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Dahiya DS, Kumar G, Parsa S, Gangwani MK, Ali H, Sohail AH, Alsakarneh S, Hayat U, Malik S, Shah YR, Pinnam BSM, Singh S, Mohamed I, Rao A, Chandan S, Al-Haddad M. Remimazolam for sedation in gastrointestinal endoscopy: A comprehensive review. World J Gastrointest Endosc 2024; 16:385-395. [PMID: 39072252 PMCID: PMC11271717 DOI: 10.4253/wjge.v16.i7.385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2024] [Revised: 05/05/2024] [Accepted: 06/04/2024] [Indexed: 07/08/2024] Open
Abstract
Worldwide, a majority of routine endoscopic procedures are performed under some form of sedation to maximize patient comfort. Propofol, benzodiazepines and opioids continue to be widely used. However, in recent years, Remimazolam is gaining immense popularity for procedural sedation in gastrointestinal (GI) endoscopy. It is an ultra-short-acting benzodiazepine sedative which was approved by the Food and Drug Administration in July 2020 for use in procedural sedation. Remimazolam has shown a favorable pharmacokinetic and pharmacodynamic profile in terms of its non-specific metabolism by tissue esterase, volume of distribution, total body clearance, and negligible drug-drug interactions. It also has satisfactory efficacy and has achieved high rates of successful sedation in GI endoscopy. Furthermore, studies have demonstrated that the efficacy of Remimazolam is non-inferior to Propofol, which is currently a gold standard for procedural sedation in most parts of the world. However, the use of Propofol is associated with hemodynamic instability and respiratory depression. In contrast, Remimazolam has lower incidence of these adverse effects intra-procedurally and hence, may provide a safer alternative to Propofol in procedural sedation. In this comprehensive narrative review, highlight the pharmacologic characteristics, efficacy, and safety of Remimazolam for procedural sedation. We also discuss the potential of Remimazolam as a suitable alternative and how it can shape the future of procedural sedation in gastroenterology.
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Affiliation(s)
- Dushyant Singh Dahiya
- Division of Gastroenterology, Hepatology & Motility, The University of Kansas School of Medicine, Kansas City, MO 66160, United States
| | - Ganesh Kumar
- Department of Internal Medicine, Chandka Medical College, Sindh 77280, Pakistan
| | - Syeda Parsa
- Department of Internal Medicine, Chandka Medical College, Sindh 77280, Pakistan
| | - Manesh Kumar Gangwani
- Department of Gastroenterology and Hepatology, University of Arkansas For Medical Sciences, Little Rock, AR 72205, United States
| | - Hassam Ali
- Division of Gastroenterology, Hepatology and Nutrition, East Carolina University/Brody School of Medicine, Greenville, NC 27858, United States
| | - Amir Humza Sohail
- Department of Surgery, University of New Mexico School of Medicine, Albuquerque, NM 87106, United States
| | - Saqr Alsakarneh
- Department of Internal Medicine, University of Missouri-Kansas City, Kansas City, MO 64108, United States
| | - Umar Hayat
- Department of Internal Medicine, Geisinger Wyoming Valley Medical Center, Wilkes Barre, PA 18711, United States
| | - Sheza Malik
- Department of Internal Medicine, Rochester General Hospital, Rochester, NY 14621, United States
| | - Yash R Shah
- Department of Internal Medicine, Trinity Health Oakland/Wayne State University, Pontiac, MI 48341, United States
| | - Bhanu Siva Mohan Pinnam
- Department of Internal Medicine, John H. Stroger Hospital of Cook County, Chicago, IL 60612, United States
| | - Sahib Singh
- Department of Internal Medicine, Sinai hospital, Baltimore, MD 21215, United States
| | - Islam Mohamed
- Department of Hepatology, University of Missouri, Columbia, MO 65211, United States
| | - Adishwar Rao
- Department of Internal Medicine, Guthrie Robert Packer Hospital, Sayre, PA 18840, United States
| | - Saurabh Chandan
- Division of Gastroenterology and Hepatology, Creighton University School of Medicine, Omaha, NE 68131, United States
| | - Mohammad Al-Haddad
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN 46202, United States
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Advances in Analgosedation and Periprocedural Care for Gastrointestinal Endoscopy. Life (Basel) 2023; 13:life13020473. [PMID: 36836830 PMCID: PMC9962362 DOI: 10.3390/life13020473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 01/28/2023] [Accepted: 02/06/2023] [Indexed: 02/10/2023] Open
Abstract
The number and complexity of endoscopic gastrointestinal diagnostic and therapeutic procedures is globally increasing. Procedural analgosedation during gastrointestinal endoscopic procedures has become the gold standard of gastrointestinal endoscopies. Patient satisfaction and safety are important for the quality of the technique. Currently there are no uniform sedation guidelines and protocols for specific gastrointestinal endoscopic procedures, and there are several challenges surrounding the choice of an appropriate analgosedation technique. These include categories of patients, choice of drug, appropriate monitoring, and medical staff providing the service. The ideal analgosedation technique should enable the satisfaction of the patient, their maximum safety and, at the same time, cost-effectiveness. Although propofol is the gold standard and the most used general anesthetic for endoscopies, its use is not without risks such as pain at the injection site, respiratory depression, and hypotension. New studies are looking for alternatives to propofol, and drugs like remimazolam and ciprofol are in the focus of researchers' interest. New monitoring techniques are also associated with them. The optimal technique of analgosedation should provide good analgesia and sedation, fast recovery, comfort for the endoscopist, patients' safety, and will have financial benefits. The future will show whether these new drugs have succeeded in these goals.
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Goudra B. Oliceridine- Opioid of the 21st Century. Saudi J Anaesth 2022; 16:69-75. [PMID: 35261592 PMCID: PMC8846232 DOI: 10.4103/sja.sja_510_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 07/08/2021] [Accepted: 07/08/2021] [Indexed: 11/04/2022] Open
Abstract
Oliceridine (Olinvyk® Trevena, PA, USA) was approved by the United States Food and Drug Administration for clinical use on Aug 8, 2020. Even though, the indication of its approval is very restrictive (to manage moderate-to-severe acute pain in adults when the pain is severe enough), for such an innovative opioid, off-label indications are bound to abound. What could be described as the “opioid of the century,” it aims to overcome some of the stubbornest barriers to opioid prescribing, namely addiction liability, respiratory depression, and gastrointestinal (GI) side effects, just to name a few. The novel opioid accomplishes this by a unique mechanism of action. By selectively acting on the G-protein sub-pathway in preference to the beta-arrestin, it aims to mitigate these unwanted µ-opioid receptors-associated opioid side effects, while preserving its analgesic activity. What remains to be seen, however, is if these observations seen in phases 2 and 3 trials will be borne in actual large-scale clinical use, both inside and outside the USA. Unfortunately, the field of anesthesia is rife with innovations that have shown enormous promise at the research stage, only to end up as damp squibs when released to the clinicians for general use. Rapcuronium and althesin are some such examples. We aim to present some of the contentious and emerging issues associated with this drug and some of the potential pitfalls of this new opioid.
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Finlay JE, Leslie K. Sedation/analgesia techniques for nonoperating room anesthesia: new drugs and devices. Curr Opin Anaesthesiol 2021; 34:678-682. [PMID: 34419992 DOI: 10.1097/aco.0000000000001057] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW The purpose of this article is to review new drugs and devices for nonoperating room anesthesia (NORA). RECENT FINDINGS Remimazolam is an ultra-short-acting, water-soluble intravenous benzodiazepine with a fast onset and offset that has been approved recently for use in procedural sedation. Phase III trials have established the effectiveness of remimazolam sedation compared with placebo and midazolam in gastrointestinal endoscopy and bronchoscopy. More research is required investigating remimazolam in real-world NORA settings, including comparisons with propofol sedation. Oliceridine is a μ-agonist with selectivity for the G protein pathway and low potency for β-arrestin recruitment. As such it may be associated with less nausea, vomiting and respiratory depression than traditional opioids used. Although no studies have been published about oliceridine use in NORA to date, results from surgical studies indicate a potential place in nonoperating room practice. Research continues into alternative methods of drug delivery, such as patient-controlled sedation but no new devices are described. SUMMARY Further studies are required before these new drugs and devices are embraced in NORA.
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Affiliation(s)
- Janna E Finlay
- Department of Anaesthesia and Pain Management, Royal Melbourne Hospital
| | - Kate Leslie
- Department of Anaesthesia and Pain Management, Royal Melbourne Hospital
- Department of Critical Care, Melbourne Medical School, University of Melbourne, Melbourne, Australia
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Noor N, Legendre R, Cloutet A, Chitneni A, Varrassi G, Kaye AD. A comprehensive review of remimazolam for sedation. Health Psychol Res 2021; 9:24514. [PMID: 34746482 DOI: 10.52965/001c.24514] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 06/01/2021] [Indexed: 01/11/2023] Open
Abstract
Benzodiazepines are one of the most commonly used medications in the field of anesthesia. They offer excellent anxiolytic and amnestic properties ideal for the perioperative period when patient anxiety is understandably heightened. Remimazolam has presented a favorable alternative to some of the common intravenous anesthetic agents used given its fast onset of action, high safety profile, and reasonably short duration of action. The drugs within the four classes of benzodiazepines, 2-keto-benzodiazepines, 3-hydroxy-benzodiazepines, triazolo-benzodiazepines, and 7-nitro-benzodiazepines provide varying degrees of anxiolysis, sedation, and amnesia. This is provided by the benzodiazepine molecule binding and causing a conformational change to the chloride ion channel to cause hyperpolarization and thus inhibition of the central nervous system. Each type of benzodiazepine has a preferred role within the realm of medicine. For instance, diazepam is used for the treatment of seizures and anxiety. Midazolam's anxiolytic and anterograde amnestic properties are taking advantage of during the perioperative period. Lorazepam is beneficial for anxiety and status epilepticus. Remimazolam, currently in phase II and III clinical trials, has demonstrated a very short during of action and low context-sensitive half-time, allowing for its rapid removal even during a prolonged infusion. Much of its properties may be credited to being a soft drug, meaning it is a metabolically active drug that is rapidly inactivated in the body. This provides anesthesiologists and other practitioners administering it with a more predictable sedative. These properties have the potential to push it towards becoming the drug of choice for premedication during the perioperative period and sedation in the ICU. Furthermore, remimazolam does not seem to rely on any specific organ to be metabolized. The drug's ester moiety makes it a substrate for non-specific tissue esterase enzymes, meaning its metabolism and elimination are not impaired in patients with hepatic and/or renal disease. Its addictive potential closely resembles that of its parent compound, midazolam. Reports of its adverse reactions include headache and somnolence after an involuntary movement during infusion. Benzodiazepines are a great adjunct to anesthetic care. Remimazolam's safety profile, pharmacokinetics, pharmacodynamics, and potential practical use make it quite favorable in this regard. It has the potential to equip anesthesiologists and other medical practitioners with a more predictable medication that has a good safety profile. However, further large clinical trials will provide us with a better understanding of the advantages and disadvantages of remimazolam.
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Affiliation(s)
- Nazir Noor
- Mount Sinai Medical Center, Miami Beach, FL
| | - Rhorer Legendre
- Louisiana State University Health Sciences Center School of Medicine, Shreveport, LA
| | - Alexandra Cloutet
- Louisiana State University Health Sciences Center School of Medicine, Shreveport, LA
| | - Ahish Chitneni
- AT Still University School of Osteopathic Medicine, Mesa, AZ
| | | | - Alan D Kaye
- Louisiana State University Health Sciences Center School of Medicine, Shreveport, LA
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Liu Y, Hu Q, Yang J. Oliceridine for the Management of Acute Postoperative Pain. Ann Pharmacother 2021; 55:1283-1289. [PMID: 33423508 DOI: 10.1177/1060028020987679] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVE To review the pharmacological characteristics, clinical evidence, and place in the management of acute postoperative pain severe enough to require an intravenous opioid. DATA SOURCES A comprehensive literature search was conducted in PubMed (January 2000 to December 1, 2020). Key search terms included oliceridine or acute postoperative pain. Other sources were derived from product labeling and ClinicalTrials.gov. STUDY SELECTION AND DATA EXTRACTION All English-language articles identified from the data sources were reviewed and evaluated. Phase I, II, and III clinical trials were included. DATA SYNTHESIS Oliceridine is a novel selective µ-receptor G-protein pathway modulator. It has the property of activating G-protein signaling while causing low β-arrestin recruitment to the µ-receptor. Intravenous oliceridine showed statistically superior analgesia than placebo in patients with moderate or severe pain after surgery, with a favorable safety and tolerability profile regarding respiratory and gastrointestinal adverse effects, compared with morphine. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE The analgesic capacity of oliceridine is at least comparable to that of morphine at clinically relevant dosages, with a rapid onset of action. Also, it may be associated with a lower incidence of adverse events at dosing regimens associated with comparable analgesia. These data suggest that oliceridine may provide an important new treatment option for the management of moderate to severe postoperative pain where an intravenous opioid is warranted. CONCLUSION Oliceridine has obvious analgesic effects in patients with moderate or severe pain after surgery; additionally, it has a favorable safety and tolerability profile.
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Affiliation(s)
- Yang Liu
- Linyi Central Hospital, Shandong, China
| | - Qiang Hu
- Linyi Central Hospital, Shandong, China
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