sugammadex

[Carlos Danger]

Hey Veneficus,

• Since suggamadex has been available in Europe:
  
  
  • Has rocuronium virtually replaced succinylcholine for emergent intubations?
    
    
  • Has rocuronium come to be used more frequently when relaxation is necessary during surgery, or even in the ICU setting?
    
    
  • Is suggamadex used with other aminosteroid NMB's, or just roc?

It was re-submitted for US FDA approval in January, and seems widely expected to receive it, at least for use in emergent intubation. I have read a fair amount about it, and it seems to have an impressive profile. Sounds almost too good to be true, in fact.

I haven't, however, been able to find much info on how the availability of suggamadex has actually impacted practice in the 4.5 years since it's been available over there.

Just curious. Thanks in advance for the info.

 

[blindsideflank]

I would expect roc to be used more often anyways ( in a higher skilled and more conrtolled setting) especially since neostigmine and glycopyrrolate have been around prior to suggamedex.
I know anesthetists in Canada that use it and many that have never considered it

 

[Veneficus]

Hey Veneficus,

• Since suggamadex has been available in Europe:
  
  
  • Has rocuronium virtually replaced succinylcholine for emergent intubations?
    
    
  • Has rocuronium come to be used more frequently when relaxation is necessary during surgery, or even in the ICU setting?
    
    
  • Is suggamadex used with other aminosteroid NMB's, or just roc?

It was re-submitted for US FDA approval in January, and seems widely expected to receive it, at least for use in emergent intubation. I have read a fair amount about it, and it seems to have an impressive profile. Sounds almost too good to be true, in fact.

I haven't, however, been able to find much info on how the availability of suggamadex has actually impacted practice in the 4.5 years since it's been available over there.

Just curious. Thanks in advance for the info.

The fast answer is "no."

Where I am at, it is actually kept in a safe (one of only 2 meds in the safe) and using it is like watching the procession of presentation of a new pope. I think there is even a requirement to read a latin inscription before injecting it.

 

[Carlos Danger]

The fast answer is "no."

Where I am at, it is actually kept in a safe (one of only 2 meds in the safe) and using it is like watching the procession of presentation of a new pope. I think there is even a requirement to read a latin inscription before injecting it.

Nice. :beerchug:

Is that because of cost?

It is an expensive drug (something like US$1600 / dose), but if it's only used for rescue in a can't intubate scenario, it's use would be fairly uncommon and the annualized cost per patient very low. Kind of like Dantrolene.

The whole reason I am curious is because, while it does sound very impressive, it just looks like one of those things that is going to have a hard time living up to the hype that precedes it. I frequently hear the term "game-changer" used to describe it, and some people speak of it the same way they do the second coming of Christ.

I guess we'll just have to hope it's approved this year and see how it works out.

There was a great study published in the Feb 2012 British Journal of Anaesthesia: Rapid sequence induction and intubation with rocuronium–sugammadex compared with succinylcholine: a randomized trial.

I would expect roc to be used more often anyways ( in a higher skilled and more conrtolled setting) especially since neostigmine and glycopyrrolate have been around prior to suggamedex.

Rocuronium and other non-depolarizers are used for intubation far more commonly in the hospitals, but it has nothing to do with the availability of neostigmine. Anti-cholinesterases aren't effective as rescue drugs because they take way too long to work.

That is why succinylcholine is still also commonly used and also why suggamadex is potentially such a big deal.

 

[jwk]

Hey Veneficus,

• Since suggamadex has been available in Europe:
  
  
  • Has rocuronium virtually replaced succinylcholine for emergent intubations?
    
    
  • Has rocuronium come to be used more frequently when relaxation is necessary during surgery, or even in the ICU setting?
    
    
  • Is suggamadex used with other aminosteroid NMB's, or just roc?

It was re-submitted for US FDA approval in January, and seems widely expected to receive it, at least for use in emergent intubation. I have read a fair amount about it, and it seems to have an impressive profile. Sounds almost too good to be true, in fact.

I haven't, however, been able to find much info on how the availability of suggamadex has actually impacted practice in the 4.5 years since it's been available over there.

Just curious. Thanks in advance for the info.

Sux is still widely considered the gold standard for emergent intubation. That being said, a lot of people will use roc because of perceived dangers of using sux. Some think high-dose roc is just as fast as sux - it's not - which is why sux is still around.

Rocuronium is widely used in surgery throughout the US. The only reason other drugs might be used instead would be cost, but it's off patent and the price has dropped since there are a number of generic sources for the drug.

Sugammadex may be a game changer but it will have to be in widespread use before that happens (Vene, you have it available already?). I know I hate using whopping doses of roc for RSI for short procedures, because it takes time for roc to wear off enough to that it's reversible with glyco/neostig. Try and reverse it too early and you dig yourself a deeper hole. Sugammadex will change that. Price will determine how popular it becomes. They could sell the hell out of it at a reasonable price point, but if it's too high, it will sit largely unused, kinda like flumazenil.

I think it's primary use is with roc, not with other non-depolarizers, but I haven't really studied it enough to know why. That's fine with me because I haven't used vec or panc in years.

 

[Merck]

While it may come to be that it is indeed a 'game-changer', the cost would have to be pretty low. Sux is fastest for the intubation so I wouldn't see a need to use roc. I also worry that using a longer-duration patalytic for RSI could lead to issues arising from inadequate sedation. How ofter do people give induction doses and then forget about maintainence meds for sedation? Everyone notices when the person half sits up and tries to self-extubate but not as many notice the heart rate climbing and the tears....

 

[chaz90]

While it may come to be that it is indeed a 'game-changer', the cost would have to be pretty low. Sux is fastest for the intubation so I wouldn't see a need to use roc. I also worry that using a longer-duration patalytic for RSI could lead to issues arising from inadequate sedation. How ofter do people give induction doses and then forget about maintainence meds for sedation? Everyone notices when the person half sits up and tries to self-extubate but not as many notice the heart rate climbing and the tears....

The advantages of Rocorunium as I understand them are not the rapid speed of onset compared to Succinylcholine as Sux is obviously still faster. Avoiding the increased ICP, risk of malignant hyperthermia, and hyperkalemia is a small price to pay for a slightly increased time of onset in many situations.

 

[Carlos Danger]

The advantages of Rocorunium as I understand them are not the rapid speed of onset compared to Succinylcholine as Sux is obviously still faster. Avoiding the increased ICP, risk of malignant hyperthermia, and hyperkalemia is a small price to pay for a slightly increased time of onset in many situations.

Rocuronium does have a little slower onset than succinylcholine.

Succinylcholine is indeed a "dirty" drug (though I think the downsides of it are exaggerated in the emergency setting), which is exactly why suggamadex is so attractive to so many.

The primary advantage of sux is not it's slightly/moderately faster onset (though that is an advantage in some patients), it is the fact that it has such a short duration. Having suggamadex on hand significantly reduces that advantage and makes roc a more attractive option for emergency induction.

For now, sux remains very commonly used pretty much everywhere in the US, from prehospital to ED to the OR.

 

[Merck]

I'm aware of the 'downsides' of sux and am quite happy to just speak anecdotally in that I've never seen a poor outcome with it's use. The incidence of MH is reported at 1:30,000 which includes all causative anaesthetic agents, not just sux. Hyper K is a theoretical risk so of course should be used with caution in potential high K folks but those are usually easily identified and I believe sux is said to possibly raise serum K 1-1.5 which may or may not be significant.

Sux is routinely used in head injury to while I'm sure there is evidence to support an increase in ICP I would wonder if there is any clinical relevance to its use.

 

[Carlos Danger]

While it may come to be that it is indeed a 'game-changer', the cost would have to be pretty low.

Suggamadex will likely be very expensive, but if it is only used in CI/CV scenarios, very little of it will need to be kept on hand. So the cost may actually not be too much of an issue.

Sux is fastest for the intubation so I wouldn't see a need to use roc.

Rocuronium is already commonly used for intubation. There are several reasons why it may be a better choice in certain populations.

Succinylcholine does have a little faster onset, but rocuronium is fast enough in most cases.

I also worry that using a longer-duration patalytic for RSI could lead to issues arising from inadequate sedation. How ofter do people give induction doses and then forget about maintainence meds for sedation? Everyone notices when the person half sits up and tries to self-extubate but not as many notice the heart rate climbing and the tears....

Anyone who can't keep their patient sedated for 45 minutes after giving rocuronium shouldn't be managing intubated patients at all.

The incidence of MH is reported at 1:30,000 which includes all causative anaesthetic agents, not just sux.

The incidence is actually much higher in some populations. Still rare, but not so rare that it isn't a serious consideration.

Hyper K is a theoretical risk so of course should be used with caution in potential high K folks but those are usually easily identified and I believe sux is said to possibly raise serum K 1-1.5 which may or may not be significant.

Hyperkalemia is not a theoretical risk, it is a very serious risk in many patients.

Succinylcholine is routinely used in head injury to while I'm sure there is evidence to support an increase in ICP I would wonder if there is any clinical relevance to its use.

The ICP increase that follows succinylcholine in inconsistent in its incidence, has never shown to be clinically harmful, and is probably offset by appropriate induction agents.

 

[Veneficus]

Sux is still widely considered the gold standard for emergent intubation. That being said, a lot of people will use roc because of perceived dangers of using sux. Some think high-dose roc is just as fast as sux - it's not - which is why sux is still around.

I was taught primarily with Vec. so that what I like.

If I had to estimate, panc. and vec. are the 2 most common selected here outside of neuro, where roc is used almost exclusively.

Sugammadex may be a game changer but it will have to be in widespread use before that happens (Vene, you have it available already?).

I live in Contental Europe, it has been here at least 3 years. But in a major academic medical center, with every surgical discipline including transplant, and easily a total of 100 beds of various ICU, I have never even heard of it being used in my time here.

The EMS service in this city is physician based, mostly orthopods, and I will ask, but I doubt that EMS here even has sugammadex on the truck. (or neostigmine for that matter) The orthopods I know are deathly afraid to RSI or use conscious sedation without an anesthesiologist. Which in the local system, even with the drugs only raises the price of a procedure about $50-75 USD so calling anesthesia is not a big deal.

I doubt very much it will ever be a "game changer" even though it works with all of our most common blocks, that sounds like marketing.

The need for a reversal agent here is considered an error and will automatically trigger a review of the case. (which may go nowhere, but it will still be reviewed)

In order for this to be a game changer, it would have to be cheaper than it is now, and it would also have to be used far more frequently. Both of which are unlikely.

I think we can agree that if you are constantly using reversal agents, something is definately wrong with what is going on.

I know I hate using whopping doses of roc for RSI for short procedures, because it takes time for roc to wear off enough to that it's reversible with glyco/neostig. Try and reverse it too early and you dig yourself a deeper hole. Sugammadex will change that. Price will determine how popular it becomes. They could sell the hell out of it at a reasonable price point, but if it's too high, it will sit largely unused, kinda like flumazenil.

I thought flumazenil was unused because of its side effect profile? Even with easy access to thiopental, it is viewed here as a very last resort.

The whole reason I am curious is because, while it does sound very impressive, it just looks like one of those things that is going to have a hard time living up to the hype that precedes it. I frequently hear the term "game-changer" used to describe it, and some people speak of it the same way they do the second coming of Christ.

It looks to be a better agent (like I said, never seen it used) than neostigmine, but "game changer" is definately overgenerous in my opinion. I think choosing an agent based on ease of reversal is not something anyone should be considering. The agent should be chosen based on the need of the patient and the procedure to be performed.

Even in EMS, if you choose to RSI, you have a reason, in the event of failure of the procedure, that reason doesn't go away and will still have to be managed.

If you are using it for the "can't intubate, can't ventilate," let us consider how often the later comes into being, especially by skilled providers?

In both of your experiences, how many times have you had a difficult tube you could not get and couldn't effectively ventilate? (I am thinking you could probably count them on one hand and jwk has done this many more years than I have)

I guess we'll just have to hope it's approved this year and see how it works out.

It hasn't changed anything here.

That is why succinylcholine is still also commonly used and also why suggamadex is potentially such a big deal.

I do not agree with the reasoning behind prehospital use of Sucs. It was selected because it assumes failure. In my opinion being prepaired for failure is one thing, planning to fail and basing your whole procedure around that means you shouldn't be doing whatever you are doing, airway related or not.

 

[Merck]

My point is that sux is not an evil drug and is widely appropriate for most cases. We use both extensively and I've yet to see a poor reaction to the administration of sux. Yes, roc can be used and I've used it when prolonged paralysis is desired and there are not large predictors of a difficult intubation but in general sux works fine.

There are few cases where raising the serum K will be really be detrimental. I'd avoid it's use perhaps in renal failure patients depending on their clinical picture and history and rhabdo, and maybe a couple other cases but in general sux is safe and easy to use.

And actually I've seen a number of RSIs where prolonged sedation is not immediately considered. These are usually in-hospital intubations and the consequence is wild fluctuations in VS and ventilator dysynchrony. Not all the time, but it does happen.

The old 'sux vs roc' argument is a very old one and I'm predicting that an available reversal agent, especially at the predicted price point, will not solve the question.

 

[FLdoc2011]

I've been using vec more and more lately, mostly due to some sux shortages we've had on our RSI kits. Also have roc available but I've only seen it used by some our pulm/CC guys who use it when they're doing a bedside trach in the ICU.

I'm not familiar with this suggamadex nor have I ready anything on it. Ultimately it's probably good to have a more "specific" reversal agent available, but I have yet to come across a need for urgent NMB reversal, at least in hospital setting where I'm just using it urgently for intubations or procedure.

EMCRIT has had some episodes dealing with RSI and paralytics and I think I'm with the group thinking that the whole paralytics = inability to ventilate is blown out of proportion. At least on the difficult airways I've been involved with I just haven't had the need to reverse and have been able to ventilate with other means. In a couple instances where we werent able to ventilate well it wasn't due to an issue where reversing the NMB would've helped at all.

 

[jwk]

I'm not familiar with this suggamadex nor have I ready anything on it. Ultimately it's probably good to have a more "specific" reversal agent available, but I have yet to come across a need for urgent NMB reversal, at least in hospital setting where I'm just using it urgently for intubations or procedure.

Sugammadex irreversibly and immediately binds with the rocuronium molecule, rendering it's NMB properties to zilch. You could supposedly give several times your usual dose of roc, 100-200 mg (why you would do that I don't know), followed immediately by the suggamadex, and your NMB is totally gone in a minute or two. It's imminent release is rumored once again in US markets.

There is nothing else on the market like it, and of course reversing it the old fashioned way, you have to wait until the block begins to wear off (1 twitch at least on TOF) before giving glyco/neostigmin, or you'll just make things worse. Folks are hoping that once and for all that they can totally abandon the use of succinylcholine and just give a megadose of roc for RSI. However, if the drug is truly as expensive as is being rumored, it will have extremely limited use in any setting.

I'm not really sure where this drug would find a spot in pre-hospital care. Do you carry glyco/neo now for reversal of NMB? I wouldn't think reversing NMB's is something that EMS would need to worry about. CI/CV scenarios should really be a very rare event, particularly with the advent of supra-glottic airways like LMA's and King's. Even if one can't intubate, the "can't ventilate" cases simply aren't that common. I've seen two in my entire career, both related to surgical trauma.

 

[medicdan]

I appreciate learning about this... I hadn't heard about it before. Will all due respect, how does one pronounce this trade name?

 

[NomadicMedic]

Sue. Gamma. Dex.

 

[medicdan]

Sue. Gamma. Dex.

thanks. I guess I must be sleep deprived... my head was in the gutter.

 

[Carlos Danger]

Suggamadex Faces New Delay

 

[Summit]

I think it's primary use is with roc, not with other non-depolarizers, but I haven't really studied it enough to know why.

Sugammadex is specifically shaped to bind with roc inactivating it. The shape of the sugammadex molecule is not such that it will bind so readily with other blockers. So my reading on the subject informs me... I hadn't even heard of suggamadex until I opened this thread.

I hear lots of things on this forum that send me off to read. Am I the only one who saw the name of this drug as Sugar-Momma-Dex?

 

[Summit]

Sugammadex was finally approved by the FDA in Dec.
We now have it in our formulary.
Works for Roc and Vec.