Remimazolam: Usage and Dosages

Remimazolam is a new drug in the world of anesthesia. It's very promising for certain patients who can't have other anesthetics.

Reviewed and approved by the pharmacist María Vijande.

Written by María Vijande

Last update: 07 June, 2022

Remimazolam is a pharmacological innovation in anesthesia. This innovation combines the properties of two drugs that are already in use – midazolam and remifentanil.

Although anesthesiology as a specialty has evolved a lot, the search for an ideal anesthetic still continues. The goal is to have drugs that have the least possible side effects. Because of this, researchers are still studying anesthesia drugs.

What is remimazolam and how does it work?

This medicine works similarly to midazolam, and has the same metabolism as remifentanil. Also, it can be used as a sedative in the intensive care unit and as a drug for sedation in some procedures.

It’s different from other available rapid-acting intravenous sedatives, where remimazolam tends to not cause apnea. In other words, remimazolam is a derivative of midazolam that has properties of remifentanil.

Uses and dosages of remimazolam

In the field of anesthesia, remimazolam is a drug that doctors can use in four areas:

• Single-dose for premedication
• Bolus followed by supplementary doses for procedural sedation
• Intravenous anesthesia, along with an opioid, as part of the total intravenous anesthesia
• Sedation in the intensive care unit (ICU)

Single-dose for premedication

Used as premedication or pre-induction sedative, remimazolam isn’t better than midazolam. However, its effects last longer, which can be good if the patient is anxious while waiting for induction. Also, the specialist should give the patient treatment for anxiety just before going into the operating room.

Additionally, remimazolam has the advantage that you can use it in patients that need short-term sedation. It’s also useful in cases where using long-term sedatives can be potentially dangerous.

Remimazolam infusion for procedural sedation

Many procedures, like gastrointestinal endoscopies, can use a short-acting benzodiazepine, along with a short-acting opioid like fentanyl.

The effect of remimazolam appears after 1 to 3 minutes. Although this is a short time, it’s actually slow. In fact, this is a disadvantage when speed is important to the process, since most gastroduodenoscopies only take about 2-3 minutes to carry out.

Although you can speed up the onset of remimazolam by using higher doses, or combine it with fentanyl, it’s not a good idea to do this. In addition, this combination can lead to respiratory problems.

IV anesthetic along with an opioid

Many anesthesia specialists use and teach their students to use a combination involving a benzodiazepine, an opioid inhaling agent, and a muscle relaxant.

Remimazolam produces dose-dependent hypnosis. It’s known that the drug doesn’t build up after being infused over a long period of time. In addition, if necessary, you can reverse it with flumazenil.

Infusion for ICU sedation with remimazolam

Often, critically ill patients, in addition to having their functions altered, experience liver or kidney organ failure. Currently, most sedatives require hepatic metabolism and renal clearance. This whole process is a problem, even if the sedation stops. Furthermore, most drugs have a significantly long drug half-life.

The ideal first-line drug for these cases would be one that has a short action, and a metabolism that doesn’t pass through the liver or kidneys. Remimazolam meets these requirements, making it the drug of choice in these critically ill patients.

The future of remimazolam

Remimazolam is likely to be the sedative of the future. There are high expectations regarding the results of the trials that are being carried out around the world. In addition, it would be ideal for patients with liver or kidney disorders.