4.3 Contraindications
Contra-indications are not applicable to the use of atropine in life-threatening emergencies (e.g. asystole).

Atropine is contraindicated in patients with known hypersensitivity to the drug, obstruction of the bladder neck e.g. due to prostatic hypertrophy, reflux oesophagitis, closed angle glaucoma, myasthenia gravis (unless used to treat the adverse effects of an anticholinesterase agent), paralytic ileus, severe ulcerative colitis and obstructive disease of the gastrointestinal tract.

4.4 Special warnings and precautions for use
Antimuscarinic agents should be used with caution in the elderly and children since these patients may be more susceptible to adverse effects. Atropine should also be used with caution in patients with hyperthyroidism, hepatic or renal disease or hypertension. Use with caution in febrile patients or when ambient temperature is high since antimuscarinics may cause an increase in temperature. Antimuscarinics block vagal inhibition of the SA nodal pacemaker and should thus be used with caution in patients with tachyarrhythmias, congestive heart failure or coronary heart disease. Parenterally administered atropine should be used cautiously in patients with chronic pulmonary disease since a reduction in bronchial secretions may lead to formation of bronchial plugs. Antimuscarinics should be used with extreme caution in patients with autonomic neuropathy.

Antimuscarinics decrease gastric motility, relax the lower oesophageal sphincter and may delay gastric emptying; they should therefore be used with caution in patients with gastric ulcer, oesophageal reflux or hiatus hernia associated with reflux oesophagitis, diarrhoea or GI infection.

There have been cases where severe bradycardia due to hyperkalaemia could not be resolved with atropine.

4.5 Interaction with other medicinal products and other forms of interaction
The effects of atropine may be enhanced by the concomitant administration of other drugs with anticholinergic activity e.g. tricyclic antidepressants, antispasmodics, anti- parkinsonian drugs, some antihistamines, phenothiazines, disopyramide and quinidine. By delaying gastric emptying, atropine may alter the absorption of other drugs.

During anaesthesia, the heart rate responsiveness to IV atropine could be decreased (and not effectively overcome by a large dose of atropine) when the subject is receiving concomitantly propofol; it could be due to propofol-induced suppression of the sympathetic nervous system.

An extreme caution should be observed when dobutamine-atropine stress echocardiography or the concomitant administration of a catecholamine with atropine has to be performed in patients who seem already extremely stressed or are in an underlying hyperadrenergic state (risk of Tako-tsubo syndrome).

4.6 Fertility, pregnancy and lactation
Atropine crosses the placenta. Studies in humans have not been done and only limited information is available from animal studies. Intravenous administration of atropine during pregnancy or at term may cause tachycardia in the foetus. Atropine should only be administered to pregnant women if the benefits outweigh the risks to the foetus. Trace amounts of atropine appear in the breast milk and may cause antimuscarinic effec