Efficacy and safety of sugammadex compared to neostigmine for reversal of neuromuscular blockade: a meta-analysis of randomized controlled trials

Background and objective Sugammadex has been introduced for reversal of rocuronium (or vecuronium)–induced neuromuscular blockade (NMB). Although its efficacy has been established, data are conflicting whether it is safer than neostigmine traditionally used for reversing NMB. Design Meta-analysis of data about effectiveness and safety of sugammadex compared to neostigmine for reversing NMB in adults was performed using the PRISMA methodology. Setting University medical hospital. Methods A comprehensive search was conducted using PubMed, Web of Science, and Cochrane Library electronic databases to identify English-language randomized controlled trials. Two reviewers independently selected the trials; extracted data on reversal times, incomplete reversals of NMB, and adverse events (AEs); and assessed the trials' methodological quality and evidence level. Only AEs that were related to study drug by a blinded safety assessor were considered for meta-analysis. Patients A total of 1384 patients from 13 articles were included in this meta-analysis. Main results Compared to neostigmine, sugammadex was faster in reversing NMB (P < .0001) and more likely to be associated with higher train-of-four ratio values at extubation (mean difference, 0.18; 95% confidence interval [CI], 0.14-0.22; P < .0001) and lower risk of postoperative residual curarization after extubation (odds ratio [OR], 0.05; 95% CI, 0.01-0.43; P = .0068). Compared to neostigmine, sugammadex was associated with a significantly lower likelihood of global AEs (OR, 0.47; 95% CI, 0.34-0.66; P < .0001), respiratory AEs (OR, 0.36; 95% CI, 0.14-0.95; P = .0386), cardiovascular AEs (OR, 0.23; 95% CI, 0.08-0.61; P = .0036), and postoperative weakness (OR, 0.45; 95% CI, 0.21-0.97; P = .0409). Sugammadex and neostigmine were associated with a similar likelihood of postoperative nausea and vomiting (OR, 1.23; 95% CI, 0.70-2.15; P = .4719), pain (OR, 1.06; 95% CI, 0.15-7.36; P = .9559), neurologic AEs (OR, 1.47; 95% CI, 0.52-4.17; P = .4699), general AEs (OR, 0.75; 95% CI, 0.47-1.21; P = .2448), and changes in laboratory tests' values (OR, 0.57; 95% CI, 0.18-1.78; P = .3368). Conclusions Results from this meta-analysis suggest that sugammadex is superior to neostigmine, as it reverses NMB faster and more reliably, with a lower risk of AEs