Hypersensitivity associated with sugammadex administration: a systematic review

Phase III clinical trial comparing the efficacy and safety of adamgammadex with sugammadex for reversal of rocuronium-induced neuromuscular block

BACKGROUND

Preliminary clinical trials of adamgammadex, a new cyclodextrin-based selective reversal agent, have demonstrated its efficacy in reversing neuromuscular block by rocuronium.

METHODS

This multicentre, randomised, double-blind, positive-controlled, non-inferiority phase III clinical trial compared the efficacy and safety of adamgammadex and sugammadex. We randomised 310 subjects to receive adamgammadex (4 mg kg-1) or sugammadex (2 mg kg-1) at reappearance of the second twitch of the train-of-four (TOF), and standard safety data were collected.

RESULTS

For the primary outcome, the proportion of patients with TOF ratio ≥0.9 within 5 min was 98.7% in the adamgammadex group vs 100% in the sugammadex group, with a point estimate and 95% confidence interval (CI) of 1.3% (-4.6%, +1.3%); the lower limit was greater than the non-inferiority margin of -10%. For the key secondary outcome, the median (inter quartile range) time from the start of administration of adamgammadex or sugammadex to recovery of TOF ratio to 0.9 was 2.25 (1.75, 2.75) min and 1.75 (1.50, 2.00) min, respectively. The difference was 0.50 (95% CI: 0.25, 0.50); the upper limit was lower than the non-inferiority margin of 5 min. In addition, there were no inferior results observed in secondary outcomes. Adamgammadex had a lower incidence of adverse drug reactions compared with sugammadex (anaphylactic reaction, recurarisation, decreased heart rate, and laryngospasm; P=0.047).

CONCLUSIONS

Adamgammadex was non-inferior to sugammadex with a possible lower incidence of adverse drug reactions compared with sugammadex. Adamgammadex may have a potential advantage in terms of its overall risk-benefit profile.

CLINICAL TRIAL REGISTRATION

Chinese Clinical Trial Registry, ChiCTR2000039525. Registered October 30, 2020. https://www.chictr.org.cn/showproj.html?proj=56825.

Efficacy and safety of adamgammadex for reversing rocuronium-induced deep neuromuscular blockade: A multicenter, randomized, phase IIb study

The rapid reversal of deep neuromuscular blockade (NMB) is important but remains challenging. This study aimed to evaluate the efficacy and safety of adamgammadex versus sugammadex in reversing deep rocuronium-induced NMB. This multicenter, randomized, phase IIb study included 80 patients aged 18-64 years, American Society of Anesthesiologists (ASA) grade 1-2, undergoing elective surgery under general anesthesia with rocuronium. Patients were randomized to the adamgammadex 7, 8, and 9 mg/kg group or the sugammadex 4 mg/kg group. The primary efficacy variable was the time to recovery of train-of-four ratio (TOFr) to 0.9. The secondary efficacy variables were the time to recovery of TOFr to 0.7, antagonistic success rate of the recovery of TOFr to 0.9 within 5 min, and incidence rate of recurarization within 30 min after drug administration. The explorative efficacy variable was the time to recovery of the corrected TOFr to 0.9 (actual/baseline TOF ratio). Adamgammadex 7, 8, and 9 mg/kg and sugammadex 4 mg/kg groups did not significantly differ in all efficacy variables. Importantly, adamgammadex 9 mg/kg permitted reversal within a geometric mean of 2.9 min. According to the safety profile, adamgammadex achieved good tolerance and low incidence of drug-related adverse events compared with the 4 mg/kg sugammadex. Adamgammadex 7, 8, and 9 mg/kg facilitated rapid reversal of deep rocuronium-induced NMB and had good tolerance and low incidence of drug-related adverse events. Therefore, adamgammadex is a potential and promising alternative to sugammadex.

Allergic Reactions to Sugammadex: A Case Series and Review of the Literature

Sugammadex is a novel agent for the reversal of neuromuscular blockade; it acts by encapsulating -rocuronium or vecuronium, eliminating the active compound from the circulation, thereby providing rapid and complete recovery even with profound or complete neuromuscular blockade. Clinical advantages, including reduced incidence of residual blockade, decreased nausea and vomiting, decreased dry mouth, less change in heart rate, and reduced pulmonary complications, have been demonstrated when comparing sugammadex to conventional agents, such as neostigmine, that inhibit acetylcholinesterase. Although generally safe and effective, anaphylactoid and allergic reactions have been reported with sugammadex. The potential for hypersensitivity reactions with sugammadex and previous reports from the literature, as well as diagnostic and treatment strategies, are presented in 3 pediatric cases.

Perioperative Anaphylaxis

Anesthesiologists routinely manage patients receiving drugs and agents, all of which have the potential for anaphylaxis, the life-threatening presentation of an allergic reaction. Clinicians must be ready to diagnose and manage the acute cardiopulmonary dysfunction that occurs.

Cardiac arrest following sugammadex administration

A 68-year-old man underwent elective surgical repair of an abdominal wall hernia under general anaesthesia. The operation required muscle relaxation, for which we used rocuronium. Following completion of surgery, 180 mg sugammadex was administered intravenously. Shortly afterwards, the patient became severely bradycardic with hypotension, refractory to treatment with ephedrine. This progressed to a pulseless electrical activity cardiac arrest. After 4 min of cardiopulmonary resuscitation, there was return of spontaneous circulation and, following a period of haemodynamic stability in which general anaesthesia was maintained, the patient emerged from anaesthesia without incident. He remained haemodynamically stable until discharge. Post-resuscitation investigations including the serum tryptase level were unremarkable except for a mild respiratory acidosis and slightly elevated D-dimers. Sugammadex-induced bradycardia has previously been described, but its mechanism remains unknown. We believe that sugammadex was the cause of cardiac arrest in this case because of the timing and sequence of events, the evolution to pulseless electric activity and the relatively uneventful post-arrest clinical course. We hope that our report will help to promote awareness about this potential complication of a now commonly-used drug.

Comparison of the Efficacy and Safety of Adamgammadex with Sugammadex for Reversal of Rocuronium-Induced Neuromuscular Block: Results of a Phase II Clinical Trial

This current phase II clinical trial was to compare the effect and safety of adamgammadex, a new cyclodextrin-based selective relaxant binding agent, with sugammadex to reverse rocuronium-induced neuromuscular block. Patients were randomised to receive adamgammadex (4 or 6 mg kg^-1) or sugammadex (2 mg kg^-1, as a positive control group) at the reappearance of the second twitch (T₂) in response to TOF stimulation. The standard safety data were collected. The 4 mg kg^-1 (n = 16) and 6 mg kg^-1 (n = 20) adamgammadex- and 2 mg kg^-1 (n = 20) sugammadex-induced recovery time of TOF ratio to 0.9 were 2.3, 1.6, and 1.5 min, respectively (p = 0.49). The 4 mg kg ^-1 adamgammadex-induced median recovery time was longer than that of 2 mg kg^-1 sugammadex (p = 0.01), and there was no difference between the 6 mg kg ^-1 adamgammadex group and 2 mg kg^-1 sugammadex group (p = 0.32). Then, the number of patients who experienced adverse events (AEs) was 6, 11, and 14 for adamgammadex at 4, 6 mg kg^-1 and sugammadex at 2 mg kg^-1, respectively. The treatment emergent AEs that occurred more than twice were detailed as follows: incision site pain, hypotension, emesis, fever, throat pain, blood bilirubin increase, abnormal T-wave of ECG, dizziness, incision site swelling, postoperative fever, expectoration, and nausea. For drug-related AEs, the increased urine acetone bodies and first-degree atrioventricular block were observed in two patients from sugammadex group. Then, the previously reported AEs were not observed in this study, including anaphylaxis, haemorrhage, recurarization, abnormal basic vital signs, or lengthened QRS intervals and QT intervals. Adamgammadex was found to be effective for reversal of rocuronium-induced neuromuscular block as sugammadex.

Adamgammadex in patients to reverse a moderate rocuronium-induced neuromuscular block

AIM

this study was to investigate the effectiveness, safety, and pharmacokinetics of adamgammadex in surgical patients, and it was approved by the Clinical Trial Ethics Sub-Committee of West China Hospital, Sichuan University (2018-Clinical Trial-58).

METHODS

Forty-eight patients aged 18-64 years were randomized to receive adamgammadex (2, 4, 6, and 8 mg.kg-1) or placebo at ratio of 10:2 for reversal of 0.6 mg.kg-1 rocuronium-induced neuromuscular block. Neuromuscular function was monitored by TOF-Watch® SX. When the T2 of train-of-four (TOF) reappeared at the end of surgery, patients received an intravenous administration of adamgammadex or placebo.

RESULTS

the recovery time of the TOF ratio to 0.9 decreased significantly from 39.3 [29.5, 50.2] min in the group that received placebo to 3.0 [2.3, 3.9] min, p < 0.0001; 2.1 [1.5, 3.0] min, p < 0.0001; 2.1 [1.8, 3.3] min, p < 0.0001; and 1.8 [1.5, 2.2] min, p < 0.0001 in the 2, 4, 6, and 8 mg.kg^-1 adamgammadex group, respectively. Then, adamgammadex also showed a shortened recovery time for the TOF ratio recovered to 0.8 and 0.7. Adamgammadex was well-tolerated, and no case in anaphylactic reactions, post-operative bleeding, recurarization, basic vital signs, and QT intervals were observed. The pharmacokinetics of adamgammadex in plasma increased in dose-dependent manner. The 24-h cumulative fraction of adamgammadex in urine was 65-83%, and that of rocuronium was increased after using adamgammadex from 15% to about 25-30%.

CONCLUSION

Adamgammadex was found to be effective for reversal of rocuronium-induced neuromuscular block, and it was safe and well-tolerated in patients.

Reply to Sagliocco, O.; Betelli, M. Comment on "Fierro et al. Severe Hypotension, Bradycardia and Asystole after Sugammadex Administration in an Elderly Patient. Medicina 2021, 57, 79"

We thank Dr. Sagliocco and Dr. Betelli for their comments [...].

Sugammadex-induced anaphylactic reaction: A systematic review

Perioperative anaphylaxis is a rare, but life-threatening hypersensitivity reaction for patients undergoing surgical procedures. Sugammadex is a relatively new drug used to reverse the neuromuscular blockade of specific anesthetics in surgery. Several case reports indicate that there may be a risk of anaphylaxis associated with the use of sugammadex This review examines the literature in order to evaluate the strength of the association between sugammadex use and anaphylaxis. A query of PubMed, EMBASE, and Web of Science was conducted using a combination of terms to identify relevant articles from inception until March 9, 2020. We included any primary study that identified sugammadex as a probable causative agent based on the World Allergy Organization diagnostic criteria for anaphylaxis. A total of 24 articles were reviewed. Across the three randomized controlled trials, there were only four cases of anaphylaxis identified. Incidence of anaphylaxis was reported in only one trial at 0.33%. Two retrospective observational studies conducted in Japan identified cases of anaphylaxis, with incidences of 0.02 and 0.04%. Among 19 case reports and series, 25 patient cases of anaphylaxis were confirmed via allergy testing to be caused by sugammadex or sugammadex-rocuronium complex. Commonly reported symptoms included hypotension, erythema, and decreased oxygen saturation. Based on the findings of this review, there appears to be a rare, but serious, association of sugammadex-induced perioperative anaphylaxis with an incidence between 0.02 and 0.04% in observational studies. It is unclear whether sugammadex on its own or in complex with rocuronium triggers this reaction, but it is clearly involved in inducing anaphylaxis. Further population studies are needed to get a more accurate global incidence rate, and more detailed allergy testing is required to better describe which step of the sugammadex reversal pathway initiates the anaphylactic attack.

Sugammadex, the Guardian of Deep Muscle Relaxation During Conventional and Robot-Assisted Laparoscopic Surgery: A Narrative Review

High intra-abdominal pressure induced by artificial pneumoperitoneum can obviously impair respiratory and circulatory functions and has a negative effect on the prognosis of patients undergoing conventional and robot-assisted laparoscopic surgery. The application of deep neuromuscular blockade during the operation is reported to lower the intra-abdominal pressure and improve patients’ outcome. However, concern lies in the risks of postoperative residual muscular paralysis with the use of deep neuromuscular blockade. Sugammadex, a specific antagonist for aminosteroids muscle relaxants, can effectively and rapidly reverse rocuronium and vecuronium induced neuromuscular blockade of different depths. Thus, sugammadex allows the ability to safeguard the application of deep neuromuscular blockade in laparoscopic operations and helps to alleviate the adverse complications associated with pneumoperitoneum. Here, we review the application of deep neuromuscular blockade in different laparoscopic surgeries and discuss the benefits and possible risks of sugammadex administration in the reversal of deep neuromuscular blockade in these operations.

Efficiency and Safety of the Selective Relaxant Binding Agent Adamgammadex Sodium for Reversing Rocuronium-Induced Deep Neuromuscular Block: A Single-Center, Open-Label, Dose-Finding, and Phase IIa Study

Background: Rapid reversal of neuromuscular block after surgery and anesthesia is often necessary. Here, we reported the primary efficacy and safety data from a phase IIa study on adamgammadex sodium, a newly developed modified γ-cyclodextrin derivative.

Methods: This was a phase IIa, single-center, randomized, open-label, and dose-finding study that enrolled 35 patients under general anesthesia who received the neuromuscular blocking agent rocuronium for induction and maintenance of neuromuscular blockade. The subjects were randomized to one of the five adamgammadex dose groups (2, 4, 6, 8, and 10 mg kg⁻¹) and to the 4 mg kg⁻¹ sugammadex group. Pharmacological efficacy was the recovery time from the start of adamgammadex or sugammadex administration to train-of-four (TOF) ratio ≥0.9, 0.8, and 0.7 among the different dose groups. Adverse events were recorded throughout the study.

Results: The efficacy in reversing deep neuromuscular block was the same between 4 mg kg⁻¹ sugammadex and adamgammadex. However, in the lowest dose groups of 2 and 4 mg kg⁻¹ adamgammadex, adequate reversal could not be achieved in all subjects. The recovery time of TOF ratio to 0.9, 0.8, and 0.7 was shorter in the adamgammadex 10 mg kg⁻¹ group than in the sugammadex 4 mg kg⁻¹ group. The average values of the TOF ratio after 3 min of administration of adamgammadex 8 and 10 mg kg⁻¹ and sugammadex 4 mg kg⁻¹ were >90%. There were no serious adverse events after the use of adamgammadex, and no subjects had to be withdrawn from the trial.

Conclusions: Adamgammadex enabled quick, predictable, and tolerable reversion of rocuronium-induced deep neuromuscular block in a dose-dependent manner. Adamgammadex doses of 6–10 mg kg⁻¹ might be the recommended dose range for further exploration of efficacy. Clinical Trial Registration: This study was registered at chictr.org.cn, identifier: ChiCTR2000038391.

Sugammadex to Reverse Neuromuscular Blockade Prior to Withdrawal of Life Support

In certain end-of-life scenarios, pharmacologic reversal of neuromuscular blockade may be indicated. However, given the depth of blockade frequently necessitated in the ICU setting, rapid reversal of neuromuscular blockade is generally not feasible with conventional reversal agents such as neostigmine that inhibit acetylcholinesterase. Sugammadex is a novel pharmacologic agent for the reversal of neuromuscular blockade that acts by directly encapsulating steroidal neuromuscular blocking agents and providing effective 1:1 binding of rocuronium or vecuronium. This unique mechanism of action is rapid and allows for complete reversal and recovery of neuromuscular function. We report the use of sugammadex to reverse neuromuscular blockade prior to compassionate extubation in three pediatric patients. Its clinical use in children is reviewed, potential applications in the palliative care arena discussed, and dosing algorithms presented.

Sugammadex and anaphylaxis: An analysis of 33 published cases

In this study, the published sugammadex-induced anaphylaxis reports were reviewed to determine similarities in their presentation during anesthesia. PubMed was searched for sugammadex-induced anaphylaxis without time limitation. Reports were evaluated if they were in English and met the criteria of anaphylaxis determined by the World Allergy Organization. Two independent reviewers extracted and assessed the data using predesigned data collection forms. In total, 23 suitable articles were found and 33 sugammadex-induced anaphylaxis cases were included in the study. The mean age was 43.09 years (from 3–89 years) and 17 (51.5%) of the patients were female. Considering all reported cases, the average onset time of anaphylaxis was 3.08 min, with a median of 3 min (range 1–8 min). The most common signs and symptoms were hypotension, tachycardia, erythema, and desaturation. Of the 20 patients who underwent confirmatory skin testing, 15 had a positive skin reaction for sugammadex. Epinephrine was not given when indicated in about 25% of cases. Sugammadex-induced anaphylaxis onset time was less than 5 min in 92.3% of all the reported cases. Rapid diagnosis and early recognition of signs and symptoms of anaphylaxis are essential for a favorable prognosis. Treatment needs to be started as soon as possible to ensure the best outcome for the patient.

The Effect of Sugammadex on Prothrombin and Activated Partial Thromboplastin Time

Sugammadex is routinely used as an effective neuromuscular blockade reversal agent. Several studies have indicated that it may prolong the prothrombin time (PT) and the activated partial thromboplastin time (aPTT). This review gathers the relevant in vivo studies to accumulate knowledge on the subject. Nine studies were included. According to the results, sugammadex seems to lead to a transient increase in aPTT and PT values, compared to standard care. However, the clinical impact seems to be trivial. Nevertheless, the trials' findings reveal great heterogeneity, preventing a meta-analysis. Therefore, more well-designed studies are needed to lead to prudent conclusions.

Recent advances in supramolecular antidotes

Poisons always have fascinated humankind. Initially considered as deleterious or hazardous substances, the modern era has witnessed the controlled utilization of dangerous poisons in medicine and cosmetics. Simultaneously, antidotes have become crucial as reversal agents to counteract the effects of a poison, and they are also used today to positively cancel the benefits of a poison after use. Currently, the majority of poisons are composed of small molecules. This review focuses on recent developments to reverse or prevent toxic effects of poisons by encapsulation in host molecules. Cyclodextrins, cucurbiturils, acyclic cucurbituril derivatives, calixarenes, and pillararenes, have been reported to largely impact the effects of toxic compounds, thus extending the current paradigm of small molecule antidotes by adding a new family of macrocyclic compounds to the current arsenal of antidotes. Along this line of research, endogenous "harmful" species are also sequestered by one or more of these supramolecular host molecules, expanding the potential of supramolecular antidotes to diverse therapeutic areas.

Sugammadex

There are a large number of publications which describe the use of cyclodextrins (CDs) in numerous fields, including biomedicine, cosmetics, food industry, wastewater remediation and catalysis. These drugs contain a number of glucose monomers in a ring, creating a cone shape: α (alpha), β (beta), and γ (gamma) cyclodextrins with 6, 7 and 8 glucose subunits respectively. With a hydrophobic interior and hydrophilic exterior, they can form complexes with hydrophobic compounds often conferring solubility and stability to other drugs. The inclusion compounds of cyclodextrins with hydrophobic molecules are able to penetrate body tissues; these can be used to release biologically active compounds under specific conditions. Sugammadex is a unique, selective relaxant binding agent (SRBA) which reverses aminosteroid-induced neuromuscular blockade. It is an alternative to anticholinesterases in anaesthesia and allows use and reversal of rocuronium as a substitute for suxamethonium for rapid sequence induction (RSI).

[Update on perioperative hypersensitivity reactions: joint document from the Brazilian Society of Anesthesiology (SBA) and Brazilian Association of Allergy and Immunology (ASBAI) - Part II: etiology and diagnosis]

This second joint document, written by experts from the Brazilian Association of Allergy and Immunology (ASBAI) and Brazilian Society of Anesthesiology (SBA) concerned with perioperative anaphylaxis, aims to review the pathophysiological reaction mechanisms, triggering agents (in adults and children), and the approach for diagnosis during and after an episode of anaphylaxis. As anaphylaxis assessment is extensive, the identification of medications, antiseptics and other substances used at each setting, the comprehensive data documentation, and the use of standardized nomenclature are key points for obtaining more consistent epidemiological information on perioperative anaphylaxis.

Update on perioperative hypersensitivity reactions: joint document from the Brazilian Society of Anesthesiology (SBA) and Brazilian Association of Allergy and Immunology (ASBAI) - Part II: etiology and diagnosis

This second joint document, written by experts from the Brazilian Association of Allergy and Immunology (ASBAI) and Brazilian Society of Anesthesiology (SBA) concerned with perioperative anaphylaxis, aims to review the pathophysiological reaction mechanisms, triggering agents (in adults and children), and the approach for diagnosis during and after an episode of anaphylaxis. As anaphylaxis assessment is extensive, the identification of medications, antiseptics and other substances used at each setting, the comprehensive data documentation, and the use of standardized nomenclature are key points for obtaining more consistent epidemiological information on perioperative anaphylaxis.

History of the development of antagonists for neuromuscular blocking agents

Muscle relaxation induced by neuromuscular blocking agents (NMBAs) is necessary for tracheal intubation and immobilization during surgery. Although acetylcholinesterase inhibitors have been successfully used as antagonists for NMBAs, they have their limitations; their effects are transient and ineffective against profound neuromuscular blockade. In the past, alternative antagonists were developed, such as germine and 4-aminopyridine, which are effective for the treatment of diseases causing muscle weakness and could potentially be used as antagonists for NMBAs. Unfortunately, these drugs did not come into practical use due to unwanted side-effects. Sugammadex is an almost ideal antagonist because it rapidly forms a rigid complex with rocuronium and produces less adverse effects. The development of novel NMBAs and antagonists, especially sugammadex, has revolutionized anesthesia practice. Recently, novel short-acting NMBAs, such as gantacurium and CW002 have been developed. Their effects can be reversed by the amino-acid L-cysteine. More recently, calabadions have been developed, which can form complexes with both steroidal and bisbenzyl-isoquinolinium NMBAs, in a similar fashion as sugammadex. Understanding the history of the NMBA antagonist's development is interesting and useful for modern anesthesiologists since it enhances their knowledge about the mechanisms involved in neuromuscular transmission and might lead to the development of ideal NMBA antagonists.

Advantages and pitfalls of clinical application of sugammadex

Sugammadex, a modified γ-cyclodextrin, is one of the drugs focused on in the anesthetic field because it provides rapid and complete reversal from neuromuscular blockade (NMB) by encapsulating rocuronium. Its introduction has revolutionized anesthesia practice because it is a safe, predictable, and reliable neuromuscular antagonist. Hence, its use has increased worldwide. Further, it has been in the spotlight for recovering from deep NMB in laparoscopic surgery and improving the surgical condition. Recently, studies have been conducted on the postoperative outcome after deep NMB and use of sugammadex in various clinical conditions. However, with increase in sugammadex use, reports regarding its complications are increasing. Appropriate dosing of sugammadex with quantitative neuromuscular monitoring is emphasized because under-dosing or over-dosing of sugammadex might be associated with unexperienced complications. Sugammadex is now leaping into an ideal reversal agent, changing the anesthesia practice.

The future of neuromuscular blocking agents

PURPOSE OF REVIEW

The present review provides a summary of the literature on recent development of new neuromuscular blocking agents and presents clinically well established and new reversal agents.

RECENT FINDINGS

Anesthesiologists are still waiting for the ideal neuromuscular blocking agent with a succinylcholine-like rapid onset and offset without side effects. Recent drug development led to a new series of neuromuscular compounds, called the chlorofumarates such as gantacurium, CW002, and CW011. These drugs have a promising pharmacodynamic profile; importantly, they can rapidly be reversed by L-cysteine adduction without relevant side effects. In addition, a new spectrum of reversal agents are currently examined in preclinical studies: adamgammadex sodium, a modified γ-cyclodextrin derivate that forms an inactive tight inclusion complex with rocuronium or vecuronium and calabadions, capable of reversing both benzylisoquinolines and steroidal neuromuscular blocking agents.

SUMMARY

Although the recent advancements in neuromuscular research are very promising, to date, the presented drugs are currently not available for clinical use. Clinical studies will determine the role of these developments in anesthesia practice. Therefore, well established combinations such as rocuronium-sugammadex are popular in clinical practice to offer quick paralysis for intubation and to optimize surgical conditions, while providing a fast neuromuscular recovery at the end of surgery.

Sugammadex: A Limited But Important Role in Emergency Medicine

Sugammadex reverses neuromuscular blockade by the steroidal nondepolarizing neuromuscular blocking agents rocuronium and vecuronium. In 2015, it was approved in the United States by the Food and Drug Administration for adult use. However, there are ongoing clinical trials investigating its use in the pediatric population. Before approval in adult use in the United States, several adverse effects were noted to occur in patients receiving sugammadex in clinical trials including prolonged QT interval, bradycardia, hypersensitivity reactions, and prolongation of coagulation parameters. Additional investigations further elucidated the risks of these adverse events. Sugammadex is approved for use in children older than 2 years in other countries in Europe and Asia. Investigations suggest that the efficacy, safety, and pharmacokinetic profile is similar in children when compared with adults. Published pediatric data favor the use of sugammadex in children older than 2 years, but there are some data in young children younger than 2 years. Case reports discuss the use of sugammadex in pediatric patients with neuromuscular diseases. Although sugammadex is typically used in the operating room for reversing neuromuscular blockade for surgical procedures, there is a small but important role for sugammadex use in the emergency department. In cases where rapid neurological examination is required after neuromuscular blockage with rocuronium or vecuronium, sugammadex can assist in facilitating a timely comprehensive neurological examination where pharmacologic or surgical management may depend on examination findings such as in the case of cerebral vascular accident, status epilepticus, or traumatic brain injury. Some clinicians have advocated for the use of sugammadex in the cannot intubate, cannot ventilate scenario. However, caution should be exercised in this situation as reversal of paralysis can take up to 22 minutes to occur.

Sugammadex: Applications in Pediatric Critical Care

Sugammadex is a novel pharmacologic agent, which reverses neuromuscular blockade with a mechanism that differs from acetylcholinesterase inhibitors such as neostigmine. There is a growing body of literature demonstrating its efficacy in pediatric patients of all ages. Prospective trials have demonstrated a more rapid and more complete reversal of rocuronium-induced neuromuscular blockade than the acetylcholinesterase inhibitor, neostigmine. Unlike the acetylcholinesterase inhibitors, sugammadex effectively reverses intense or complete neuromuscular blockade. It may also be effective in situations where reversal of neuromuscular blockade is problematic including patients with neuromyopathic conditions or when acetylcholinesterase inhibitors are contraindicated. This article reviews the physiology of neuromuscular transmission as well as the published literature, regarding the use of sugammadex in pediatric population including the pediatric intensive care unit population. Clinical applications are reviewed, adverse effects are discussed, and dosing algorithms are presented.

Safety, tolerability, and pharmacokinetics of adamgammadex sodium, a novel agent to reverse the action of rocuronium and vecuronium, in healthy volunteers

Neuromuscular blockers (NMBs) selectively block neuromuscular transmission at the N2-nicotinic receptor on motor neurons to paralyze skeletal muscles, and are mainly used to facilitate tracheal intubation and surgical procedures. Rapid reversal is necessary in clinical practice to avoid profound block and reduce recovery time. Adamgammadex sodium is a modified γ-cyclodextrin derivative consisting of a lipophilic core and a hydrophilic outer end that forms an inactive tight inclusion complex with free molecules of rocuronium and vecuronium. In preclinical study, adamgammadex produced a concentration-dependent reversion effect of neuromuscular blockade induced by rocuronium in beagle dogs. Furthermore, adamgammadex had a less potential side effects than sugammadex and other clinical used neuromuscular block antagonists. In this study, the objective was to assess the safety, tolerability, and pharmacokinetics of single intravenous injection of adamgammadex in healthy volunteers. Approved by the China Food and Drug Administration, 52 healthy volunteers (half male and half female) were enrolled in this single-center, randomized, double-blind placebo-controlled study. No serious adverse effects were happened in this study. The overall frequency of adverse effects in adamgammadex was similar for that in placebo, and there was no specific adverse effect in adamgammadex. All of the volunteers bearing the adverse effects were recovered to normal without any treatment or intervention. In pharmacokinetic study, the value of half-time, T_max, and clearance were not changed significantly, and the C_max and AUC_0-∞ increased with a similar ratio of the escalating doses. For dose proportionality analysis of adamgammadex, the estimate of slope was close to 1, and it was not significantly different from 1 after doses (AUC_0-∞, 0.9965 [90%CI, 0.9468, 1.046]; C_max, 0.9462 [90%CI, 0.8800, 1.012]). Therefore, adamgammadex exposure in plasma increased in a dose- proportional manner. The urinary route is a significant excretory pathway for adamgammadex, and it is mostly completed at 8 h. All the results in this study showed that adamgammadex may be a novel safe neuromuscular blockade reversal agent .

Anaphylaxis induced by sugammadex and sugammadex-rocuronium complex -a case report

BACKGROUND

In sugammadex-induced anaphylaxis, sugammadex and/or sugammadex-rocuronium complex have possible allergenic epitope.

CASE

We report a case of sugammadex-induced anaphylaxis during general anesthesia in a 60-year-old male undergoing orthopedic hand surgery, manifesting as profound hypotension and urticaria. The timing of onset was closely associated with sugammadex administration. The patient recovered after extensive therapy including fluid, epinephrine, other vasopressors, steroid, and antihistamine administration. By intradermal skin test which was done at four weeks after anaphylaxis, we confirmed positive reactions to both sugammadex and sugammadex-rocuronium complex.

CONCLUSIONS

This is a rare case of sugammadex-induced anaphylaxis that both sugammadex and sugammadex-rocuronium complex were confirmed as allergenic epitopes.

An EAACI position paper on the investigation of perioperative immediate hypersensitivity reactions

Perioperative immediate hypersensitivity reactions are rare. Subsequent allergy investigation is complicated by multiple simultaneous drug exposures, the use of drugs with potent effects and the many differential diagnoses to hypersensitivity in the perioperative setting. The approach to the investigation of these complex reactions is not standardized, and it is becoming increasingly apparent that collaboration between experts in the field of allergy/immunology/dermatology and anaesthesiology is needed to provide the best possible care for these patients. The EAACI task force behind this position paper has therefore combined the expertise of allergists, immunologists and anaesthesiologists. The aims of this position paper were to provide recommendations for the investigation of immediate-type perioperative hypersensitivity reactions and to provide practical information that can assist clinicians in planning and carrying out investigations.

An update on allergy and anaphylaxis in pediatric anesthesia

Childhood allergy is common, and increasing. Many children are incorrectly labeled as having allergy or adverse drug reactions. This can pose a dilemma for anesthetists and lead to a change in practice or drug selection. We review the pathophysiology of hypersensitivity reactions and the implications for anesthesia of food allergy, atopy, and family history of allergy in children. The epidemiology of anaphylaxis is discussed. We discuss the common triggers of perioperative anaphylaxis in children and explore emerging triggers including chlorhexidine and sugammadex. Accurate data on pediatric perioperative anaphylaxis is limited worldwide, with marked geographic variation. This highlights the need for accurate local, district and/or nationwide incident reporting. The clinical features, diagnosis, and management of anaphylaxis under anesthesia are discussed. We review the process of expert allergy testing following a suspected case of anaphylaxis to guide future safe anesthesia administration. The preoperative consultation is an opportunity for referral for allergy testing to allow de-labeling. This has the potential for improved antibiotic stewardship and more effective treatment with first-line therapeutic agents.

Profound Bradycardia and Cardiac Arrest After Sugammadex Administration in a Previously Healthy Patient: A Case Report

We report the case of a 60-year-old man who underwent open radical prostatectomy for prostate adenocarcinoma. He had no known cardiac disease or symptoms other than controlled hypertension and remote history of cocaine use. The patient was given sugammadex for reversal of neuromuscular blockade and, within 1 minute, developed severe, drug-resistant bradycardia followed by pulseless electrical activity arrest. Advanced cardiac life support was initiated and continued for 15 minutes before the return of spontaneous circulation. Subsequent cardiac workup showed no abnormalities. We believe the cause of arrest was sugammadex, considering the time of administration, the absence of cardiac disease, and stable operative course.

Case series of 331 cases of sugammadex compared to neostigmine in patients under 2 years of age

BACKGROUND

Sugammadex is a novel neuromuscular blockade reversal agent approved by the Food and Drug Administration in 2015, but little literature exists for patients less than 2 years of age.

AIMS

The aims of this study were to: describe a cohort of patients 2 years old and younger who received sugammadex; describe any adverse effects of sugammadex in this age group; compare time from end of surgery to out of operating room for sugammadex versus neostigmine; compare time between last dose of neuromuscular blocking drug and reversal; and use train-of-four data to assess reversal.

METHODS

Chart review of the medical record and the anesthesia information system captured all patients in this age cohort who received sugammadex or neostigmine over a two-year period. Adverse medication events were pulled from a mandatory quality improvement field in the electronic anesthesia record. T-tests were used for analyses.

RESULTS

No adverse effects were reported with 331 doses of sugammadex. The average time in minutes between end of surgery and out of operating room was similar for neostigmine (19.6) versus sugammadex (19.4) (mean difference 0.2, 95% CI -1.5-1.8, P = 0.85). The average time in minutes between last dose of neuromuscular blocking drug and reversal agent was longer for neostigmine (103) than for sugammadex (84) (mean difference 19, 95% CI 13-26, P < 0.001).

CONCLUSIONS

Sugammadex administration in this young population did not result in any adverse effects. It appears to be equally effective as neostigmine in patients under 2 years of age.

Comparative epidemiology of suspected perioperative hypersensitivity reactions

Suspected perioperative hypersensitivity reactions are rare but contribute significantly to the morbidity and mortality of surgical procedures. Recent publications have highlighted the differences between countries concerning the respective risk of different drugs, and changes in patterns of causal agents and the emergence of new allergens. This review summarises recent information on the epidemiology of perioperative hypersensitivity reactions, with specific consideration of differences between geographic areas for the most frequently involved offending agents.

Anaphylaxis Induced by Sugammadex in a Patient with Papillary Serous Carcinoma of the Uterine Adnexa Undergoing Exploratory Laparotomy

In this case report, we present a patient who developed anaphylaxis immediately after sugammadex administration. A 67-year-old female with the diagnosis of papillary serous carcinoma was scheduled for an exploratory laparotomy exam under anesthesia and total abdominal hysterectomy. At the end of the operation, sugammadex was administered; it was rapidly accompanied with marked hypotension and bradycardia.

Multiple boluses of phenylephrine were administered with minimal effect. Boluses of epinephrine and vasopressin were given and the patient's hemodynamic instability rapidly abated. A 12-lead electrocardiogram (ECG) obtained in the post-anesthesia care unit (PACU) showed sinus tachycardia and a prolonged corrected QT (QTc) interval. A tryptase level was drawn in the operating room. After an uneventful PACU stay, the patient was observed overnight in the intensive care unit (ICU) as a precaution. Cardiology service was consulted, and they agreed with the anesthesia team that the cause of the patient's hemodynamic instability collapse was consistent with the diagnosis of anaphylaxis. The serum tryptase returned with a level of 62.3 ng/mL, confirming the diagnosis. The patient was discharged on postoperative Day 4.

Anaphylaxis may result from sugammadex usage, and this might cause severe hypotension and cardiac arrhythmias. The prompt recognition and treatment of hypotension and anaphylaxis are critical to minimize morbidity and prevent mortality in these patients.

Anaphylactic Reactions to Native and Light-Exposed Sugammadex Suggested by Basophil Activation Test: A Report of 2 Cases

We describe 2 patients who developed anaphylactic shock after sugammadex administration during anesthesia. Both had no history of prior sugammadex administration. The serum tryptase concentrations were elevated after the allergic reaction. Basophil activation testing 1 month after the events was positive for sugammadex in 1 patient, and negative in the other. However, it was positive for light-exposed sugammadex solution in both patients, suggesting a possible allergic reaction to a denatured compound of sugammadex generated by light exposure of the sugammadex solution.

Neuromuscular blocking agents induced anaphylaxis: Results and trends of a French pharmacovigilance survey from 2000 to 2012

BACKGROUND

Perioperative anaphylaxis mainly involves neuromuscular blocking agents (NMBAs) with an IgE-mediated mechanism. In France, this life-threatening condition is reported by anesthetists and allergologists, and two safety alerts concerning suxamethonium were raised in 2011 and 2012. This led to start a national survey over the 2000-2012 period which objectives were to provide a descriptive analysis, to estimate incidence rates, and to analyze the trends over this period.

METHODS

The French pharmacovigilance database was retrospectively queried for all the available NMBAs. Anaphylaxis cases with elevated tryptase and positive skin tests were qualified as "confirmed cases." Subgroup analysis compared atracurium and cisatracurium vs suxamethonium and rocuronium.

RESULTS

A total of 680 confirmed cases and 944 nonconfirmed cases were identified. Suxamethonium was the most implied NMBA (64%). Incidence rates (according to sales data) of suxamethonium and rocuronium were, respectively, 10- and 13-folds higher than those of the others NMBAs, regardless the confirmed/nonconfirmed status. Cisatracurium incidence rates remained stable over the period, while suxamethonium and atracurium increased and rocuronium first decreased but re-increased after 2006. Male patients were more frequent in the subgroup "atracurium-cisatracurium" (P = .019), whereas obesity and emergency setting were more frequent in the subgroup "rocuronium-suxamethonium." Shared characteristics were the poorly documented previous exposure to NMBA(s) and an insufficient adherence of patients to perform skin tests, showing the need to improve this procedure.

CONCLUSION

Suxamethonium and rocuronium are markedly more involved in perioperative anaphylaxis than the other available NMBAs. Patients should be more informed about their perioperative anaphylaxis and its consequences.

Hypersensitivity incidence after sugammadex administration in healthy subjects: a randomised controlled trial

BACKGROUND

We evaluated the incidence of hypersensitivity or anaphylaxis after repeated single-dose sugammadex administration in non-anaesthetised adults.

METHODS

In this multicentre, double-blind study (NCT02028065), healthy volunteer subjects were randomised (2:2:1 ratio) to one of three groups to receive three repeated intravenous injections of sugammadex 4 or 16 mg kg^-1, or placebo, separated by a ∼5 week intervals. Targeted hypersensitivity assessments were performed 0.5, 4, and 24 h post-dosing, and hypersensitivity signs/symptoms were referred to a blinded independent Adjudication Committee. Anaphylaxis was determined per Sampson (Criterion 1). The primary endpoint was the proportion with confirmed hypersensitivity.

RESULTS

Of 375 evaluable subjects, 25 had confirmed hypersensitivity [sugammadex 4 mg kg^-1: 10/151 (6.6%); sugammadex 16 mg kg^-1: 14/148 (9.5%); placebo: 1/76 (1.3%)]. The differences in incidence rates vs placebo were 5.3% (95% confidence interval: -0.9, 10.7) for sugammadex 4 mg kg^-1 and 8.1% (1.7, 14.2) for 16 mg kg^-1. Incidence was similar across sugammadex doses and dosing occasions, including in subjects with reactions to previous doses. Three subjects (16 mg kg^-1 group) required antihistamines/corticosteroids and discontinued the study, per protocol; symptoms resolved and no subject required epinephrine. One subject with anaphylaxis after the first 16 mg kg^-1 dose recovered completely post-treatment. There were no clinically relevant anti-sugammadex antibody or tryptase findings.

CONCLUSIONS

Hypersensitivity in response to sugammadex administration can occur in healthy subjects without history of previous sugammadex exposure. Hypersensitivity incidence was similar across sugammadex doses and numerically higher than placebo, with no evidence of sensitisation with repeated administration. Hypersensitivity is unlikely to be mediated through sugammadex-specific immunoglobulin G- or E-mediated mast cell stimulation in healthy volunteers.

CLINICAL TRIAL REGISTRATION

NCT02028065.

Sugammadex hypersensitivity and underlying mechanisms: a randomised study of healthy non-anaesthetised volunteers

BACKGROUND

We investigated potential for hypersensitivity reactions after repeated sugammadex administration and explored the mechanism of hypersensitivity.

METHODS

In this double-blind, placebo-controlled study (NCT00988065), 448 healthy volunteers were randomised to one of three arms to receive three repeat i.v. administrations of either sugammadex 4 mg kg^-1, 16 mg kg^-1, or placebo. Primary endpoint was percentage of subjects with hypersensitivity (assessed by an independent adjudication committee). Secondary endpoint of anaphylaxis was classified per Sampson and Brighton criteria. Exploratory endpoints included skin testing, serum tryptase, anti-sugammadex antibodies [immunoglobulin (Ig) E/IgG], and other immunologic parameters.

RESULTS

Hypersensitivity was adjudicated for 1/148 (0.7%), 7/150 (4.7%), and 0/150 (0.0%) subjects after sugammadex 4 mg kg^-1, 16 mg kg^-1, and placebo, respectively. After sugammadex 16 mg kg^-1, one subject met Sampson criterion 1 and Brighton level 1 (highest certainty) anaphylaxis criteria; two met Brighton level 2 criteria. After database lock it was determined that certain protocol deviations could have introduced bias in the reporting of hypersensitivity signs/symptoms in a subject subset. Objective laboratory investigations indicated that potential underlying hypersensitivity mechanisms were unlikely to have been activated; the results suggest that most of the observed hypersensitivity reactions were unlikely IgE/IgG-mediated.

CONCLUSION

Dose-dependent hypersensitivity or anaphylaxis reactions to sugammadex were observed when administered without prior neuromuscular blocking agent. Laboratory investigations do not suggest prevalent allergen-specific IgE/IgG-mediated immunologic hypersensitivity. Because it could not be fully excluded that estimates of hypersensitivity/anaphylaxis incidence were unbiased, an additional study was conducted to characterise the potential for hypersensitivity reactions and is described in a companion report.

CLINICAL TRIAL REGISTRATION

http://www.clinicaltrials.gov NCT00988065; Protocol number P06042.

Association between sugammadex and anaphylaxis in pediatric patients: A nested case-control study using a national inpatient database

BACKGROUND

Sugammadex is used as a reversal drug during anesthesia. Although several case reports have described anaphylaxis following sugammadex infusion, little is known about the relationship between sugammadex and anaphylaxis, particularly in pediatric patients.

AIMS

The aim of this retrospective study was to investigate the association between sugammadex and in-hospital anaphylaxis in pediatric patients who underwent general anesthesia.

METHODS

We identified patients who underwent general anesthesia in a Japanese national inpatient database between July 2010 and March 2016. We conducted 1-4 case-control matching between patients with and without perioperative anaphylaxis. We calculated the adjusted odds ratio for sugammadex use and occurrence of anaphylaxis, using a conditional logistic regression analysis with adjustment for duration of anesthesia, antibiotics, and blood transfusions.

RESULTS

Among 835 405 patients who underwent general anesthesia, we identified 149 (0.018%) patients with anaphylactic shock and 472 (0.056%) with a combination of anaphylaxis associated signs/symptoms and skin lesions. Sugammadex use was not significantly associated with anaphylactic shock (odds ratio, 0.80; 95% confidence interval, 0.53-1.21; P = .29) or the combination of anaphylaxis associated signs/symptoms and skin lesions (odds ratio, 1.25; 95% confidence interval, 0.97-1.60; P = .08).

CONCLUSION

The present study showed no significant association between sugammadex and perioperative anaphylaxis in pediatric patients who underwent general anesthesia.

Crowdsourcing sugammadex adverse event rates using an in-app survey: feasibility assessment from an observational study

Background

Mobile applications (apps) have become a ubiquitous source of clinical decision support. We sought to ascertain the feasibility of using an app platform to obtain a crowdsourced measure of adverse drug reaction reporting rates associated with sugammadex administration and compare it with traditionally-derived estimates.

Methods

Using the widely-distributed anesthesia calculator app, 'Anesthesiologist', we surveyed anesthesia providers regarding their experience with adverse drug reactions associated with sugammadex administration.

Results

Data were analyzed from 2770 participants in 119 countries responding between March 2016 and May 2017, who were estimated to have administered between 1.6-2.9 million doses (588-1040 administrations per participant). A low and high-end reporting rate of adverse events was estimated based on respondents' reported frequency and duration of sugammadex use. The estimated reporting rate of anaphylaxis due to sugammadex was 0.0055-0.098%, similar in range to previously published estimates.

Conclusions

Use of an in-app survey facilitated a global assessment of anesthesia providers and could have useful applications in monitoring adverse events and estimating their rates. Further work is needed to validate this approach for other medications and clinical domains.