe effects respectively. Actual dosage received by children may have been considerably lower than estimated since incomplete injection in many cases was suspected. Regardless, adverse events reported were generally mild and self-limited. Few children required hospitalization. Adverse reactions reported were dilated pupils (43%), tachycardia (39%), dry membranes (35%), flushed skin (20%), temperature 37.8° C or 100° F (4%), and neurologic abnormalities (5%). There was also local pain and swelling. In patients with electrocardiograms, 22 of 91 (24%) children had severe tachycardia of 160-190 bpm. Neurologic abnormalities consisted of irritability, agitation, confusion, lethargy, and ataxia. Atropine 2mg is only approved for pediatric patients weighing more than 41kg at the recommended dosing. Mild to moderate pain may be experienced at the site of injection. Common adverse reactions of atropine include dryness of the mouth, blurred vision, dry eyes, photophobia, confusion, headache, dizziness, tachycardia, palpitations, flushing, urinary hesitance or retention, constipation, abdominal pain, abdominal distention, nausea, vomiting, loss of libido, and impotency (6.1, 6.2). To report SUSPECTED ADVERSE REACTIONS, contact Rafa Laboratories at 1-386-418-7911 or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch