Remimidazolam

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No clinical use, excited to try a new anesthetic. What is the clinical/physiologic reason for BZDs causing delerium? Will a short half life prevent it? (Open ended serious questions, maybe dumb)
 
Is it already on the US market? If it's as quick on/off as claimed, propofol may be out on its ass in fifteen years, when generic mfgs really pick it up.
 
I can imagine some scenarios where it could be useful, but just like fentanyl has not been replaced by remifentanil, I dont see propofol or regular midazolam being replaced by remimidazolam.

One thing I can think of is it being used for conscious sedation in colonoscopies.
 
Remimazolam was advertised to our GI docs at my academic place that it will allow them to do endoscopy without anesthesiologists. A sedation nurse will give some fentanyl and they will run the remimazolam infusion. Patient obstructs and desaturates? Turn off the remimazolam and they miraculously wake up! What a revelation. I wonder who they'll call after that ...
 
Mehd School said:
Remimazolam was advertised to our GI docs at my academic place that it will allow them to do endoscopy without anesthesiologists. A sedation nurse will give some fentanyl and they will run the remimazolam infusion. Patient obstructs and desaturates? Turn off the remimazolam and they miraculously wake up! What a revelation. I wonder who they'll call after that ...
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Skip the fent altogether. Bolus the remimaz and start the drip. Things go south then give romazicon (which should be at the ready before each procedure). And unlike fent and midaz no need to worry about re-narcotization in recovery.

The plus side is that I fcking hate GI. Downside is that GI can be lucrative for anesthesia depending on payor mix and volume.
 
So we are looking to use it for a few types of cases…. Preop heart transplant, lvad, preop AS…. That want endoscopies prior to planned full on anticoagulation later. Some bad lung bronch cases. I think interest in some sick tees and cardio versions - all asa 4 plus types that won’t tolerate a big slug of propfol and elderly/demented/delirious for some mac cases in radiology etc.
according to the rep It’s hemodynamically neutral (used the words “train tracks”) and than its essentially gone 10 minutes after last dose - so good in delirious or demented or icu psychosis type stuff. Just wondering if it’s going to live up to the hype. It won’t replace midazolam as preop med for 99% of the people - I think it’s value lies more in general without a tube kind of cases. Hoping to trial it soon
 
vector2 said:
Skip the fent altogether. Bolus the remimaz and start the drip. Things go south then give romazicon (which should be at the ready before each procedure). And unlike fent and midaz no need to worry about re-narcotization in recovery.
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I'll forward this on to the sedation nurses who don't know how any of this $hit works
 
Mehd School said:
Remimazolam was advertised to our GI docs at my academic place that it will allow them to do endoscopy without anesthesiologists. A sedation nurse will give some fentanyl and they will run the remimazolam infusion. Patient obstructs and desaturates? Turn off the remimazolam and they miraculously wake up! What a revelation. I wonder who they'll call after that ...
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But does it actually work decently? Or is it just a hollow shell like SEDASYS?
 
amyl said:
So we are looking to use it for a few types of cases…. Preop heart transplant, lvad, preop AS…. That want endoscopies prior to planned full on anticoagulation later. Some bad lung bronch cases. I think interest in some sick tees and cardio versions - all asa 4 plus types that won’t tolerate a big slug of propfol and elderly/demented/delirious for some mac cases in radiology etc.
according to the rep It’s hemodynamically neutral (used the words “train tracks”) and than its essentially gone 10 minutes after last dose - so good in delirious or demented or icu psychosis type stuff. Just wondering if it’s going to live up to the hype. It won’t replace midazolam as preop med for 99% of the people - I think it’s value lies more in general without a tube kind of cases. Hoping to trial it soon
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Does it cause respiratory depression? Because if it does, 10 minutes is still long enough to kill someone.

Seems like it would be good for ICU sedation more than GI suite.
 
dr doze said:
But does it actually work decently? Or is it just a hollow shell like SEDASYS?
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I think comparing a new drug to a novel, incredibly complex sedation system is strange. Why wouldn't you expect a fast acting benzodiazepine to work?
 
Mehd School said:
I think comparing a new drug to a novel, incredibly complex sedation system is strange. Why wouldn't you expect a fast acting benzodiazepine to work?
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I dont know the front end kinetics of remimidazolam, but the remi- part alludes to nonspecific esterase metabolism and elimination. Not onset.
 
Mehd School said:
I think comparing a new drug to a novel, incredibly complex sedation system is strange. Why wouldn't you expect a fast acting benzodiazepine to work?
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I think that the comparison is valid because they are both sold with the same goal- To reduce the need for expensive anesthesia personnel for procedures.

Also the SEDASYS system was not that complex. Headphones on the patient telling them to squeeze a handle that vibrates to asses level of consciousness. Adjusted the propofol drip in response to patient’s ability to follow commands. Also linked to patients vital signs. Couldn’t get the patients deep enough safely.
 
dr doze said:
I think that the comparison is valid because they are both sold with the same goal- To reduce the need for expensive anesthesia personnel for procedures.

Also the SEDASYS system was not that complex. Headphones on the patient telling them to squeeze a handle that vibrates to asses level of consciousness. Adjusted the propofol drip in response to patient’s ability to follow commands. Also linked to patients vital signs. Couldn’t get the patients deep enough safely.
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Point taken. We'll see how it unfolds. They held an inservice meeting with our GI docs/fellows. I am good friends with one as he was my senior medicine resident when I was an intern. They briefly discussed the mechanics of the drugs and then told them how they could instruct the nurses to give the drug. They very explicitly were told that this will eliminate the need for an anesthesiologist and even urged them to get comfortable with the drug so that they could bill for the sedation as well.
 
Mehd School said:
Point taken. We'll see how it unfolds. They held an inservice meeting with our GI docs/fellows. I am good friends with one as he was my senior medicine resident when I was an intern. They briefly discussed the mechanics of the drugs and then told them how they could instruct the nurses to give the drug. They very explicitly were told that this will eliminate the need for an anesthesiologist and even urged them to get comfortable with the drug so that they could bill for the sedation as well.
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History repeats itself. They gave the same pitch when midazolam came out. GI docs were dosing it like Valium leading to adverse effects like death. Could still be the bees’ knees when used appropriately.


pubmed.ncbi.nlm.nih.gov

The effect of age on the relative potency of midazolam and diazepam for sedation in upper gastrointestinal endoscopy - PubMed

Diazepam and midazolam are considered safe and effective sedative agents for diagnostic procedures. However, there have been recent reports of deaths in older patients receiving midazolam for sedation. We examined the relative potency of diazepam compared with midazolam as a function of age in...
pubmed.ncbi.nlm.nih.gov pubmed.ncbi.nlm.nih.gov

pubmed.ncbi.nlm.nih.gov

Intravenous midazolam for upper gastrointestinal endoscopy: a study of 800 consecutive cases relating dose to age and sex of patient - PubMed

In many endoscopy units midazolam is replacing diazepam as the intravenous sedative of first choice. Midazolam is approximately twice as potent as diazepam. Although generally considered a safe drug, there have been a number of recent reports, particularly in the elderly, of the drug causing...
pubmed.ncbi.nlm.nih.gov pubmed.ncbi.nlm.nih.gov
 
History repeats itself. Remimazolam will allow GI docs to take the risk and sedate a few more patients. However one of those patients will be super sick and have a bad outcome. Our advantage is our patient selection. Also, deciding which patients need to be intubated prior to procedure. You can give the GI docs the newest shiny basketball doesn’t mean they will be Lebron James of course they will make a few more buckets but they aint pros……
I am interested in reminazolam as a stable bolus sedative hypnotic alternative to etomidate.
Also, using it in neuro cases reminaz/ remifent for super fast wakeups.
 
amyl said:
according to the rep It’s hemodynamically neutral (used the words “train tracks”)
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Hilarious. I'm pretty sure the package insert says otherwise.

Yes: Clinically notable hypoxia, bradycardia, and hypotension were observed in Phase 3 studies of
BYFAVO. Continuously monitor vital signs during sedation and through the recovery...

Yeah this should be funny (ie interestingly dangerous after people start to believe something without data). All the CRNAs I work with/for give precedex boluses without a thought. Even after I passed out the editorial to the recent negative precedex study / stopped early due to safety.
 
narcusprince said:
History repeats itself. Remimazolam will allow GI docs to take the risk and sedate a few more patients. However one of those patients will be super sick and have a bad outcome. Our advantage is our patient selection. Also, deciding which patients need to be intubated prior to procedure. You can give the GI docs the newest shiny basketball doesn’t mean they will be Lebron James of course they will make a few more buckets but they aint pros……
I am interested in reminazolam as a stable bolus sedative hypnotic alternative to etomidate.
Also, using it in neuro cases reminaz/ remifent for super fast wakeups.
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If I recall, SEDASYS was initially rolled out for PS 1s and 2s for screening colonoscopies. With anesthesia code team available in the facility.

Just. Didn’t. Work.

Probably try the same path with this stuff.
 
Patients don’t tolerate an EGD (or Colonoscopy) with Versed alone so not sure how they would with Remimidaz. Disclaimer: I don’t know much about the drug and have never used it/seen it used.

In theory good for ICU, but similar to Remifent, you’d use SO MUCH drug I don’t see how it would be economical. Maybe a use similar to precedex in vent weaning?
 
Airway said:
No clinical use, excited to try a new anesthetic. What is the clinical/physiologic reason for BZDs causing delerium? Will a short half life prevent it? (Open ended serious questions, maybe dumb)
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coffeebythelake said:
This
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I wouldn’t be so sure. The postoperative cognitive dysfunction that’s linked to benzodiazepines can persist much beyond five half-lives of the drugs, with a proposed mechanism of cognitive dysfunction being neuroinflammation / who knows what else. Before more data becomes available I would still avoid giving this to patients in whom delirium / cognitive dysfunction is high risk.
 
Airway said:
Hilarious. I'm pretty sure the package insert says otherwise.

Yes: Clinically notable hypoxia, bradycardia, and hypotension were observed in Phase 3 studies of
BYFAVO. Continuously monitor vital signs during sedation and through the recovery...

Yeah this should be funny (ie interestingly dangerous after people start to believe something without data). All the CRNAs I work with/for give precedex boluses without a thought. Even after I passed out the editorial to the recent negative precedex study / stopped early due to safety.
Click to expand...
Can you post precedex study or send to me in pm? Would like to read
 
We are not going to let gi drs run wild with this stuff… anesthesia will give here. We were more thinking the select patients that can’t tolerate a big slug of propofol but that we want quick on off sedation. P-dex lasts too long. We have some pretty sick folks who need pre anticoagulants scopes. Hell half the time I think cards sx sends them down hoping we find avms, etc. so they’re off the hook with the families.

I too am very skeptical- which is why I wanted to know if anyone used it.
 
Urzuz said:
I wouldn’t be so sure. The postoperative cognitive dysfunction that’s linked to benzodiazepines can persist much beyond five half-lives of the drugs, with a proposed mechanism of cognitive dysfunction being neuroinflammation / who knows what else. Before more data becomes available I would still avoid giving this to patients in whom delirium / cognitive dysfunction is high risk.
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I agree with you. That was an unanswered question about this drug vs midazolam. Honestly I think that is the most important question.
 
Mehd School said:
Remimazolam was advertised to our GI docs at my academic place that it will allow them to do endoscopy without anesthesiologists. A sedation nurse will give some fentanyl and they will run the remimazolam infusion. Patient obstructs and desaturates? Turn off the remimazolam and they miraculously wake up! What a revelation. I wonder who they'll call after that ...
Click to expand...
This is practically the same as giving a midaz plan bolus and running a remifentanyl infusion, which is generally not going to get through an EGD or colonoscopy very well or quickly.

The bolus propofol matches the stimulation of an EGD/colo very well, no drug will replace it, and no other drug will allow fast turnover for the GI docs like prop.
 
dipriMAN said:
This is practically the same as giving a midaz plan bolus and running a remifentanyl infusion, which is generally not going to get through an EGD or colonoscopy very well or quickly.

The bolus propofol matches the stimulation of an EGD/colo very well, no drug will replace it, and no other drug will allow fast turnover for the GI docs like prop.
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Agreed that benzo+opiate sedation for a colo is a nasty patient experience for the most part, compared to propofol. But I would think that remi-benzo plus remi-opioid ought to allow for fast turnover for those GI docs who want to use it.

I don't see any universe where it replaces propofol, except that universe where the GI docs don't care if their patients are miserable during the procedure. Well, maybe that's this universe after all.

I'm looking forward to seeing how remimazolam works out as an induction agent. Benzo inductions are really smooth but the tail end effects are a problem. I'm going to guess there won't be any difference in POCD - the notion that it's the surgery, disease, and hospitalization rather than just the anesthesia has pretty solid footing.
 
Midazolam scopes are **** because we can't give them "GA depth" doses and still have them wake up at the end of the case... which is exactly what we do with propofol. This eliminates that issue.

That said, I don't see the exact target audience for the drug, outside of minimally invasive procedures for really, really sick people who are somehow also day surgery cases.
 
woopedazz said:
Midazolam scopes are **** because we can't give them "GA depth" doses and still have them wake up at the end of the case... which is exactly what we do with propofol. This eliminates that issue.

That said, I don't see the exact target audience for the drug, outside of minimally invasive procedures for really, really sick people who are somehow also day surgery cases.
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How many patients have you given a couple of midaz for a block and had them go apneic? I just don't see how such an increased depth of sedation doesn't equal respiratory depression, which is the real reason you need anesthesia for these cases. Unless they don't plan on giving any opioid at all...
 
Ronin786 said:
How many patients have you given a couple of midaz for a block and had them go apneic? I just don't see how such an increased depth of sedation doesn't equal respiratory depression, which is the real reason you need anesthesia for these cases. Unless they don't plan on giving any opioid at all...
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I rarely Midazolam my blocks. But I agree wholeheartedly.
 
pgg said:
Agreed that benzo+opiate sedation for a colo is a nasty patient experience for the most part, compared to propofol. But I would think that remi-benzo plus remi-opioid ought to allow for fast turnover for those GI docs who want to use it.

I don't see any universe where it replaces propofol, except that universe where the GI docs don't care if their patients are miserable during the procedure. Well, maybe that's this universe after all.

I'm looking forward to seeing how remimazolam works out as an induction agent. Benzo inductions are really smooth but the tail end effects are a problem. I'm going to guess there won't be any difference in POCD - the notion that it's the surgery, disease, and hospitalization rather than just the anesthesia has pretty solid footing.
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I have many friends and family members who’ve had benzo/opioid sedation for endoscopy who did not think it was a nasty experience. In fact, most don’t remember anything. One orthopedist I worked with said “you could have driven a truck up my a** and I wouldn’t have cared.” Benzo/opioid works well for the vast majority of people. Here on the west coast, 90%+ of endoscopy is still done that way. We only get involved with medically complicated patients or those with substance abuse/tolerance issues.
 
Remimazolam may be alternative to propofol in those with egg or soy allergy or hypertriglyceridemia?
 
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Sounds like this would work well for cath lab sedation cases like TAVR, BiV pacemakers, or ablation cases. If it cuts down on the hospital costs associated with delirium it will be worth it.
 
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Leon'sMom said:
https://diprivan-us.com/wp-content/themes/diprivan-us/docs/DIPRIVAN_PI.pdf
http://labeling.pfizer.com/ShowLabeling.aspx?id=4591
Propofol - FDA prescribing information, side effects and uses

Contraindications: allergies to eggs, egg products, soybeans, soy products.
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You ever given propofol to a 3 year old before? Your handouts say they'll probably die if you do that.

The protein chains are different. They aren't cross-reactive. There is a body of evidence supporting the use of propofol in patients with egg/soy allergy.
 
Guillemot said:
Everything I see posted by this person (Leon'sMom) seems like they have a relatively low degree of medical education. Shouldn't this forum be limited to physicians?
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Not necessarily, med students are welcome as well. There are some interlopers who can provide valuable expertise on certain subjects as well.
 
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