Comparison of incidence of anaphylaxis between sugammadex and neostigmine: a retrospective multicentre observational study

Abstract

Background: Although cases of anaphylaxis caused by sugammadex have been reported, its incidence remains uncertain. Conversely, no studies have evaluated the incidence of anaphylaxis to neostigmine. Methods: This was a retrospective multicentre observational study of patients who underwent surgery under general anaesthesia between 2012 and 2016 to compare the incidence of anaphylaxis with sugammadex with that of neostigmine at four tertiary hospitals in Japan. To ensure the quality of diagnosis, only cases with a clinical history suggestive of anaphylaxis, along with positive results from in vitro or in vivo testing, were assessed. Results: From a total of 49 532 patients who received general anaesthesia included in this study, 18 cases of anaphylaxis were reported, of which six were attributable to sugammadex and none to neostigmine. There were no fatalities attributable to anaphylaxis. The incidence of anaphylaxis caused by all drugs or by sugammadex was calculated as 0.036% (95% confidence interval [CI]: 0.022e0.057%) and 0.02% (of the number of sugammadex cases) (95% CI: 0.007e0.044%), respectively. Conclusions: The results suggest that neostigmine might be safer than sugammadex when assessing only the incidence of anaphylaxis. We believe that there is room for reconsideration of the choice of reversal agent for neuromuscular blocking agents by all anaesthetists. Clinical trial registration: UMIN000022365; UMIN000033561.

Neuromuscular blockade management in the critically Ill patient

“…In addition, the NMBA-sugammadex complex can be removed via standard dialysis techniques [82]. Concern exists over hypersensitivity reactions following sugammadex administration [83]; however, the overall incidence of such events remains low and rarely impacts routine clinical care [84]. While not currently widely used in the critical care setting, its use may expand as new evidence emerges describing its use as a rescue therapy for residual blockade [85] and its role in reducing the incidence of reintubation [86] and promoting enhanced recovery protocols in the ICU [87].…”

Anaphylactic Shock Case After Sugammadex Application

“…The mechanism of action of sugammadex is 10 times faster than neostigmine and has lesser side effects. In a multicenter study comparing the incidence of anaphylaxis between sugammadex and neostigmine, it was stated that neostigmine may be safer than sugammadex and it may be beneficial to revise the choice of reversal agents by anesthesiologists (3) . In the same study, it was reported that six of 29962 patients (0.02%) developed anaphylaxis due to sugammadex, and no patient had anaphylaxis due to neostigmine (0/3157) (3) .…”

“…It has been reported that allergic reactions due to sugammadex are more common at high clinical doses (16-96 mg kg -1 ) (9) . However, cases of anaphylaxis related to sugammadex use at low doses (1.9-2.2-1.2 mg kg -1 ) have been also reported (3,10) . In this case, the dose of sugammadex was 200 mg (2.6 mg kg -1 ).…”

“…Skin prick and intradermal tests are the gold standard for the diagnosis of drug hypersensitivity and should be performed at least 4-6 weeks after the reaction due to false-negative results (14) . In addition, histamine release test and basophil activation tests have been suggested in clinical practice (3,14,16) . Serum tryptase and histamine levels could not be measured with our existing laboratory facilities and skin tests could not be performed because the patient died on the 3rd day of the follow-up.…”

A cautionary tale of an emergency cerebrovascular procedure in the COVID-19 era

“…Sugammadex is a selective relaxant-binding agent developed for rapid reversal of non-depolarizing neuromuscular blockade from rocuronium 7 . Anaphylaxis is a known but rare complication of the administration of sugammadex 8 and occurs in 0.036% of cases. When it occurs urgent re-intubation is necessary.…”