Paweł Radkowski, Julia Oszytko, Agnieszka Kowalczyk, Kamil Sobolewski, Dariusz Onichimowski

The validity of neuromuscular monitoring during routine use of sugammadex

 

2026-06-01

Background. The study focuses on suggamadex (SGM) - an innovative octasodium salt derivative of -cyclodextrin that has revolutionized the reversal of neuromuscular blockade (NMB) in modern anesthesiology. The analysis covers the specific chemical structure of the drug, which allows for selective binding of neuromuscular blocking agents (NMBA), such as rocuronium and vecuronium, into stable inclusion complexes. The work concentrates on the pharmacokinetics and pharmacodynamics of the preparation, as well as its safety profile compared to traditionally used neostigmine. An important element of the research is also the market context related to the expiration of the patent protection for SGM in 2023, which enabled the introduction of cheaper generic equivalents to the Polish market.

Aim of the study. The primary objective of the article is to systematize contemporary medical knowledge regarding the use of SGM in routine clinical practice and in high-risk patient populations. The work aims to demonstrate the superiority of SGM over acetylcholinesterase inhibitors in terms of speed and predictability of neuromuscular recovery. The analysis includes the optimization of dosing in obese patients based on total body weight (TBW), children, the elderly, and patients with renal failure or myasthenia gravis. An additional goal is to assess the validity of widespread implementation of the drug as a standard of care, considering the rapid decrease in therapy costs.

Materials and methods. The article is a review of scientific literature from 2016–2026, supplemented by selected older sources. The selection process was conducted using PubMed and Google Scholar databases, applying Polish and English keywords: “sugammadex”, “generics”, “anesthesiology”, “intensive care”, “adverse effects”, and “pharmacoeconomics”.

Results. The analysis revealed that SGM is characterized by 100% bioavailability after intravenous administration and minimal metabolism, being excreted primarily by the kidneys. The average time for the TOF (train-of-four) ratio to recover to >0.9 after rocuronium administration is between 1.4 and 1.5 minutes, a result unattainable for neostigmine. In children, the use of SGM is associated with a significant reduction in time to extubation and a lower incidence of postoperative nausea and vomiting (PONV). In emergency “cannot intubate, cannot ventilate” (CICV) situations, administration of a high dose of the drug (16 mg/kg) can prevent the need for an FONA (front-of-neck airway) procedure. The analysis confirmed that the introduction of generic preparations reduced the price of the drug from approximately 6710 PLN to about 1545 PLN per bulk package. Rare adverse effects, such as bradycardia or anaphylaxis (1 in 6000-14000 administrations), were reported.

Conclusions. SGM is currently the safest and most effective agent for reversing NMB, offering a clear clinical advantage over neostigmine due to the absence of muscarinic effects. The expiration of patent protection and the emergence of inexpensive generics have removed the main economic barrier, making the drug available for routine use. Widespread implementation of SGM allows for the optimization of operating room efficiency, shortening patient recovery time, and significantly reducing the risk of pulmonary complications resulting from residual blockade. Despite the development of new molecules, such as adamagammadex or cucurbiturils, SGM remains the cornerstone of modern and safe anesthesiology.

Keywords: anesthesiology, sugammadex, pharmacoeconomics, generic drugs, non-depolarizing neuromuscular blocking agents.

© Farm Pol, 2025, 81(11): 635–644