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 only midazolam and propofol.
Remimazolam has a rapid onset and short duration, and it is broken down by tissue esterases rather than by the liver or kidneys. The update brings together randomised trials, meta-analyses and real-world studies on efficacy, safety, dosing and patient selection, with a focus on higher-risk patients.
For endoscopists, the practical interest lies in patients for whom propofol carries more risk or needs an anaesthetist, and those with liver or kidney impairment in whom midazolam may accumulate. Remimazolam's availability and cost in Indian endoscopy units vary, and the exact recommendations should be read in the full update.
- Consider remimazolam as a sedation option, particularly in older or higher-risk patients.
- Its metabolism does not depend on liver or kidney function, which helps in cirrhosis and CKD.
- Flumazenil can reverse it, as with other benzodiazepines.
- Monitor oxygen saturation and blood pressure as with any procedural sedation.
- Check the full ASGE update for dosing before introducing it.
Why it matters
Sedation choices in patients with cirrhosis have been limited to drugs that accumulate or need an anaesthetist.
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