Systemic bioavailability of

ocularly applied 1% atropine

eyedrops
Timo Kaila1, Juha-Matti Korte2 and K. Matti Saari2
1 2
Department of Pharmacology and Clinical Pharmacology and Department of
Ophthalmology, University of Turku, Turku, Finland

ABSTRACT.
Purpose: To investigate the pharmacological basis of systemic effects of atro- reviewed earlier (Kentala 1991). Approxi-
pine eyedrops, we estimated the bioavailability of ophthalmic 1% atropine solu- mately two-thirds of atropine is metab-
tion in healthy volunteers. olized in the liver (Kalser & McLain
Methods: In a randomized crossover study we administered 0.3 mg atropine 1970). Urine excretion is the main route
either intravenously or ocularly to six healthy volunteers. The plasma concen- of elimination in man (Kalser 1971).
trations of the biologically active atropine enantiomer, 1-hyoscyamine, were de- The basis for the systemic anticholin-
termined using a muscarinic cholinoceptor binding assay. ergic effects of atropine eyedrops is the ab-
Results: The mean area under the curve from zero to infinitum (AUC0–≤) for sorption of the l-hyoscyamine from the eye
into the systemic circulation. The lack of
1-hyoscyamine was 1.862∫0.580 mg/L ¡ hr after intravenous, and 1.092∫0.381
literature on the systemic bioavailability
ml/L ¡ hr after ocular administration (mean∫s.d, nΩ6), respectively. The mean
of atropine eyedrops is mainly due to the
bioavailability was 63.5∫28.6% (mean∫SD, nΩ6; min 19%, max 95%). Large
fact that plasma l-hyoscyamine levels after
interindividual differences characterized the absorption and elimination phases ocular atropine application are below the
of 1-hyoscyamine kinetics. The terminal half-life (t1/2b) of 1-hyoscyamine in detection limit of ordinary analytical tech-
plasma was not affected by the route of drug administration. niques. Because the kinetics of the active
Conclusion: The systemic bioevailability of 1-hyoscyamine was considerable and and inactive atropine enantiomer differ
may explain the systemic anticholinergic side effects reported in association from one another (Kentala et al. 1990), the
with the clinical use of atropine eyedrops. bioavailability measurements should be
carried out using methods measuring pref-
Key words: anticholinergic agents – atropine – bioavailability – enantiomer – hyoscyamine – mus- erentially the biologically active enanti-
carinic cholinoceptor – radioligand binding assay. omer, l-hyoscyamine.
In this study we determined plasma l-
Acta Ophthalmol. Scand. 1999: 77: 193–196 hyoscyamine concentrations using a sen-
Copyright c Acta Ophthalmol Scand 1999. ISSN 1395-3907 sitive radioligand binding assay. The sys-
temic bioavailability of l-hyoscyamine
was estimated by administering 0.3 mg
atropine in a randomized and crossover

A tropine eyedrops are used to produce

a longlasting mydriasis and cyclo-
plegia in the eye (Brown 1990). In the
literature there are no published data on
the systemic bioavailability of topically
applied ocular anticholinergic agents in
humans, although these drugs frequently
produce systemic side effects, such as
dryness of mouth or inhibition of
sweating, and sometimes also more severe
adverse reactions, such as disturbances in
the mental and cardiac functions (Brown
1990; Baker & Farley 1958). In children
even cases of death have been ascribed to
the systemic toxicity of atropine eyedrops
(Hoefnagel 1961).
Atropine is a belladonna alkaloid
which consists of two enantiomers, l-hy-
oscyamine and d-hyoscyamine. Only the
l-enantiomer binds with a high affinity to
muscarinic acetylcholine receptors, is
biologically active and responsible for the
therapeutic and anticholinergic side ef-
fects of atropine (Brown 1990). After ad-
ministration of racemic d,l-atropine no
conversion between the two enantiomers
takes place during and after absorption
(Kentala 1991). Atropine is a potent
compound and is known to antagonize
human muscarinic cholinoceptor actions
at plasma concentrations less than 100
pg/ml (Brown 1990; Lahdes et al. 1988;
Kentala et al. 1990).
The metabolism of atropine has been
fashion either as an intravenous bolus in-
jection or as a 1% eyedrop instilled in the
eye of the healthy volunteers.
Materials and Methods
Subjects and study design
Six healthy medical students, one male
and five female, entered the study after
giving their informed written consent.
Their age varied between 24 and 29 years
(mean 25.5∫2.2 years) and weight be-
tween 56 and 75 kg (mean 64.3∫7 kg).
Demographic data of the subjects is
shown in Table 1. All subjects were deter-
mined to be in good general health on the

193
Table 1. Demographic data of tho volunteers.
Subject Sex Age yrs
A female 24
B female 29
C female 24
D female 27
E female 24
F male 24
Mean 25.5
SD 2.2
basis of medical history, physical exami-
nation, electrocardiogram (ECG) and
routine laboratory safety tests including
blood hemoglobin, serum creatinine,
serum alanine transaminase and fasting
blood glucose. Prior to the initiation of
the study, the study protocol and the
written informed consent form were ap-
proved by the Joint Commission on Eth-
ics of the University of Turku and the
Turku University Central Hospital.
The study was carried out using a ran-
domized crossover design. The volunteers
fasted from midnight and abstained from
smoking on the testing days. Alcohol in-
take and use of any medication was pro-
hibited for 48 hours prior to the session.
The subjects came two different times to
the laboratory. An intravenous cannula
was inserted in a forearm vein for blood
sampling. After randomization the sub-
jects received 0.3 mg atropine either in 0.3
ml of intravenous atropine sulphate
(Atropin 1 mg/ml inject, Leiras Pharma-
ceuticals, Turku, Finland) given as a bo-
lus injection into the opposite forearm
vein, or in 30 ml of 1% atropine sulphate
ophthalmic solution (Oftan Atropin 10
mg/ml eyedrops, Star Pharmaceuticals,
Tampere, Finland) instilled unilaterally
Weight kg Height cm
68 170
56 165
67 179
60 170
60 173
75 192
64.3 174.8
7.0 9.6
to the lower cul-de-sac of the eye. The
eyedrops were administered with an ad-
justable Finnpipette (Labsystems Co.,
Helsinki, Finland) for laboratory use. An
interval of two weeks was kept between
the intravenous and ocular drug adminis-
tration. Venous blood samples of 5 ml
were taken for l-hyoscyamine analysis at
3, 5, 8, 10, 15, 20, 30 and 50 minutes, and
1, 1 1/2, 2, 3, 4, 5, 6, 7 and 8 hours after
drug dosing. Plasma l-hyoscyamine con-
centrations were analyzed with a radiore-
ceptor binding assay (RRA) measuring
drug binding to rat neuronal muscarinic
cholinoceptors (Lahdes et al. 1988). The
detection limit of the radioreceptor bind-
ing assay for l-hyoscyamine in plasma
was 20 pg/ml. The intra-assay and in-
terassay coefficient of variation (CV) in
the concentration range of 20–2000 pg/ml
was less than 10%.
The systolic and diastolic blood press-
ures and heart rate were recorded with an
automatic measuring device (sphygmo-
manometer BP–203 M II, Nippon Kohn-
en Co., Japan).
Kinetic calculations
The maximal plasma concentration
(Cmax) and the corresponding time to
reach the maximum (tmax) were recorded
from the individual plasma concen-
tration-time curves. The area under the
plasma concentration curve (AUC) from
time zero to infinity was calculated using
the linear trapezoidal rule. The AUC
from the time of last measured 1-hyoscy-
amine concentration to infinity was cal-
culated using the slope of the log plasma
concentration vs time curve in the ter-
minal elimination phase (Cbt ). The
bioavailability of the ocular atropine (F)
was calculated by comparing the
AUC0–≤ values for the intravenous and
AUC0–≤ocular
ocular atropine: FΩ ¿100.
AUC0–≤iv
Total clearance (CL) was obtained from
Dose
the formula CLΩ . The half-live for
AUC≤
the terminal elimination phase (t21b) was
calculated using a two or three exponen-
tial model of log-linear least squares fit-
ting model in the SIPHAR software
(SIMED, Creteil, France).
Statistical analysis
The parameters measured are given in the
text as means∫SD (nΩ6). The differences
in the heart rate and blood pressure be-
tween intravenous and ocular administra-
tion groups were statistically tested using
analysis of variance (ANOVA). The effect
of repeated measurements in different ex-
aminations as also the interactions of
these effects with grouping variables were
tested using analysis of repeated measure-
ments. The calculations in repeated meas-
urements ANOVA were performed with
general linear model procedure. The dif-
ferences were considered significant at
p∞0.05.

Table 2. Pharmacokinetic parameters of 1-hyoscyamine after intravenous and ocular application of 0.3 mg atropine.

AUCiv AUCocul CLiv CLocul t21 betaiv t12 betaocul Cmaxocul Tmaxocul
Subject ng/ml ¡ h ng/ml ¡ h F% ml/min/kg ml/min/kg (h) (h) pg/ml min

A 1.56 1.25 80 2.4E-05 2.9E-05 4.1 2.7 275 30

B 1.67 1.12 67 2.7E-05 3.9E-05 4.3 2.9 330 60
C 1.86 0.36 19 2E-05 1E-04 2 1.5 166 5
D 1.15 1.09 95 2.8E-05 2.8E.05 3.6 3.6 265 8
E 1.51 1.21 80 2.8E-05 3.6E-05 1.3 2 345 60
F 3 1.2 40 1.1E-05 1.1E-05 2.5 2 355 3
Mean 1.79 1.02 63.5 2.3E-05 4E-05 2.97 2.45 288.33 27.67
SD 0.64 0.33 28.6 6.5E-06 3.1E-05 1.22 0.76 72.91 26.85

The systemic bioavailability (F) was calculated using the formula: F%ΩAUCocular/AUCiv ¡ 100.
Clearance (CL) refers to the total clearance, CLΩD/AUC. T12 beta refers to the half-life in the terminal phase of plasma elimination kinetics. The
half-lifes of ocular atropine are approximates, because the complex patterns of drug absorption did not allow an exact determination of the
parameter. Cmax refers to the maximal plasma concentration and Tmax refers to the time required to reach Cmax after ocular application.

194

Fig. 1. Plasma atropine kinetics in subjects A, B, C, D, E and F after intravenous (open circles)
and ocular (closed squares) application of 0.3 mg atropine. Plasma 1-hyoscyamine concentrations
are given in the logarithmic scale as pg/ml units.
Results
The systemic bioavailability of the biolo-
gically active atropine component, 1-hy-
oscyamine, varied markedly between the
subjects. The bioavailability ranged from
19 to 95%, with a mean value of
63.5∫28.6% (mean∫SD, nΩ6). The indi-
vidual plasma 1-hyoscyamine concen-
tration-time curves after intravenous and
ocular dosing are presented in Fig. 1, and
several pharmacokinetic parameters are
presented in Table 2.
No l-hyoscyamine was detectable in
plasma in the baseline samples. Already
three minutes after intravenous and ocu-
lar dosing, however, measurable amounts
of l-hyoscyamine were always detectable
in plasma. The interindividual differences
in the rate, extent and duration of the
ocular drug absoption were large. The
initial ocular absorption phase lasted ap-
proximately one hour. The Cmax values
after ocular dosing ranged from 166 to
355 pg/ml, and tmax values from 3 to 60
minutes (Table 2 ). During the terminal
phase of drug elimination from plasma
the l-hyoscyamine levels were surprisingly
similar after intravenous and ocular dos-
ing (Fig. 1), although interindivudual dif-
ferences in the elimination rate were
large. The average half-life of l-hyoscyam-
ine for the terminal elimination phase
ranged from 1.3 to 4.3 hours (Table 2),
and the 95% confidence intervals were be-
tween 1.7 and 4.2 after intravenous ad-
ministration and between 1.7 and 3.2
after ocular administration. After ocular
drug application the complex systemic
absorbtion phase interfered with the esti-
mation of terminal half-life values.
There were no statistically significant
differences in the systolic (pΩ0.49) and
diastolic (pΩ0.70) blood pressures and
heart rates (pΩ0.25) between the intra-
venous and ocular treatment groups at
different time levels.
Similarly, there were no statistically
significant differences in the systolic (pΩ
0.59) and diastolic (pΩ0.20) blood press-
ures or heart rates (pΩ0.20) between dif-
ferent time levels inside the treatment
groups (Fig. 2. ANOVA).
Discussion
This is the first study to estimate the
systemic bioavailability of 1% atropine
eyedrops in humans. The systemic bio-
availability of 1-hyoscyamine in the vol-
unteers of this study varied between 19
and 95% with a mean bioavailability of
64%. The large interindividual variation
may be due to the fact that considerable
drug amounts are easily overflown from
the conjunctival sac at the time of eye-
drop instillation. We tried to reduce the
drug losses caused by the overflow by
applying only a 30 m1 volume of oph-
thalmic 1% atropine solution, using a
micropipette.
Therefore the mean 64% bioavail-
ability of 1-hyoscyamine found in this
study is likely to exceed that of clinical
practice in which the average eyedrop size
may exceed 40 m1. The terminal elimin-
ation rate of 1-hyoscyamine in the plasma
after intravenous and ocular dosing was
similar (Fig. 1).
Our subjects did not spontaneously re-
port any systemic side effects after intra-
venous or ocular atopine administration.
We could detect no atropine effects on
the heart rate or blood pressure. The lack
of effects was probably due to the low
dose of atropine (0.3 mg) and the fact
that the volunteers in this study were
healthy young adults, who are known to
be more resistant than elderly people and
children to the anticholinergic side effects
of atropine (Brown 1990; Kentala et al.
1990; Kentala et al. 1989).
The cardiac effects of atropine are
closely related to plasma 1-hyoscyamine
concentrations (Kentala et al. 1990). At
195

Fig. 2. Systolic (left panel, upper part) and diastolic (left panel, lower part) blood pressure and
heart rate (right panel) after intravenous (open circles) and ocular (closed circles) applications of
0.3 mg atropine (means SD of six volunteers in both groups)
plasma concentrations less than 0.5 ng/
ml l-hyoscyamine can slow heart rate,
whereas at plasma concentrations exceed-
ing 1.0 ng/ml l-hyoscyamine accelerates
heart rate via vagolysis (Volz-Zang et al.
1995; Wellstein & Pitschner 1988; Kanto
et al. 1990). In our subjects even the peak
plasma l-hyoscyamine concentrations
after ocular drug application were less
than 0.4 ng/ml (Fig. 1). In this study nei-
ther intravenous nor ocular application
of 0.3 mg atropine showed any significant
effect on blood pressure or heart rate. In
ordinary clinical practice a single 1%
atropine eyedrop can contain 0.5 mg
atropine, a drug amount which corre-
sponds to a recommended parenteral pre-
anestetic atropine dose for adults. If there
is no eyedrop overflow from the conjunc-
tival sac, systemically absorbed l-hyoscy-
amine can produce systemic side effets in
children, elderly people and subjects sen-
sitive to muscarinic receptor blocade.
When treating such patients with atro-
pine eyedrops the considerable systemic
196
bioavailability of l-hyoscyamine should
be taken into account.
In conclusion, after the application of
1% atropine eyedrops the systemic bio-
availability of l-hyoscyamine is consider-
able. Large interindividual differences
characterize both the absorption and
elimination phases of the l-hyoscyamine
kinetics. The ocular route of atropine ad-
ministration does not affect the elimin-
ation kinetics of l-hyoscyamine.
Supported by grants from Leiras Co,
Turku, and Paulo Foundation, Helsinki,
Finland.
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Received on February 13th, 1998.
Accepted on September 25th, 1998.
Corresponding author:
Prof. K. M.Saari
Department of Ophthalmology
University of Turku
Kiinamyllynkatu 4–8
FIN-20520 Turku
Finland