Sugammadex compared with neostigmine/glycopyrrolate for routine reversal of neuromuscular block: a systematic review and economic evaluation

Abstract

The cost-effectiveness of sugammadex for the routine reversal of muscle relaxation produced by rocuronium or vecuronium in UK practice is uncertain. We performed a systematic review of randomized controlled trials of sugammadex compared with neostigmine/glycopyrrolate and an economic assessment of sugammadex for the reversal of moderate or profound neuromuscular block (NMB) produced by rocuronium or vecuronium. The economic assessment aimed to establish the reduction in recovery time and the 'value of time saved' which would be necessary for sugammadex to be potentially cost-effective compared with existing practice. Three trials indicated that sugammadex 2 mg kg⁻¹ (4 mg kg⁻¹) produces more rapid recovery from moderate (profound) NMB than neostigmine/glycopyrrolate. The economic assessment indicated that if the reductions in recovery time associated with sugammadex in the trials are replicated in routine practice, sugammadex would be cost-effective if those reductions are achieved in the operating theatre (assumed value of staff time, £4.44 per minute), but not if they are achieved in the recovery room (assumed value of staff time, £0.33 per minute). However, there is considerable uncertainty in these results. Sugammadex has the potential to be cost-effective compared with neostigmine/glycopyrrolate for the reversal of rocuronium-induced moderate or profound NMB, provided that the time savings observed in trials can be achieved and put to productive use in clinical practice. Further research is required to evaluate the effects of sugammadex on patient safety, predictability of recovery from NMB, patient outcomes, and efficient use of resources.

Fig 1

Flow chart of studies through the review process.

Fig 2

Threshold analysis comparing the reversal of rocuronium-induced block with sugammadex vs reversal with neostigmine/glycopyrrolate. The region above (below) the bold line represents the combinations of reduction in recovery time associated with sugammadex and value of each minute of recovery time saved at which sugammadex is (is not) cost saving under the base-case assumptions for each scenario. Separate graphs are plotted for moderate and profound block. The horizontal dashed (dotted) line represents an estimate of the value of each minute saved were all the time savings to occur in the operating theatre (recovery room), while the dotted and dashed vertical line represents an estimate of the reduction in recovery time associated with sugammadex.