Neostigmine, pyridostigmine, and edrophonium are primary excreted via both glomerular filtration and active tubular secretion. Neostigmine is water-soluble and roughly 50% of it undergoes renal excretion compared to 75% of pyridostigmine and edrophonium. Clearance of these drugs is significantly reduced in patients with ESRD and dosing adjustments may need to be made accordingly. When dosing neostigmine a ceiling effect is noted around 0.035 – 0.05 mg/kg in healthy individuals. Recurarization is unlikely in ESRD patients because the reduction in plasma clearance of anticholinesterases exceeds that of neuromuscular blocking agents. When used in combination with cholinergic blocking drugs (atropine & glycopyrrolate) no dosing adjusted is needed as toxic side effects are unlikely when administered as a single dose during neuromuscular reversal.
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