ASGE gives its first guidance on remimazolam for endoscopic sedation

Design

Clinical practice update from a specialty society

Population

Patients undergoing GI endoscopy under procedural sedation

Primary outcome

Recommendations on remimazolam efficacy, safety, dosing and selection

Effect

Remimazolam positioned as an alternative to midazolam and propofol, notably in high-risk patients

The American Society for Gastrointestinal Endoscopy has issued a clinical practice update on remimazolam, an ultra-short-acting benzodiazepine approved by the FDA for procedural sedation in 2020. Its 2018 sedation guideline covered midazolam and propofol but not remimazolam.

The update draws on randomised trials, meta-analyses and real-world studies to address efficacy, safety, dosing and patient selection. Remimazolam acts quickly, wears off quickly and is metabolised by tissue esterases rather than the liver or kidney, which is why the update highlights its use in high-risk patients. Like other benzodiazepines, it can be reversed with flumazenil.

For endoscopy units where propofol requires an anaesthetist, remimazolam offers a route to deeper, shorter sedation that recovers faster than midazolam. Its place in Indian practice depends on availability and cost, which vary between centres. The specific dosing recommendations are in the full update.

• Consider remimazolam as an alternative to midazolam where faster recovery is needed.
• Its organ-independent metabolism makes it relevant in liver or kidney disease; check the update's dosing for these patients.
• Monitor as for any sedative: capnography or oximetry, airway support and trained staff.
• Keep flumazenil available, as for other benzodiazepines.
• Follow local credentialing rules; the update does not replace them.

Why it matters

It brings a newer sedative into formal endoscopy guidance for the first time.

Don't overread it

This is a practice update summarising existing evidence, not a new trial; check the full text for dosing.

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