UMEM Educational Pearls

Title: Sugammadex for Reversal of Non-Depolarizing Neuromuscular Blockers

Category: Pharmacology & Therapeutics

Keywords: sugammadex, rocuronium, NMBA, vecuronium (PubMed Search)

Posted: 12/29/2015 by Bryan Hayes, PharmD (Updated: 1/2/2016)
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After three failed attempts, the FDA finally granted approval for Merck's non-depolarizing neuromuscular blocker reversal agent sugammadex (Bridion). Though the product has been used in Europe and Asia for several years, hypersensitivity concerns led to the delayed approval in the U.S.

Important points

Reverses rocuronium, vecuronium, and to a lesser degree, pancuronium
Full reversal obtained about 3 minutes after administration
Eliminated entirely by the kidneys in about 8 hours (6 times longer in patients with CrCl < 30 mL/min)
Dosing is generally 2-4 mg/kg. Total body weight should be used in obese patients

Application to Clinical Practice

Potential for use in situations where a neuro exam is needed shortly after intubation (eg, status epilepticus, ICH)
The risk of serious hypersensitivity appears to be < 1% in published literature
Cost will most assuredly be high
Long duration in patients with reduced kidney function means further attempts to re-paralyze with roc, vec, or pancuronium may be unsuccessful

The EM PharmD blog discusses sugammadex's approval in more detail.

References

Welliver M, et al. Worldwide experience with sugammadex sodium: implications for the United States. AANA J 2015;83(2):107-15. [PMID 26016169]
Welliver M, et al. Discovery, development, and clinical application of sugammadex sodium, a selective relaxant binding agent. Drug Des Devel Ther 2009;2:49-59. [PMID 19920893]
Staals LM, et al. Reduced clearnace of rocuronium and sugammadex in patients with severe to end-stage renal failure: a pharmacokinetic study. Br J Anaesth 2010;104(1):31-9. [PMID 20007792]
Llaurado S, et al. Sugammadex ideal body weight dose adjusted by level of neuromuscular blockade in laparoscopic bariatric surgery. Anesthesiology 2012;117(1):93-8. [PMID 22549697]

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