Sugammadex compared with neostigmine/glycopyrrolate for routine reversal of neuromuscular block: A systematic review and economic evaluation

Centre for Reviews and Dissemination, University of York, Heslington, York YO10 5DD, UK.
BJA British Journal of Anaesthesia (Impact Factor: 4.85). 10/2010; 105(5):558-67. DOI: 10.1093/bja/aeq269
Source: PubMed


The cost-effectiveness of sugammadex for the routine reversal of muscle relaxation produced by rocuronium or vecuronium in UK practice is uncertain. We performed a systematic review of randomized controlled trials of sugammadex compared with neostigmine/glycopyrrolate and an economic assessment of sugammadex for the reversal of moderate or profound neuromuscular block (NMB) produced by rocuronium or vecuronium. The economic assessment aimed to establish the reduction in recovery time and the 'value of time saved' which would be necessary for sugammadex to be potentially cost-effective compared with existing practice. Three trials indicated that sugammadex 2 mg kg⁻¹ (4 mg kg⁻¹) produces more rapid recovery from moderate (profound) NMB than neostigmine/glycopyrrolate. The economic assessment indicated that if the reductions in recovery time associated with sugammadex in the trials are replicated in routine practice, sugammadex would be cost-effective if those reductions are achieved in the operating theatre (assumed value of staff time, £4.44 per minute), but not if they are achieved in the recovery room (assumed value of staff time, £0.33 per minute). However, there is considerable uncertainty in these results. Sugammadex has the potential to be cost-effective compared with neostigmine/glycopyrrolate for the reversal of rocuronium-induced moderate or profound NMB, provided that the time savings observed in trials can be achieved and put to productive use in clinical practice. Further research is required to evaluate the effects of sugammadex on patient safety, predictability of recovery from NMB, patient outcomes, and efficient use of resources.

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    • "Data regarding cost effectiveness for sugammadex is rare. Although the reversal time with sugammadex is clearly shorter than with neostigmine or spontaneous recovery, this does not necessarily mean that this gained time can be translated to an increase in patient cases in the operating room or a reduced hospital stay and cost reduction for the patient.109–111 "
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    ABSTRACT: Sugammadex is the first clinical representative of a new class of drugs called selective relaxant binding agents. It has revolutionized the way anesthesiologists think about drug reversal. Sugammadex selectively binds rocuronium or vecuronium, thereby reversing their neuromuscular blocking action. Due to its 1:1 binding of rocuronium or vecuronium, it is able to reverse any depth of neuromuscular block. So far, it has been approved for use in adult patients and for pediatric patients over 2 years. Since its approval in Europe, Japan, and Australia, further insight on its use in special patient populations and specific diseases have become available. Due to its pharmacodynamic profile, sugammadex, in combination with rocuronium, may have the potential to displace succinylcholine as the "gold standard" muscle relaxant for rapid sequence induction. The use of rocuronium or vecuronium, with the potential of reverse of their action with sugammadex, seems to be safe in patients with impaired neuromuscular transmission, ie, neuromuscular diseases, including myasthenia gravis. Data from long-term use of sugammadex is not yet available. Evidence suggesting an economic advantage of using sugammadex and justifying its relatively high cost for an anesthesia-related drug, is missing.
    Full-text · Article · Sep 2013 · Core Evidence
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    • "Implementation of sugammadex into clinical practice improved the control of neuromuscular blockades. Fast, effective, and safe reversal with limited side effects made the application of steroidal neuromuscular drugs during surgery more attractive (Naguib 2007; Welliver et al. 2009; Paton et al. 2010). The presence of permanent positive charge on the steroid skeleton and chemical instability of ester moieties easily hydrolyzing even in neutral aqueous media (Jansen 1997) made PM, VM, and RM analytically challenging molecules. "
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    ABSTRACT: Novel and rapid capillary electrophoresis-coupled tandem mass spectrometry (CE-MS/MS) and capillary electrophoresis with capacitively coupled contactless conductivity detection (CE-C4D) methods have been developed for the separation and determination of three neuromuscular blocking agents: pancuronium, vecuronium, and rocuronium. In both cases, the separation was conducted in background electrolytes based on acidic acetate-ammonium buffers to avoid possible decomposition of the analytes that are known to be unstable in alkaline media. Baseline resolution of the analytes was achieved in the presence of modified γ-cyclodextrin by CE with C4D detection. The two detection techniques were compared with regard to analytical figures of merit including linear dynamic range, limit of detection, limit of quantification, precision, and accuracy. The calibration curves showed good linearity for both detection methods examined (characterized by r2 ≥ 0.9908). The LODs of the CE-MS/MS and the CE-C4D methods differed at least by two orders of magnitude considering all analytes. The differences in precision and accuracy of these methods were evaluated and discussed. The assays of pancuronium, vecuronium, and rocuronium in commercial injection solutions by CE-MS/MS and CE-C4D were performed and the results compared.
    Full-text · Article · Sep 2013 · Analytical Letters
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    • "The rates of residual paralysis were 41% and 52% when a TOF ratio less than 0.7 or 0.8 was applied, respectively, signifying that the occurrence of residual paralysis increases as the TOF threshold for its recognition enhances.13–15 Our investigation showed that a long interval (more than 120 minutes) between the last administration of muscle relaxant and the evaluation of the measured TOF ratio in the PACU ensure full recovery. "
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    ABSTRACT: Residual neuromuscular blockade continues to be a clinical problem after surgical procedures. The purpose of this study was to determine the incidence of residual paralysis in the postanesthesia care unit (PACU) after a single intubating dose of twice of the 95% estimated dose (ED95) of a nondepolarizing muscle relaxant with an intermediate duration of action. Two hundred and sixteen patients scheduled for elective surgery under general anaesthesia requiring tracheal intubation were included in the study. They received a single intubating dose of intravenous atracurium (0.5 mg/kg) to facilitate tracheal intubation. At the end of surgery, if train of four (TOF)-ratio was ≤ 0.9, neostigmine 40 μg/kg intravenously was given. If TOF-ratio was ≥ 0.9, no neostigmine was given. Also, in awake patients with TOF > 0.9, residual neuromuscular paralysis was evaluated by using clinical tests such as head lift test and tongue depressor test. TOF was less than 0.9 in 48 (22.2%) patients while after 120 minutes, no patients had TOF less than 0.9. Of 33 patients whose operation lasted less than 120 minutes, 4 patients had TOF less than 0.9 at the end of surgery. There was no case of hypoventilation or hypoxia at PACU. The incidence of negative value in clinical tests was high. Our study gave the impression that more than two hours between the administration of a single intubating dose of an intermediate-acting nondepolarizing muscle relaxant (atracurium) and arrival to the PACU can probably guarantee the lack of a residual paralysis.
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