Saturday, September 18, 2021

Nimbex Is Dead. Long Live Sugammadex



I've been a lifelong fan of cisatracurium (Nimbex). It has been my neuromuscular blocker of choice ever since residency. Why do I love it so much? Let me count the ways.

I've found that Nimbex is very predictable in its metabolism. I've been burned badly before when I used another agent like rocuronium on a patient with renal insufficiency and the patient had incomplete reversal at the end of the case that necessitated reintubation. Not good for the patient or your reputation as an anesthesiologist.

Thanks to its Hoffman elimination, I don't have to worry about a patient's kidney or liver function. The drug just metabolizes at a very steady and predictable manner. This is particularly important when a patient may have an unknown issue with their renal or hepatic functions and suddenly you're wondering why the patient isn't waking up. Nimbex is also very easy to reverse. Neostigmine easily takes care of the drug and the patient emerges quickly. 

Sure you can't use Nimbex for rapid sequence induction but that's okay. Most cases don't require RSI anyway. Due to Nimbex's property of predictable reversal, I've stuck with it long after many of my colleagues switched to roc. But now that's all changed thanks to the miracle of sugammadex.

Sugammadex (Bridion) is a drug invented specifically to reverse the paralysis induced by rocuronium. But it also works with other aminosteroid compounds like vecuronium. I feel it has revolutionized NMB reversal the way propofol transformed the induction of anesthesia.

First of all, Bridion works very fast. I'm always amazed by how quickly a patient starts moving after it is given, even if there is still a fair amount of inhalational agents on board.

Rocuronium no longer needs to be carefully titrated in order for it to be reversible at the end of the case. This is especially relevant in procedures that finish rapidly like in ENT. Those cases always present the conundrum of the need for deep paralysis followed by a quick emergence. There's no greater predicament for the anesthesiologist than staring down at a patient with zero muscle twitches and an impatient surgeon wanting to get his next case started ASAP. Prior to sugammadex there was no way to reverse a deeply paralyzed patient effectively.

One can give roc to anybody with sugammadex. Before, I was always leery of using Bridion in dialysis patients because there was always a small chance that the reversal agent would wear off before the body has cleared the NMB. I have yet to see that happen. It's just as easy to wake up a patient with renal failure as a patient with normal kidney functions.

With all these advantages, rocuronium and sugammadex have become the combo of choice in our department. Nimbex use has practically disappeared. Bridion is in such high demand that our pharmacy is complaining about the high cost of the drug. Whereas one 200 mg vial of sugammadex costs about $100, one vial of neostigmine costs $10, and that can be used with multiple patients. Our sugammadex costs are now disrupting our pharmacy's budget because people are using it so often. In addition, the anesthesiologists frequently use more than one vial per patient as some are now becoming too lazy to titrate their NMBs properly.

Are there costs that are saved because we use so much sugammadex? One has to consider the cost benefit analysis for a weak patient in PACU that requires reintubation. What are the costs of prolonged OR use because the patient took a longer time than anticipated to wake up? What is the cost of the psychological trauma in a patient who is gasping for breath because he is too weak to breathe? Or the patient who is too weak to protect his own airway when extubated too early and she aspirates, requiring hospitalization for pneumonia? All these should be taken into consideration when calculating the cost of using sugammadex.

Are there downsides to sugammadex? I've already mentioned the exorbitant price of the drug. That hopefully will come down in a few years when the drug goes off patent and generics flood the market.

Worse than that though is that I think sugammadex makes anesthesiologists lazy and they lose an essential skill. It's a real art to titrate paralytic agents properly so it can be reversed quickly at the end of a case. It's not something that can be taught in a book since each patient is unique in their ability to metabolize NMBs and every surgical case is different. With sugammadex, it doesn't matter at all. This is particularly detrimental to the anesthesia residents. It is just as easy to wake up a patient with zero twitches as one with four twitches. There is no learning there. Just give more sugammadex! But they didn't learn anything about the art of controlling anesthesia.

This is all part of the long standing trend of making anesthesia ever faster and easier to use. From halothane to desflurane. Pentathol to propofol. Pancuronium to rocuronium. If we're not careful, anesthesia could become too easy to administer. There are plenty of people who would love to get anesthesiologists out of their procedure rooms. From gastroenterologists to cardiologists, having one less physician in the room would be a dream come true. If anybody ever makes reversal agent for propofol, anesthesiologists would soon be unemployed.

21 comments:

  1. Well put. I too love Nimbex and have since residency. And, I too share a concern that it is easy to get lazy with Bridion. We have restricted it's use to rescue only, and that being said, with about 600 cases a month, we use about 16 vials. We try to teach our residents proper use of nerve stimulators and dosing NMB. Thank you for sharing this post.

    ReplyDelete
  2. Strongly disagree with this. Anything that decreases the cognitive load from organizing your OR to using a glidescope is a tool not a crutch. Having this view is archaic.

    ReplyDelete
    Replies
    1. Do your research on the adverse reactions to Suggamadex. 1% of patients experience life threatening bradycardia and some of those lose pulse altogether. It happened to me and though we were able to successfully resuscitate the patient, in spite of our best efforts the patient suffered anoxic brain injury. I will never use it again. We have been successfully taking care of patients for years without it and I don't believe the advantages outweigh the risks.

      Delete
    2. So sorry to hear this....very painful!! I love Suggamadex but will always use a little Glycopyrrolate first, unless the heart rate is over 90. And I will treat with Glyco if the heart rate drops more than 20 b/min.

      Delete
  3. Well, from this interventional pulmonologist, I do not think I would want to replace my anesthesiologists…they are the guardian angels in the room, I am busy working in a patient’s airway with cutting, freezing and zapping tools,I know my anesthesiologists are making sure all is ok with the patient under anesthesia, one less thing I have to worry about!

    ReplyDelete
  4. It's worthwhile to note that rocuronium and sugammadex are both associated with hypersensitivity reactions (high incidence for the former). As a previous poster mentioned, it would be dangerous to minimize our toolkit in the name of standardization to the point where we miss the issues that occur 0.01-5% of the time - that's where anesthesiologists are always deemed necessary and essential to navigate the situation.

    ReplyDelete
  5. Does the author have a financial relationship with Merck? Your piece reads like an advertisement. Your mention of cost implications is a gross over simplification. Most physicians don’t appreciate the real implications of using expensive medications- not the immediate impact on your hospital bottom line, but the ever increasing price of health care that creates a barrier to access, or financial ruin for patients because of the services we provide. In my institution, sugammadex is 20 times more expensive than neostigmine/glyco reversal; patients are charged $350 per vial of sugammadex. If anesthesia providers paid a little better attention to dosing and surgery at hand, we wouldn’t need sugammadex in the VAST majority of procedures. We could cut cost by millions (or billions) and help reduce the overall cost of health care that is choking the US economy. Incomplete reversal does still exist, but we know how to avoid it; we just don’t put enough thought into it. Result- it “seems” unavoidable, so sugammadex “seems” like a miracle drug worth its weight in gold. The net effect is that we drive the cost of US health care ever higher, and the quality doesn’t really change. Sugammadex’ widespread use is the result of a successful marketing campaign built on half-truths and anesthesia providers who place the needs of their surgeons’ needs (rapid reversal) ahead of their patients’ (financial impact). It’s a beautiful example of what’s wrong with US health care.

    ReplyDelete
    Replies
    1. I have no financial interests or conflicts to report. Just my own personal observation.

      Delete
  6. I had my anesthesia training in the 70': sometime I did not even have the ECG monitor in the room , the trainee had to use all " six senses " as monitor ! Even though I appreciate the modern monitors, but I am afraid that we are loosing our human touch with patients, people !

    ReplyDelete
    Replies
    1. Unfortunately I’ve seen too many cases of residents who are engrossed in their cellphones when they think the attending is not watching. Not a good look for the future of our profession.

      Delete
  7. Our Pharmacy does not approve Suggamadex for GFR less that 30 and also not for patients on dialysis so for me this is not a solution. I still have to use Nimbex. We all know it still works in these patients but my understanding was that it is not appoved yet. Can you comment on FDA approval for Sugammadex with renal failure?

    ReplyDelete
  8. Sugammadex hasn't yet been officially approved by the FDA for renal failure patients. However some studies have shown good reversal of roc in dialysis patients. Clinical trials are ongoing. We have not had any instances of recurarization using SGX in ESRF at our facility.

    ReplyDelete
  9. Sorry, not really following the logic here. Seems that you had a good drug that met your needs and then you switched to a more expensive combo . Can you explain what was the need for the switch?

    ReplyDelete
  10. SGX produced much faster reversal than neostigmine and in our experience has less risk of patient needing reintubation. Just because something is good doesn’t mean there can’t be room for improvement. We all thought vecuronium was great compared to pancuronium too.

    ReplyDelete
  11. I've never used it but it sounds like a great advance. I was a fan of the original Trachrium, which I found even more reliable than the cis version. But I agree that anesthesiologist skills are diminishing and less qualified CRNA or just RNs may be the future if everything is made too simple. I recently went for a perineal procedure and asked for a caudal and not one anesthesiologist in a 100+ man group had done one or had even been trained to do them. They no longer make Tetracaine!Glide scope makes intubation easy. People can't put in a simple CVP or aline without ultrasound. I used to combine Tensilon with atropine since the 80s for faster reversal and it even came premixed. Gone! Most improvements have been good, altho more expensive and some take longer. But there is much less thinking on the part of the administrator of the drugs that are so much safer.

    ReplyDelete
  12. When I talk to residents about using halothane or isoflurane, they look at me with a sad bemused expression. Makes me feel like a dinosaur.

    ReplyDelete
    Replies
    1. Cyclopropane was an agent of choice in my day. Just listen real close with your precordial steh and maintain constant physical contact with the patient to ground out any static electricity. ORs were a peaceful place before all those electronic doo dads and buzzing Bovies!

      Delete
    2. Young surgeons these days also like their OR music turned up to 11. They also pretend they’re from the hood and listen to all sorts of rap crap.

      Delete
  13. Rocuronium is an excellent predictable drug with extremely rare adverse effects. It rarely requires reversal. If you were paying for your medication ls out of your own pocket as I do, you would not be using suggamdex routinely.

    ReplyDelete
    Replies
    1. SGX is free for the residents to use so their ability to titrate NMB’s is lacking. Our residents barely know how to dose neostigmine.

      Delete