Two Cases of Inadequate Response to Remimazolam

Abstract

We report the inadequate efficacy of remimazolam in two patients undergoing long-term benzodiazepine analog therapy. Remimazolam is a recently developed ultrashort-acting benzodiazepine. It is primarily used as an anesthetic in surgical procedures, as it has minimal effect on cardiac function and antagonists are available. It is expected to become more widely used in the future. On the other hand, similar to other benzodiazepines, benzodiazepine tolerance can also pose a challenge with remimazolam. Herein, we report two cases who were taking long-term oral benzodiazepine analogs. One patient did not fall asleep despite a sufficient dose of remimazolam and required a change to propofol. The other patient required a high dose of remimazolam to fall asleep; however, multiple signs of arousal were noted intraoperatively. Our findings suggest that remimazolam may not be an ideal anesthetic in long-term benzodiazepine analog users. Comprehensive assessment of preoperative medications and careful monitoring of intraoperative sedation levels are necessary. Furthermore, it may be advisable to consider the use of alternative agents such as propofol.

Remimazolam: its clinical pharmacology and evolving role in anesthesia and sedation practice

“…As remimazolam is primarily metabolized in the liver [57 ▪▪ ,58], severe hepatic impairment can cause a prolonged effect of remimazolam [59 ▪▪ ]. Remimazolam tolerance has been reported in long-term benzodiazepine users, such that some patients do not respond to even high doses of remimazolam [60,61,62 ▪ ]. Patients with severe hepatic impairment or long-term benzodiazepine use may not be appropriate for remimazolam anesthesia/sedation.…”