Mestinon

Mestinon Under the Tongue - A Possible Emergency Measure for Myasthenic Difficulty in Swallowing

Martin Sampson, M.D.

Since 1984 we have learned of many instances where people in great Myasthenic difficulty were able to be tided over by the placement of Mestinon under the tongue.

The first instance involved the niece of our Chapter's then vice president for Administration. The niece was not functioning well on her usual Mestinon dosage and was admitted to a hospital to determine the corrective treatment. She entered the hospital at 1:00 p.m. and was due for Mestinon at 3:00 p.m. However, the attending physician had failed to leave an order with the nurse to administer the child's Mestinon and no other physician was available. By 9:00 p.m. the child was in distress. She was choking on her own saliva and had to be suctioned.

A nurse wanted to give the child Mestinon syrup but could not locate any in the hospital. At this point the child's mother - a Myasthenic herself - sensed her child's imminent danger and instinctively placed half a Mestinon tablet under her child's tongue. Apparently, the drug was absorbed rapidly from that site for the child began to recover and was able to swallow without difficulty within 15 minutes after the tablet had been placed under her tongue.

Ruth Sampson, R.N., (former chair of our Chapter's Nurses Advisory Board and former secretary of the National Nurses Advisory Board) reported the foregoing in her milestone report entitled "Physical, Emotional, Social, and Family Interactions in Childhood Myasthenia Gravis," which was published as a book chapter in 1984.

Another of our members, our Chapter's then treasurer had a thymectomy in 1984. About a week after the thymectomy she was back home and found that she was having difficulty swallowing and breathing despite her usual Mestinon dosage (taken by mouth). She realized that she was probably going into a Myasthenic crisis. She tried taking Mestinon syrup but was unable to swallow the syrup (which is frequently the case with those myasthenics who have swallowing problems). She then remembered Ruth Sampson's description of the above experience and placed a Mestinon tablet under her tongue. Her swallowing and breathing difficulties were diminished within 30 minutes after she put the tablet under her tongue and hence she was tided over until an ambulance was able to bring her to her local hospital.

Our Chapter's Medical Advisory Board was apprised of the foregoing in 1984. The board, and particularly Dr. Peter Kornfield then in charge of the MG Clinic at Englewood Hospital, advised that we should publicize this information for the benefit of those who might in the future suffer pre-myasthenic-crisis symptoms - especially difficulty in swallowing. This was done and the results since then have been gratifying.

WHAT IS MESTINON® (pyridostigmine bromide,USP) AND HOW DOES IT WORK?

mestinon

MESTINON® is an orally active cholinesterase inhibitor. MESTINON® prevents the breakdown of acetylcholine (pronounced "a cee til coline") by allowing more acetylcholine to accumulate. Acetylcholine is the chemical that sends nerve impulses to the muscle. With more acetylcholine, there is more control of voluntary functions such as eye movements, limited strength, swallowing and breathing.1,3,4
WHAT DISEASE DOES MESTINON® TREAT?
MESTINON® is useful in the treatment of myasthenia gravis. After nearly 50 years of use, MESTINON® continues to be used as the first line of therapy in the treatment of myasthenia gravis. 1,2
WHAT IS THE RIGHT DOSE OF MESTINON® FOR ME?
The size and frequency of the dosage must be adjusted to the needs of the individual patient. Follow the prescribed dose regimen carefully. Record the response after each dose for the initial period of taking MESTINON®, or in times of instability of your myasthenia gravis weakness, to help your physician adjust the dose. Take care to discuss dosage changes with your physician since too much MESTINON® can result in extreme muscle weakness.1
WHAT ARE THE POSSIBLE ADVERSE REACTIONS and PRECAUTIONS?
MESTINON® is contraindicated in mechanical intestinal or urinary obstruction, and particular caution should be used in its administration to patients with bronchial asthma. The most common side effects of MESTINON® include nausea, vomiting, diarrhea, abdominal cramps, increased salivation,tearing and increased bronchial secretions. Additional side effects of MESTINON® are muscle twitching, muscle cramps and weakness. MESTINON® is mainly eliminated unchanged by the kidney. Therefore, lower doses may be required in patients with renal (kidney) disease. The safety of MESTINON® during pregnancy or lactation in humans has not been established nor has the safety and effectiveness in pediatric patients. Although failure of patients to show improvement with MESTINON® may reflect underdosage, it can also be caused by overdosage.1
THREE DOSAGE FORMS OF MESTINON®
Conventional MESTINON® Tablets each contain 60 mg pyridostigmine bromide; each tablet also contains: lactose, silicon dioxide and stearic acid.1

MESTINON® Syrup: One teaspoon of raspberry flavored syrup contains 60 mg of pyridostigmine bromide. In addition to pyridostigmine bromide, each teaspoon of MESTINON® Syrup contains 5% alcohol, glycerin, lactic acid, sodium benzoate, sorbitol, sucrose, FD&C Red #40, FD&C Blue #1, flavors and water. MESTINON® Syrup permits accurate dosage adjustment for children and "brittle" (fragile) myasthenic patients who require fractions of 60 mg doses. It is more easily swallowed, especially in the morning by patients with swallowing difficulties.1

MESTINON® Timespan® Tablets contain 180 mg pyridostigmine bromide. Timespan® Tablets are a slow release dosage form. In addition to pyridostigmine bromide, each Mestinon® Timespan® Tablet contains carnauba wax, corn-derived proteins, magnesium stearate, silica gel and tribasic calcium phosphate. As with most timed release dosage forms, MESTINON® Timespan® should not be crushed or broken into pieces. A broken Timespan® Tablet may disturb the timed release mechanism and could result in immediate release instead of slow release of the pyridostigmine bromide.
STORAGE OF MESTINON® TABLETS AND TIMESPAN®
MESTINON® Tablets and Timespan® are very hygroscopic (pronounced "hi gro ska pic") which means they readily pick up and retain moisture. Moist MESTINON® Tablets may become mottled or discolored or crumble easily. Moisture affects the appearance of MESTINON® but it does not alter the effectiveness of the drug.
Do not store MESTINON® Tablets or TIMESPAN® Tablets in bathrooms or kitchens where there is a higher incidence of moisture in the air.
MESTINON® Tablets are packaged in a bottle of 100 or 500 tablets. MESTINON® Timespan® is packaged in a bottle of 30 tablets. Do not remove the desiccant(s) (a small canister containing a drying agent) from any MESTINON® prescription bottle