Interactions between nerve agent pretreatment and drugs commonly used in combat anesthesia

Pyridostigmine is a drug stockpiled for oral pretreatment of nerve agent exposure; however, the soldier is still vulnerable to conventional warfare injuries, which are commonly associated with the need for anesthesia and surgery. In order to determine if we should be concerned about pyridostigmine-drug interactions, a comprehensive search of existing literature on pyridostigmine and selected drugs contained in the Defense Medical Standardization Board D-Day Items list was completed. It appears that the most significant interaction might be with the neuromuscular blocking drugs used in anesthesia, which in turn could pose the greatest casualty management concerns. Other potential interactions are discussed, along with a review of the pharmacology of pyridostigmine.