Pro-Con debate: Sugammadex

Pro-Con debate: Sugammadex

Sunday 2 June, 1700-1800H – Piano Hall

One of three intriguing pro-con debates during Sunday’s program at Euroanaesthesia is on whether or not sugammadex should be the first line reversal agent.

Arguing the ‘pro’ side of the debate is Dr Hans D de Boer, a staff anaesthesiologist and pain specialist in the Department of Anesthesiology, Pain Medicine and Procedural Sedation and Analgesia at the Martini Hospital in Groningen, Netherlands.

He will start with some background, that sugammadex is a modified γ-cyclodextrin and the first selective relaxant binding agent based on an encapsulating principle for inactivation of a neuromuscular blocking agent. It is used to reverse the steroidal non-depolarising neuromuscular blocking drugs rocuronium and vecuronium.

Sugammadex was approved by EMEA (2008) and the FDA (2015) and is now available for paediatric and adult anaesthesia in the majority of countries worldwide. Since its introduction in clinical anaesthesia and emergency medicine, sugammadex has changed neuromuscular management dramatically.

Dr de Boer says: “The complex formation of sugammadex and rocuronium or vecuronium occurs at all levels of neuromuscular block (from deep to shallow) and results in a more fast-acting pharmacological reversal when compared to anticholinesterase agents. Consequently, reversal with sugammadex has been shown to result in a marked reduction of postoperative residual neuromuscular block and concomitant postoperative pulmonary complications in the PACU.”

He adds that sugammadex has also been shown to have an excellent safety profile compared with the more traditional reversal of neuromuscular blockade with anticholinesterase agents. Furthermore, sugammadex has shown benefits in specific patient populations like patients with neuromuscular disorders like myasthenia gravis.

He will argue: “Another advantage of the introduction of sugammadex is that deeper levels of neuromuscular blockade throughout laparoscopic surgical procedures can be used to allow lower intraabdominal insufflation pressures, which result in optimal surgical conditions and less postoperative pain. Also. the use of sugammadex has been shown to increase the quality of physiological recovery during early postoperative periods, compared with that of neostigmine.”

He concludes: “Based on all the published data, sugammadex should be the first line reversal agent.”

The ‘con’ part of the debate will be argued by the Secretary of the ESA, Professor Radmilo Jankovic, who is based at the Department for Anesthesia and Intensive Care, Clinical Center Niš, School of Medicine, University of Niš, Serbia.

“Sugammadex is a powerful rocuronium-induced reversal agent. While its introduction has changed the clinical practice of neuromuscular reversal dramatically, some serious concerns have been raised over the past few years,” explains Prof Jankovic. “The most important adverse event connected with sugammadex is a life-threatening hypersensitivity reaction, for which immediate detection and treatment are imperative.”

He will say that, though there is currently no firm evidence, there are some concerns regarding transient coagulation alteration caused by sugammadex. In a study by Carron et al, the effects of sugammadex on coagulation in morbidly obese patients undergoing general surgery were investigated. Even though no major or minor bleeding events were observed postoperatively, prolongation of INTEM Ct were observed after administration of sugammadex, 2mg/kg and 4 mg/kg.

Prof Jankovic says: “Furthermore, higher doses of sugammadex administered in an attempt to ensure full and sustained reversal may affect the effectiveness of rocuronium in case of immediate need for reoperation or reintubation.”

He concludes: “In the end, excessive doses of sugammadex may result in excessive costs.“