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Perioperative Reactions to Sugammadex

  • Anaphylaxis (M Sanchez-Borges, Section Editor)
  • Published:
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Abstract

Purpose of the review

The γ-cyclodextrin sugammadex, chemically modified to encapsulate the steroidal muscle relaxant rocuronium, was introduced into anesthesia as the first selective relaxant binding agent to reverse neuromuscular blockade. In the face of sugammadex’s alleged propensity to cause anaphylaxis, the agent was finally approved by the FDA in 2015. With its steadily increasing usage, it has become apparent that there is a small but concerning incidence of perioperative anaphylaxis to sugammadex and some reactions that are anaphylactic like but where diagnosis has not been definitive. The purpose here is to examine the symptoms of the induced reactions, successful treatments undertaken, diagnostic conclusions reached, and the terminology applied to the reactions studied.

Recent findings

Following relatively large numbers of early reports of anaphylaxis to sugammadex in Japan (where it was approved in 2010), accumulated data and evidence for the drug’s involvement in provoking reactions has been assembled (from Japan and elsewhere) and analyzed from 33 case reports and other relevant publications. A feature of the diagnostic conclusions is the varied terminology and nomenclature ascribed to the observed reactions with up to nine different diagnostic descriptions used. Although anaphylaxis is the most commonly applied designation, compelling evidence for an immune basis for many of the reported reactions is lacking. In accord with early predictions, the sugammadex-rocuronium inclusion complex has been shown to be allergenic with IgE/FcεRI-dependent anaphylaxis occurring in some patients. The basis of the immune recognition appears to be a shape alteration involving the thiocarboxyethyl sodium side chains attached at the primary ring of the host sugammadex molecule creating a new allergenic determinant.

Summary

Although still relatively rare, severe, even life threatening, anaphylactic-like reactions to sugammadex are becoming increasingly recognized. Not all reactions have been shown definitively to be true IgE antibody-mediated immediate allergic responses, and there is a lack of consistency in the terminology used by investigators in their diagnostic conclusions. Reactions, at least some IgE mediated, also occur in response to the sugammadex-rocuronium complex. Progress has been made in identifying the fine-structural recognition of the complex. The relative incidences of reactions to free and complexed sugammadex and a comparison of the fine structural allergenic determinants recognized on each, remain to be determined and compared.

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  1. Molecular Immunology Unit, Kolling Institute of Medical Research, Royal North Shore, Hospital of Sydney, Sydney, NSW, Australia

    Brian A. Baldo PhD

  2. Department of Medicine, University of Sydney, Sydney, NSW, Australia

    Brian A. Baldo PhD

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Baldo, B.A. Perioperative Reactions to Sugammadex. Curr Treat Options Allergy 7, 43–63 (2020). https://doi.org/10.1007/s40521-020-00248-w

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