In this episode, I’ll discuss an article about the side effects of sugammadex vs neostigmine.
Despite its relatively higher cost, sugammadex is a very popular reversal agent for neuromuscular blockade in the perioperative setting compared to the alternative of neostigmine.
A group of authors published a retrospective cohort study in the journal Anesthesia and Analgesia to attempt to show the noninferiority of sugammadex vs neostigmine when it comes to just evaluating side effects.
Over 70,000 patients were analyzed for the primary outcome of a collapsed composite of bradycardia, anaphylaxis, bronchospasm, and cardiac arrest occurring between administration of the reversal agent and departure from the operation room.
This composite outcome was purposely limited only to side effects that require pharmacologic treatment as a proxy for clinically meaningful side effects.
About 18% of the patients received sugammadex and 72% received neostigmine. The most common individual side effect was bradycardia (2.4% in the sugammadex group versus 2.2% neostigmine).
The authors found the incidence of the composite outcome was 3.4% in patients given sugammadex and 3.0% in patients given neostigmine. This was a statistically significant difference in favor of neostigmine, meaning non-inferiority was not found. Neostigmine was superior to sugammadex with an estimated odds ratio of 0.83.
Despite this, the authors argue that the difference favoring neostigmine is not clinically significant, because the number needed to treat with neostigmine to avoid 1 event is 250.
This seems like a strange analysis given that due to the frequency of use of these agents, such a difference in favor of neostigmine could amount to hundreds of fewer side effects per year in a hospital that does 50 OR cases per weekday.
Furthermore, the authors state in their conclusion that the episodes avoided are a “minor complication” even though they explained in their methods that the side effects analyzed were all clinically meaningful because they required pharmacologic treatment.
This is a large dataset that adds significantly to the body of knowledge comparing these two medications and it is up to individual institutions to decide whether the statistically significant reduction in side effects with neostigmine is of any clinical significance.
To access my free download area with 20 different resources to help you in your practice, go to pharmacyjoe.com/free.
If you like this post, check out my book – A Pharmacist’s Guide to Inpatient Medical Emergencies: How to respond to code blue, rapid response calls, and other medical emergencies.
Leave a Reply