View source for Pilocarpine

{{Short description|Medication used to treat glaucoma and dry mouth}}
{{Use dmy dates|date=January 2025}}
{{cs1 config |name-list-style=vanc |display-authors=6}}
{{Infobox drug
| Watchedfields = changed
| verifiedrevid = 464206617
| image = Pilocarpine.svg
| image_class = skin-invert-image
| width = 180
| alt = 
| image2 = Pilocarpine ball-and-stick model.png
| width2 = 
| alt2 = 
| caption = <!-- Clinical data -->
| pronounce = 
| tradename = Isopto Carpine, Salagen, others
| Drugs.com = {{drugs.com|monograph|pilocarpine}}
| MedlinePlus = a608039
| DailyMedID = Pilocarpine
| pregnancy_AU = B3
| pregnancy_AU_comment = 
| pregnancy_category = 
| routes_of_administration = [[Ophthalmic drug administration|Ophthalmic]], [[Oral administration|by mouth]]
| class = {{plainlist|
*[[Cholinergic]],
*[[Miotic]]<ref name=AHFS2016/>}}
| ATC_prefix = N07
| ATC_suffix = AX01
| ATC_supplemental = {{ATC|S01|EB01}}

<!-- Legal status -->| legal_AU = S4
| legal_AU_comment = 
| legal_BR = <!-- OTC, A1, A2, A3, B1, B2, C1, C2, C3, C4, C5, D1, D2, E, F -->
| legal_BR_comment = 
| legal_CA = <!-- OTC, Rx-only, Schedule I, II, III, IV, V, VI, VII, VIII -->
| legal_CA_comment = 
| legal_DE = <!-- Anlage I, II, III or Unscheduled -->
| legal_DE_comment = 
| legal_NZ = <!-- Class A, B, C -->
| legal_NZ_comment = 
| legal_UK = POM
| legal_UK_comment = 
| legal_US = Rx-only
| legal_US_comment = <ref name="Vuity FDA label">{{cite web | title=Vuity- pilocarpine hydrochloride solution/ drops | website=DailyMed | url=https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=8d806897-8a2a-4518-8c68-0ec3b778de50 | access-date=19 December 2021}}</ref>
| legal_EU = 
| legal_EU_comment = 
| legal_UN = <!-- N I, II, III, IV / P I, II, III, IV -->
| legal_UN_comment = 
| legal_status = <!-- For countries not listed above -->

<!-- Pharmacokinetic data -->| bioavailability = 
| protein_bound = 
| metabolism = 
| metabolites = 
| onset = 
| elimination_half-life = 0.76 hours (5 mg), 1.35 hours (10 mg)<ref>{{cite journal | vauthors = Gornitsky M, Shenouda G, Sultanem K, Katz H, Hier M, Black M, Velly AM | title = Double-blind randomized, placebo-controlled study of pilocarpine to salvage salivary gland function during radiotherapy of patients with head and neck cancer | journal = Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontics | volume = 98 | issue = 1 | pages = 45–52 | date = July 2004 | pmid = 15243470 | doi = 10.1016/j.tripleo.2004.04.009 }}</ref>
| duration_of_action = 
| excretion = Urine

<!-- Identifiers -->| CAS_number_Ref = {{cascite|correct|??}}
| CAS_number = 92-13-7
| CAS_number2 = 54-71-7
| PubChem = 5910
| IUPHAR_ligand = 305
| DrugBank_Ref = {{drugbankcite|correct|drugbank}}
| DrugBank = DB01085
| ChemSpiderID_Ref = {{chemspidercite|correct|chemspider}}
| ChemSpiderID = 5699
| UNII_Ref = {{fdacite|correct|FDA}}
| UNII = 01MI4Q9DI3
| UNII2 = 0WW6D218XJ
| KEGG_Ref = {{keggcite|correct|kegg}}
| KEGG = D00525
| KEGG2 = D02200
| ChEBI_Ref = {{ebicite|correct|EBI}}
| ChEBI = 8207
| ChEMBL_Ref = {{ebicite|correct|EBI}}
| ChEMBL = 550
| NIAID_ChemDB = 
| PDB_ligand = 
| synonyms = <!-- Chemical and physical data -->
| IUPAC_name = (3''S'',4''R'')-3-Ethyl-4-((1-methyl-1''H''-imidazol-5-yl)methyl)dihydrofuran-2(3''H'')-one
| C = 11
| H = 16
| N = 2
| O = 2
| SMILES = O=C2OC[C@H](Cc1n(cnc1)C)[C@@H]2CC
| StdInChI_Ref = {{stdinchicite|correct|chemspider}}
| StdInChI = 1S/C11H16N2O2/c1-3-10-8(6-15-11(10)14)4-9-5-12-7-13(9)2/h5,7-8,10H,3-4,6H2,1-2H3/t8-,10-/m0/s1
| StdInChI_comment = 
| StdInChIKey_Ref = {{stdinchicite|correct|chemspider}}
| StdInChIKey = QCHFTSOMWOSFHM-WPRPVWTQSA-N
| density = 
| density_notes = 
| melting_point = 
| melting_high = 
| melting_notes = 
| boiling_point = 
| boiling_notes = 
| solubility = 
| sol_units = 
| specific_rotation = 
}}

<!-- Definition and medical uses -->
'''Pilocarpine''' is a [[lactone]] [[alkaloid]] originally extracted from plants of the ''[[Pilocarpus]]'' genus.<ref name="Vardanyan_2006">{{cite book |doi=10.1016/B978-044452166-8/50013-3 |chapter=Cholinomimetics |title=Synthesis of Essential Drugs |date=2006 | vauthors = Vardanyan RS, Hruby VJ |pages=179–193 |isbn=978-0-444-52166-8 }}</ref> It is used as a medication to reduce [[pressure inside the eye]] and treat [[dry mouth]].<ref name="AHFS2016" /><ref name="Tar2019">{{cite book |title=Tarascon Pocket Pharmacopoeia 2019 Deluxe Lab-Coat Edition |date=2018 |publisher=Jones & Bartlett Learning |isbn=978-1-284-16754-2 |page=224 |url=https://books.google.com/books?id=pYZ-DwAAQBAJ&pg=PP224 }}</ref> As an [[eye drop]] it is used to manage [[angle closure glaucoma]] until surgery can be performed, [[ocular hypertension]], [[open angle glaucoma|primary open angle glaucoma]], and to [[miosis|constrict the pupil]] after dilation.<ref name="AHFS2016" /><ref name="WHO2008">{{cite book | title = WHO Model Formulary 2008 | year = 2009 | isbn = 978-92-4-154765-9 | vauthors = ((World Health Organization)) | veditors = Stuart MC, Kouimtzi M, Hill SR | hdl = 10665/44053 | author-link = World Health Organization | publisher = World Health Organization | hdl-access=free | page=439 }}</ref><ref>{{cite web |title=Glaucoma and ocular hypertension. NICE guideline 81 |url=https://bnf.nice.org.uk/treatment-summary/glaucoma-and-ocular-hypertension.html |publisher=National Institute for Health and Care Excellence. |access-date=19 September 2019 |date=November 2017 |quote=Ocular hypertension... alternative options include carbonic anhydrase inhibitors such as brinzolamide or dorzolamide, a topical sympathomimetic such as apraclonidine or brimonidine tartrate, or a topical miotic such as pilocarpine, given either as monotherapy or as combination therapy.}}</ref> However, due to its side effects, it is no longer typically used for long-term management.<ref>{{cite journal | vauthors = Lusthaus J, Goldberg I | title = Current management of glaucoma | journal = The Medical Journal of Australia | volume = 210 | issue = 4 | pages = 180–187 | date = March 2019 | pmid = 30767238 | doi = 10.5694/mja2.50020 | quote = Pilocarpine is no longer routinely used for long term IOP control due to a poor side effect profile | s2cid = 73438590 }}</ref> Onset of effects with the drops is typically within an hour and lasts for up to a day.<ref name="AHFS2016">{{cite web |title=Pilocarpine |url=https://www.drugs.com/monograph/pilocarpine.html|publisher=The American Society of Health-System Pharmacists|access-date=8 December 2016|url-status=live|archive-url=https://web.archive.org/web/20161228200133/https://www.drugs.com/monograph/pilocarpine.html|archive-date=28 December 2016}}</ref> By mouth it is used for dry mouth as a result of [[Sjögren syndrome]] or [[radiation therapy]].<ref name="Ric2015">{{cite book| vauthors = Hamilton R |title=Tarascon Pocket Pharmacopoeia 2015 Deluxe Lab-Coat Edition|date=2015|publisher=Jones & Bartlett Learning|isbn=978-1-284-05756-0|page=415}}</ref>

<!-- Side effects and mechanism -->
Common side effects of the eye drops include irritation of the eye, increased tearing, headache, and blurry vision.<ref name=AHFS2016/> Other side effects include [[allergic reactions]] and [[retinal detachment]].<ref name=AHFS2016/> Use is generally not recommended during [[pregnancy]].<ref>{{cite web|title=Pilocarpine ophthalmic Use During Pregnancy |url=https://www.drugs.com/pregnancy/pilocarpine-ophthalmic.html|website=Drugs.com |access-date=28 December 2016|url-status=live|archive-url=https://web.archive.org/web/20161228200001/https://www.drugs.com/pregnancy/pilocarpine-ophthalmic.html|archive-date=28 December 2016}}</ref> Pilocarpine is in the [[miotics]] family of medication.<ref name=BNF69>{{cite book|title=British national formulary: BNF 69|date=2015|publisher=British Medical Association|isbn=978-0-85711-156-2|page=769|edition=69}}</ref> It works by activating [[cholinergic receptors]] of the [[muscarinic acetylcholine receptor|muscarinic type]] which cause the [[trabecular meshwork]] to open and the [[aqueous humor]] to drain from the eye.<ref name=AHFS2016/>

<!-- History and culture -->
Pilocarpine was isolated in 1874 by Hardy and Gerrard and has been used to treat glaucoma for more than 100 years.<ref name=Sn2005>{{cite book| vauthors = Sneader W |title=Drug Discovery: A History|date=2005|publisher=John Wiley & Sons|isbn=978-0-471-89979-2 |page=98|url=https://books.google.com/books?id=Cb6BOkj9fK4C&pg=PA98|url-status=live|archive-url=https://web.archive.org/web/20161229100153/https://books.google.ca/books?id=Cb6BOkj9fK4C&pg=PA98|archive-date=2016-12-29}}</ref><ref>{{cite journal | vauthors = Rosin A | title = [Pilocarpine. A miotic of choice in the treatment of glaucoma has passed 110 years of use] | language = ro | journal = Oftalmologia | volume = 35 | issue = 1 | pages = 53–55 | year = 1991 | pmid = 1811739 }}</ref><ref>{{cite journal | vauthors = Holmstedt B, Wassén SH, Schultes RE | title = Jaborandi: an interdisciplinary appraisal | journal = Journal of Ethnopharmacology | volume = 1 | issue = 1 | pages = 3–21 | date = January 1979 | pmid = 397371 | doi = 10.1016/0378-8741(79)90014-x }}</ref> It is on the [[WHO Model List of Essential Medicines|World Health Organization's List of Essential Medicines]].<ref name="WHO21st">{{cite book | vauthors = ((World Health Organization)) | title = World Health Organization model list of essential medicines: 21st list 2019 | year = 2019 | hdl = 10665/325771 | author-link = World Health Organization | publisher = World Health Organization | location = Geneva | id = WHO/MVP/EMP/IAU/2019.06. License: CC BY-NC-SA 3.0 IGO | hdl-access=free }}</ref> It was originally made from the South American plant ''Pilocarpus''.<ref name=Sn2005/>

== Medical uses ==
Pilocarpine stimulates the secretion of large amounts of [[saliva]] and [[sweat]].<ref>{{cite web |title=Pilocarpine |url=https://www.medlineplus.gov/druginfo/meds/a608039.html |url-status=live |archive-url=https://web.archive.org/web/20100306135234/http://www.nlm.nih.gov/medlineplus/druginfo/meds/a608039.html |archive-date=2010-03-06 | work = MedLinePlus | publisher = U.S. National Library of Medicine }}</ref> It is used to prevent or treat [[xerostomia|dry mouth]], particularly in [[Sjögren syndrome]], but also as a side effect of [[radiation therapy]] for [[head and neck cancer]].<ref>{{cite journal | vauthors = Yang WF, Liao GQ, Hakim SG, Ouyang DQ, Ringash J, Su YX | title = Is Pilocarpine Effective in Preventing Radiation-Induced Xerostomia? A Systematic Review and Meta-analysis | journal = International Journal of Radiation Oncology, Biology, Physics | volume = 94 | issue = 3 | pages = 503–511 | date = March 2016 | pmid = 26867879 | doi = 10.1016/j.ijrobp.2015.11.012 | hdl-access = free | hdl = 10722/229069 }}</ref>

It may be used to help differentiate [[Adie syndrome]] from other causes of [[anisocoria|unequal pupil size]].<ref>{{Cite book|url=https://books.google.com/books?id=D9GfBwAAQBAJ&pg=PA812|title=Kanski's Clinical Ophthalmology E-Book: A Systematic Approach| vauthors = Kanski JJ, Bowling B |date=2015-03-24|publisher=Elsevier Health Sciences|isbn=978-0-7020-5574-4 |page = 812}}</ref><ref>{{cite book |doi=10.1016/B978-0-7506-9322-6.50011-8 |chapter=Drugs Affecting the Autonomic Nervous System |title=Clinical Ocular Pharmacology |date=1989 | vauthors = Jaanus SD, Pagano VT, Bartlett JD |pages=69–148 |isbn=978-0-7506-9322-6 }}</ref>

It may be used to treat a form of [[dry eye]] called aqueous deficient dry eye (ADDE).<ref>{{cite book | title = Cornea E-Book | vauthors = Mannis MJ, Holland EJ | publisher = Elsevier Health Sciences | date = September 2016 | chapter = Chapter 33: Dry Eye | chapter-url = https://books.google.com/books?id=ywwlDQAAQBAJ&pg=388 | page = 388 | isbn = 978-0-323-35758-6 | oclc = 960165358 }}</ref>

===Surgery===
Pilocarpine is sometimes used immediately before [[descemet membrane endothelial keratoplasty|certain types of corneal grafts]] and [[Intraocular lens#Anterior chamber iols (ACIOL)|cataract surgery]].<ref>{{cite thesis | vauthors = Parker J |title=Descemet Membrane Endothelial Keratoplasty (DMEK): A Review |date=2017 |publisher=Leiden University |hdl=1887/50484 }}</ref><ref>{{cite book | vauthors = Ahmed E |title=Comprehensive Manual of Ophthalmology |date=2010 |publisher=JP Medical Ltd |isbn=978-93-5025-175-1 |page=345 |url=https://books.google.com/books?id=6prpFb-UcKAC&pg=PA345 }}</ref> It is also used prior to YAG laser iridotomy. In ophthalmology, pilocarpine is also used to reduce symptomatic glare at night from lights when the patient has undergone implantation of [[phakic intraocular lens]]es; the use of pilocarpine would reduce the size of the pupils, partially relieving these symptoms.{{Dubious|date=September 2019}} The most common concentration for this use is pilocarpine 1%.{{citation needed|date=September 2019}} Pilocarpine is shown to be just as effective as [[apraclonidine]] in preventing intraocular pressure spikes after [[trabeculoplasty|laser trabeculoplasty]].<ref name="Zhang">{{cite journal | vauthors = Zhang L, Weizer JS, Musch DC | title = Perioperative medications for preventing temporarily increased intraocular pressure after laser trabeculoplasty | journal = The Cochrane Database of Systematic Reviews | volume = 2017 | issue = 2 | article-number = CD010746 | date = February 2017 | pmid = 28231380 | pmc = 5477062 | doi = 10.1002/14651858.CD010746.pub2 }}</ref>

=== Presbyopia ===
In 2021, the US [[Food and Drug Administration]] (FDA) approved pilocarpine hydrochloride as an [[eye drop]] treatment for [[presbyopia]], age-related difficulty with near-in vision. It works by causing the pupils to constrict, increasing [[depth of field]], similar to the effect of [[pinhole glasses]].<ref>{{cite journal | vauthors = Grzybowski A, Ruamviboonsuk V | title = Pharmacological Treatment in Presbyopia | journal = Journal of Clinical Medicine | volume = 11 | issue = 5 | page = 1385 | date = March 2022 | pmid = 35268476 | pmc = 8910925 | doi = 10.3390/jcm11051385 | doi-access = free }}</ref><ref name="Vuity FDA label" />

===Other===
Pilocarpine is used to stimulate sweat glands in a [[sweat test]] to measure the [[concentration]] of [[chloride]] and [[sodium]] that is excreted in sweat. It is used to diagnose [[cystic fibrosis]].<ref>{{Cite book|url=https://books.google.com/books?id=r6IsDwAAQBAJ&pg=PT3|title=Chemistry and Synthesis of Medicinal Agents: (Expanding Knowledge of Drug Chemistry)| vauthors = Prasad RK |date=2017-07-11|publisher=BookRix|isbn=978-3-7438-2141-5}}</ref>

== Adverse effects ==
Use of pilocarpine may result in a range of adverse effects, most of them related to its [[non-selective]] action as a muscarinic receptor agonist. Systemic (oral) pilocarpine has been known to cause excessive salivation, sweating, bronchial [[mucus]] secretion, [[bronchospasm]], [[bradycardia]], [[vasodilation]], and [[diarrhea]]. Eye drops can result in brow [[pain|ache]] and chronic use in [[miosis]]. It can also cause temporary blurred vision or darkness of vision, temporary shortsightedness, [[hyphema]] and retinal detachment.

==Pharmacology==
Pilocarpine is a drug that acts as a muscarinic receptor agonist. It acts on a subtype of muscarinic receptor ([[Muscarinic acetylcholine receptor M3|M<sub>3</sub>]]) found on the [[iris sphincter muscle]], causing the muscle to contract - resulting in pupil constriction ([[miosis]]). Pilocarpine also acts on the [[ciliary muscle]] and causes it to contract. When the ciliary muscle contracts, it opens the [[trabecular meshwork]] through increased tension on the [[scleral spur]]. This action facilitates the rate that [[aqueous humor]] leaves the [[human eye|eye]] to decrease [[intraocular pressure]]. Paradoxically, when pilocarpine induces this ciliary muscle contraction (known as an [[Accommodation (eye)|accommodative spasm]]) it causes the eye's [[lens]] to thicken and move forward within the eye. This movement causes the iris (which is located immediately in front of the lens) to also move forward, narrowing the [[Anterior chamber angle]]. Narrowing of the anterior chamber angle increases the risk of increased [[intraocular pressure]].<ref>{{cite book |doi=10.1016/B978-0-7020-5193-7.00073-X |chapter=Laser Peripheral Iridoplasty |title=Glaucoma |date=2015 | vauthors = Teekhasaenee C |pages=716–721 |isbn=978-0-7020-5193-7 }}</ref>

==Society and culture==
=== Preparation ===
Plants in the genus ''[[Pilocarpus]]'' are the only known sources of pilocarpine, and commercial production is derived entirely from the leaves of ''[[Pilocarpus microphyllus]]'' (Maranham Jaborandi). This genus grows only in South America, and ''Pilocarpus microphyllus'' is native to several states in northern Brazil.<ref name="ivcdb">{{cite journal|title=Production of Pilocarpine in Callus of Jaborandi (''Pilocarpus microphyllus'' Stapf)|jstor=4293939| vauthors = De Abreu IN, Sawaya AC, Eberlin MN, Mazzafera P  |journal=In Vitro Cellular & Developmental Biology - Plant|volume=41|issue=6|date=November–December 2005|pages=806–811|publisher=[[Society for In Vitro Biology]]|doi=10.1079/IVP2005711|bibcode=2005IVCDB..41..806A |s2cid=26058596}}</ref>

Pilocarpine is extracted from the leaves of ''Pilocarpus microphyllus'' in a multi-step process : the sample is moistened with dilute [[sodium hydroxide]] to transform the alkaloid into its free-base form then extracted using [[chloroform]] or a suitable organic solvent. Pilocarpine can then be further purified by re-extracting the resulting solution with aqueous [[sulfuric acid]] then readjusting the pH to basic using [[ammonia]] and a final extraction by chloroform.<ref>{{cite journal | vauthors = Avancini G, Abreu IN, Saldaña MD, Mohamed RS, Mazzafera P | title = Induction of pilocarpine formation in jaborandi leaves by salicylic acid and methyljasmonate | journal = Phytochemistry | volume = 63 | issue = 2 | pages = 171–175 | date = May 2003 | pmid = 12711138 | doi = 10.1016/S0031-9422(03)00102-X | bibcode = 2003PChem..63..171A }}</ref><ref>{{cite journal | vauthors = Sawaya AC, Abreu IN, Andreazza NL, Eberlin MN, Mazzafera P | title = HPLC-ESI-MS/MS of imidazole alkaloids in Pilocarpus microphyllus | journal = Molecules | volume = 13 | issue = 7 | pages = 1518–1529 | date = July 2008 | pmid = 18719522 | doi = 10.3390/molecules13071518 | doi-access = free | pmc = 6245396 }}</ref><ref name=Sch2007>{{cite book |doi=10.1201/b15129-14 |chapter=Glaucoma |title=Eye Care in Developing Nations | editor = Fourth | date=2007 |pages=99–116 |isbn=978-1-84076-103-0 | vauthors = Schwab L |doi-broken-date=12 July 2025 }}</ref>

It can also be synthesized from 2-ethyl-3-carboxy-2-butyrolactone in a 8 steps process from the acyl chloride (by treatment with [[thionyl chloride]]) via a [[Arndt–Eistert reaction]] with [[diazomethane]] then by treatment with [[potassium phthalimide]] and [[potassium thiocyanate]].<ref name = "Vardanyan_2006" />

=== Brand names ===

Pilocarpine is available under several brand names such as: Diocarpine (Dioptic), Isopto Carpine ([[Alcon]]), Miocarpine (CIBA Vision), Ocusert Pilo-20 and -40 (Alza), Pilopine HS (Alcon), Salagen (MGI Pharma), Scheinpharm Pilocarpine (Schein Pharmaceutical), Timpilo (Merck Frosst), and Vuity (AbbVie).

== Research ==

Pilocarpine is used to induce chronic [[epilepsy]] in [[rodent]]s, commonly [[rat]]s, as a means to study the disorder's physiology and to examine different treatments.<ref name = "Károly_2018">{{cite thesis|title=Immunohistochemical investigations of the neuronal changes induced by chronic recurrent seizures in a pilocarpine rodent model of temporal lobe epilepsy| doi = 10.14232/phd.9734 |publisher=University of Szeged| vauthors = Károly N | date = 2018 |doi-access=free }}</ref><ref>{{cite journal | vauthors = Morimoto K, Fahnestock M, Racine RJ | title = Kindling and status epilepticus models of epilepsy: rewiring the brain | journal = Progress in Neurobiology | volume = 73 | issue = 1 | pages = 1–60 | date = May 2004 | pmid = 15193778 | doi = 10.1016/j.pneurobio.2004.03.009 | s2cid = 36849482 }}</ref> Smaller doses may be used to induce salivation in order to collect samples of [[saliva]], for instance, to obtain information about [[IgA]] antibodies.

== References ==
{{Reflist}}

== External links ==
{{wikisource|1911 Encyclopædia Britannica/Pilocarpine|Pilocarpine}}

{{Antiglaucoma preparations and miotics}}
{{Muscarinic acetylcholine receptor modulators}}
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