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Optimizing Reversal of Neuromuscular Block in Older Adults: Sugammadex or Neostigmine

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Abstract

Residual neuromuscular paralysis, the presence of clinically significant weakness after administration of pharmacologic neuromuscular blockade reversal, is associated with postoperative pulmonary complications and is more common in older patients. In contemporary anesthesia practice, reversal of neuromuscular blockade is accomplished with neostigmine or sugammadex. Neostigmine, an acetylcholinesterase inhibitor, increases the concentration of acetylcholine at the neuromuscular junction, providing competitive antagonism of neuromuscular blocking drug and facilitating muscle contraction. Sugammadex, a modified gamma-cyclodextrin, antagonizes neuromuscular blockade by encapsulating rocuronium and vecuronium in a one-to-one ratio for renal clearance, a pharmacokinetic property that led to the recommendation that sugammadex not be administered to those with end-stage renal disease. While data are limited, reports suggest sugammadex is efficacious and well tolerated in individuals with reduced renal function. Sugammadex provides a more rapid and complete reversal of neuromuscular blockade than neostigmine. There is also accumulating evidence that sugammadex may provide a protective effect against the development of postoperative pulmonary complications, nausea, and vomiting, and that it may have beneficial effects on the rate of bowel and bladder recovery after surgery. Accordingly, sugammadex administration is beneficial for most older patients undergoing surgery.

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Acknowledgments

The authors would like to thank Ngoc Wasson (funded by the Department of Anesthesiology and Perioperative Medicine, Oregon Health & Science University) for her support with formatting, revising, and reference management during manuscript writing.

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  1. Department of Anesthesiology & Perioperative Medicine, Oregon Health & Science University, Portland, OR, USA

    Brandon M. Togioka & Katie J. Schenning

  2. Department of Obstetrics and Gynecology, Oregon Health & Science University, 3181 S.W. Sam Jackson Park Road, Mail Code: UHN-2, Portland, OR, 97239-3098, USA

    Brandon M. Togioka

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Correspondence to Brandon M. Togioka.

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Brandon Togioka has received two investigator-initiated research grants from Merck & Co., the company that owns and sells ugammadex. The opinions expressed in this article are those of the authors and do not necessarily reflect those of Merck & Co. Katie Schenning declares no conflicts of interest.

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BT: This author helped with manuscript design, literature review, summary of data, drafting and critically revising the manuscript. KS: This author helped with manuscript design, literature review, summary of data, drafting and critically revising the manuscript.

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Togioka, B.M., Schenning, K.J. Optimizing Reversal of Neuromuscular Block in Older Adults: Sugammadex or Neostigmine. Drugs Aging 39, 749–761 (2022). https://doi.org/10.1007/s40266-022-00969-4

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