Remimazolam versus propofol for sedation in gastrointestinal endoscopic procedures: a systematic review and meta-analysis.
Open accessAbstract
BACKGROUND Propofol has a favourable efficacy profile in gastrointestinal endoscopic procedures, however adverse events remain frequent. Emerging evidence supports remimazolam use in gastrointestinal endoscopy. This systematic review and meta-analysis compares remimazolam and propofol, both combined with a short-acting opioid, for sedation of adults in gastrointestinal endoscopy. METHODS We searched MEDLINE, Embase, and Cochrane databases for randomised controlled trials comparing efficacy-, safety-, and satisfaction-related outcomes between remimazolam and propofol, both combined with short-acting opioids, for sedation of adults undergoing gastrointestinal endoscopy. We performed sensitivity analyses, subgroup assessments by type of short-acting opioid used and age range, and meta-regression analysis using mean patient age as a covariate. We used R statistical software for statistical analyses. RESULTS We included 15 trials (4516 subjects). Remimazolam was associated with a significantly lower sedation success rate (risk ratio [RR] 0.991; 95% confidence interval [CI] 0.984-0.998; high-quality evidence) and a slightly longer induction time (mean difference [MD] 9 s; 95% CI 4-13; moderate-quality evidence), whereas there was no significant difference between the sedatives in other time-related outcomes. Remimazolam was associated with significantly lower rates of respiratory depression (RR 0.41; 95% CI 0.30-0.56; high-quality evidence), hypotension (RR 0.43; 95% CI 0.35-0.51;…
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Claims the paper makes
6 of 17 cited sources checked · 4 supported · 0 flagged · accuracy not yet measured
- Premisecitation
In that prior meta-analysis, patients who received propofol for sedation reported greater satisfaction than those who received midazolam.
“Additionally, patients who received propofol for sedation reported greater satisfaction than those who received midazolam.47”
Quote in the paperNot a substantial claim1 of 1 sources checked- cites [47] Dossa, 2020, Propofol versus midazolam with or without short-acting opioids for sedation in colonoscopy: a systematic review and meta-analysis of safety, satisfaction, and efficiency outcomes, Gastrointest Endosc source
- Premisecitation
Remimazolam does not prolong cardiac repolarisation.
“In contrast, remimazolam does not prolong cardiac repolarisation, and it has demonstrated minimal cardiorespiratory depression.48,49”
Quote in the paperSubstantial claim1 of 2 sources checked- cites [48] Chen, 2021, Induction and maintenance of procedural sedation in adults: focus on remimazolam injection, Expert Rev Clin Pharmacol source
- cites [49] Kleiman, 2020, Potential strategy for assessing QT/QTc interval for drugs that produce rapid changes in heart rate: electrocardiographic assessment of the effects of intravenous remimazolam on cardiac repolarization, Br J Clin Pharmacol source
- Study design and conductown data
Only two RCTs had some concerns regarding deviations from the intended intervention.
“Only two RCTs 40,42 had some concerns regarding deviations from the intended intervention.”
Quote in the paperNot a substantial claim1 of 2 sources checked- cites [40] Cui, 2023, Efficacy and safety of remimazolam tonsilate combined with propofol in digestive endoscopy: a randomised trial, J Clin Pharm Ther source
- cites [42] Liu, 2023, Effect of remimazolam tosilate on the incidence of hypoxemia in elderly patients undergoing gastrointestinal endoscopy: a bi-center, prospective, randomized controlled study, Front Pharmacol source
Section 2.3 (Randomization and blinding) identifies this study as a randomized trial and says the anesthetists knew treatment assignments. The Discussion acknowledges that this may have introduced bias. The paper does not assess deviations from the intended intervention or establish that only two RCTs had concerns; those are assessments made across trials by the citing authors. (LLM, conf=0.78)
Experimental — accuracy not yet measured
- Premisecitation
Remimazolam has demonstrated minimal cardiorespiratory depression.
“In contrast, remimazolam does not prolong cardiac repolarisation, and it has demonstrated minimal cardiorespiratory depression.48,49”
Quote in the paperSubstantial claim1 of 2 sources checked- cites [48] Chen, 2021, Induction and maintenance of procedural sedation in adults: focus on remimazolam injection, Expert Rev Clin Pharmacol source
- cites [49] Kleiman, 2020, Potential strategy for assessing QT/QTc interval for drugs that produce rapid changes in heart rate: electrocardiographic assessment of the effects of intravenous remimazolam on cardiac repolarization, Br J Clin Pharmacol source
The Introduction (page not available) reports a transient blood-pressure drop and increased heart rate in animal cardiovascular safety studies, while the Results report no clinically significant effects on several ECG measures. Our copy does not report respiratory outcomes or establish that overall cardiorespiratory depression was minimal. (LLM, conf=0.72)
Experimental — accuracy not yet measured
- Findingown data
Remimazolam is associated with a lower risk of respiratory depression compared with propofol (RR 0.41; 95% CI 0.30-0.56; high-quality evidence).
“Remimazolam was associated with significantly lower rates of respiratory depression (RR 0.41; 95% CI 0.30e0.56;high-quality evidence)”
- Also stated in: § Safety-related outcomes · plain
“Sedation using remimazolam resulted in a lower risk of respiratory depression compared with propofol (n¼3488; RR 0.41; 95% CI 0.30e0.56;P<0.01;I 2 ¼46%; highquality evidence; Fig. 2a; Table 2).”
Quote in the paperSubstantial claim - Also stated in: § Safety-related outcomes · plain
- Findingown data
There is no significant difference between remimazolam and propofol in total sedation time (MD 1.94 min; 95% CI −0.09 to 3.97 min; moderate-quality evidence).
“the analysis showed no significant difference between the groups (n¼1019; MD 1.94 min; 95% CI e0.09 to 3.97 min; P¼0.06;I 2 ¼65%; moderate-quality evidence; Table 2; Supplementary Fig. S2b).”
Quote in the paperSubstantial claim - Findingown data
There is no significant difference between remimazolam and propofol in time to full alertness (MD 0.24 min; 95% CI −0.47 to 0.95 min; moderate-quality evidence).
“The results revealed no significant difference between the groups (n¼3432; MD 0.24 min; 95% CI e0.47 to 0.95 min; P¼0.51;I 2 ¼90%; moderate-quality evidence; Table 2; Supplementary Fig. S2c).”
Quote in the paperSubstantial claim - Findingown data
There is no significant difference between remimazolam and propofol in endoscopist satisfaction (MD −0.31; 95% CI −0.65 to 0.04; high-quality evidence).
“and endoscopist satisfaction (MD e0.31; 95% CI e0.65 to 0.04; high-quality evidence)”
- Also stated in: § Satisfaction-related outcomes · plain
“There was no significant difference between the groups (n¼1704; MD À0.31; 95% CI e0.65 to 0.04; P¼0.08;I 2 ¼66%; high-quality evidence; Table 2; Supplementary Fig. S5b).”
Quote in the paperSubstantial claim - Also stated in: § Satisfaction-related outcomes · plain
- Findingown data
There is no significant difference between remimazolam and propofol in procedure duration (MD 0.50 min; 95% CI −0.15 to 1.15 min; moderate-quality evidence).
“the analysis indicated no significant difference between the groups (n¼3070; MD 0.50 min; 95% CI e0.15 to 1.15 min; P¼0.13;I 2 ¼63%; moderate-quality evidence; Table 2; Supplementary Fig. S2d).”
Quote in the paperNot a substantial claim - Findingown data
Remimazolam is associated with a lower risk of hypotension requiring treatment compared with propofol (RR 0.25; 95% CI 0.12-0.52; high-quality evidence).
“hypotension requiring treatment (RR 0.25; 95% CI 0.12e0.52;high-quality evidence)”
- Also stated in: § Safety-related outcomes · boosted
“Remimazolam was associated with a significantly lower risk of hypotension requiring treatment compared with propofol (n¼1792; RR 0.25; 95% CI 0.12e0.52;P<0.01;I 2 ¼26%; high-quality evidence; Fig. 2c; Table 2).”
Quote in the paperSubstantial claim - Also stated in: § Safety-related outcomes · boosted
- Findingown data
Remimazolam is associated with a lower risk of hypotension compared with propofol (RR 0.43; 95% CI 0.35-0.51; moderate-quality evidence).
“hypotension (RR 0.43; 95% CI 0.35e0.51;moderate-quality evidence)”
- Also stated in: § Safety-related outcomes · hedged
“The analysis indicated that remimazolam was associated with a significantly lower risk of hypotension compared with propofol (n¼4439; RR 0.43; 95% CI 0.35e0.51;P<0.01;I 2 ¼65%; moderate-quality evidence; Fig. 2b; Table 2).”
Quote in the paperSubstantial claim - Also stated in: § Safety-related outcomes · hedged
- Findingown data
There is no significant difference between remimazolam and propofol in patient satisfaction (MD 0.41; 95% CI −0.07 to 0.89; moderate-quality evidence).
“There was no difference in patient (MD 0.41; 95% CI e0.07 to 0.89; moderate-quality evidence)”
- Also stated in: § Satisfaction-related outcomes · plain
“There was no significant difference between the groups (n¼790; MD 0.41; 95% CI e0.07 to 0.89; P¼0.09;I 2 ¼88%; moderate-quality evidence; Table 2; Supplementary Fig. S5a).”
Quote in the paperSubstantial claim - Also stated in: § Satisfaction-related outcomes · plain
- Findingown data
In adults undergoing gastrointestinal endoscopy, remimazolam compared with propofol (both combined with a short-acting opioid) is associated with a small reduction in sedation success rate (RR 0.991; 95% CI 0.984-0.998; high-quality evidence).
“Remimazolam was associated with a significantly lower sedation success rate (risk ratio [RR] 0.991; 95% confidence interval [CI] 0.984e0.998;high-quality evidence)”
- Also stated in: § Primary outcome · hedged
“Remimazolam was associated with little to no difference in sedation success compared with propofol (n¼2273; RR 0.991; 95% CI 0.984e0.998;P¼0.01;I 2 ¼0%; highquality evidence; Fig. 1; Table 2).”
Quote in the paperSubstantial claim - Also stated in: § Primary outcome · hedged
- Findingown data
There is no significant difference between remimazolam and propofol in time to anaesthesia discharge (MD 0.29 min; 95% CI −0.62 to 1.20 min; moderate-quality evidence).
“the analysis showed that there was no significant difference between the drugs (n¼2271; MD 0.29 min; 95% CI e0.62 to 1.20 min; P¼0.53;I 2 ¼88%; moderate-quality evidence; Table 2; Supplementary Fig. S2e).”
Quote in the paperSubstantial claim - Findingown data
The subgroup analysis based on age range revealed significant subgroup differences exclusively for induction time (P=0.01) and hypotension (P=0.05).
“The subgroup analysis based on age range revealed significant subgroup differences exclusively for induction time (P¼0.01)and hypotension (P¼0.05).”
Quote in the paperNot a substantial claim - Findingown data
There is no significant difference between remimazolam and propofol in the risk of nausea/vomiting (RR 1.00; 95% CI 0.86-1.16; high-quality evidence).
“There was no statistically significant difference in the risk of nausea/vomiting between both sedative drugs (n¼3450; RR 1.00; 95% CI 0.86e1.16;P¼0.99;I 2 ¼0%; highquality evidence; Table 2; Supplementary Fig. S4).”
Quote in the paperSubstantial claim - Findingown data
Remimazolam is associated with a lower risk of bradycardia compared with propofol (RR 0.42; 95% CI 0.30-0.58; high-quality evidence).
“and bradycardia (RR 0.42; 95% CI 0.30e0.58;high-quality evidence)”
- Also stated in: § Safety-related outcomes · boosted
“Sedation using remimazolam resulted in a significantly lower risk of bradycardia compared with propofol (n¼2589; RR 0.42; 95% CI 0.30e0.58;P<0.01;I 2 ¼0%; highquality evidence; Fig. 2d; Table 2).”
Quote in the paperSubstantial claim - Also stated in: § Safety-related outcomes · boosted
- Findingown data
Remimazolam compared with propofol is associated with a slightly longer induction time (MD 9 s; 95% CI 4-13 s; moderate-quality evidence).
“a slightly longer induction time (mean difference [MD] 9 s; 95% CI 4e13; moderate-quality evidence)”
- Also stated in: § Time-related outcomes · plain
“Remimazolam provided a clinically unimportant increase in induction time compared with propofol (n¼3647; MD 9 s; 95% CI 4e13 s; P<0.01;I 2 ¼93%; moderatequality evidence; Table 2; Supplementary Fig. S2a).”
Quote in the paperSubstantial claim - Also stated in: § Time-related outcomes · plain
- Findingown data
In the present meta-analysis, remimazolam presented a reduced risk of important respiratory and cardiovascular adverse events in low-risk patients (ASA physical status <3 and non-obese patients) compared with propofol.
“Confirming those findings, the present meta-analysis showed that remimazolam presented a reduced risk of important respiratory and cardiovascular adverse events in low-risk patients (ASA physical status <3 and non-obese patients) compared with propofol.”
Quote in the paperSubstantial claim - Findingown data
For hypotension, the pooled risk ratio for remimazolam vs propofol was 0.43 (95% CI 0.35 to 0.51), p<0.01, I2=65%, with moderate-quality evidence.
“| Hypotension | 14 | 2374/2065 | RR 0.43 (0.35e0.51) | <0.01 | 65 | 444 |”
Quote in the paperSubstantial claim - Findingown data
For time to full alertness, the pooled mean difference for remimazolam vs propofol was 0.24 min (95% CI -0.47 to 0.95), p=0.51, I2=90%, with moderate-quality evidence.
“| Time to full alertness | 9 | 1865/1567 | MD 0.24 (e0.47 to 0.95) | 0.51 | 90 | 444 |”
Quote in the paperNot a substantial claim - Findingown data
Remimazolam reduces the risk of respiratory depression compared with propofol.
“(iv) remimazolam reduces the risk of respiratory depression, hypotension requiring treatment, and bradycardia, while likely decreasing the risk of hypotension;”
Quote in the paperSubstantial claim - Findingown data
Remimazolam and propofol likely exhibit comparable times to anaesthesia discharge.
“(iii) remimazolam and propofol likely exhibit comparable total sedation times, times to full alertness, procedure durations, and times to anaesthesia discharge;”
Quote in the paperSubstantial claim - Findingown data
For procedure duration, the pooled mean difference for remimazolam vs propofol was 0.50 min (95% CI -0.15 to 1.15), p=0.13, I2=63%, with moderate-quality evidence.
“| Procedure duration | 11 | 1562/1508 | MD 0.50 (e0.15 to 1.15) | 0.13 | 63 | 444 |”
Quote in the paperNot a substantial claim - Findingown data
For induction time, propofol yielded a shorter induction time only in the younger subgroup.
“The only exceptions were: (i) induction time, where propofol yielded a shorter induction time only in the younger subgroup; and (ii) hypotension, with the younger subgroup exhibiting a slightly greater benefit with remimazolam use compared with the older subgroup.”
Quote in the paperNot a substantial claim - Findingown data
There was no significant relationship between age and the relative efficacy of remimazolam compared with propofol for outcomes other than induction time and hypotension.
“There was no significant relationship between age and the relative efficacy of remimazolam compared with propofol for other outcomes (Supplementary Figs S9eS11).”
Quote in the paperNot a substantial claim - Findingown data
Remimazolam and propofol likely exhibit comparable total sedation times.
“(iii) remimazolam and propofol likely exhibit comparable total sedation times, times to full alertness, procedure durations, and times to anaesthesia discharge;”
Quote in the paperSubstantial claim - Findingown data
Propofol probably slightly reduces induction time compared with remimazolam.
“(ii) propofol probably slightly reduces the induction time;”
Quote in the paperSubstantial claim - Findingown data
Remimazolam and propofol provide comparable rates of endoscopist satisfaction.
“(v) remimazolam and propofol provide comparable rates of endoscopist satisfaction, while probably offering comparable rates of patient satisfaction.”
Quote in the paperSubstantial claim - Findingown data
Remimazolam and propofol likely exhibit comparable procedure durations.
“(iii) remimazolam and propofol likely exhibit comparable total sedation times, times to full alertness, procedure durations, and times to anaesthesia discharge;”
Quote in the paperSubstantial claim - Findingown data
For respiratory depression, the pooled risk ratio for remimazolam vs propofol was 0.41 (95% CI 0.30 to 0.56), p<0.01, I2=46%, with high-quality evidence.
“| Respiratory depression | 13 | 1869/1619 | RR 0.41 (0.30e0.56) | <0.01 | 46 | 4444 |”
Quote in the paperSubstantial claim - Findingown data
Remimazolam and propofol likely exhibit comparable times to full alertness.
“(iii) remimazolam and propofol likely exhibit comparable total sedation times, times to full alertness, procedure durations, and times to anaesthesia discharge;”
Quote in the paperSubstantial claim - Findingown data
For total sedation time, the pooled mean difference for remimazolam vs propofol was 1.94 min (95% CI -0.09 to 3.97), p=0.06, I2=65%, with moderate-quality evidence.
“| Total sedation time | 3 | 537/482 | MD 1.94 (e0.09 to 3.97) | 0.06 | 65 | 444 |”
Quote in the paperNot a substantial claim - Findingown data
The subgroup analysis by the type of short-acting opioid used did not reveal significant differences between the subgroups.
“The subgroup analysis by the type of short-acting opioid used also did not reveal significant differences between the subgroups.”
Quote in the paperNot a substantial claim - Findingown data
For hypotension, the younger subgroup exhibited a slightly greater benefit with remimazolam use compared with the older subgroup.
“The only exceptions were: (i) induction time, where propofol yielded a shorter induction time only in the younger subgroup; and (ii) hypotension, with the younger subgroup exhibiting a slightly greater benefit with remimazolam use compared with the older subgroup.”
Quote in the paperNot a substantial claim - Findingown data
Funnel plot analysis for procedure duration, respiratory depression, bradycardia, and nausea/vomiting showed a symmetrical distribution according to weight, converging towards the pooled effect as weight increased.
“On funnel plot analysis for procedure duration, respiratory depression, bradycardia, and nausea/vomiting, studies occupied a symmetrical distribution according to weight and converged towards the pooled effect as the weight increased (Fig. 4).”
Quote in the paperNot a substantial claim - Findingown data
Propofol provides marginally higher sedation success than remimazolam.
“The main findings from the pooled analyses were: (i) propofol provides a marginally higher sedation success;”
Quote in the paperSubstantial claim - Findingown data
Remimazolam reduces the risk of hypotension requiring treatment compared with propofol.
“(iv) remimazolam reduces the risk of respiratory depression, hypotension requiring treatment, and bradycardia, while likely decreasing the risk of hypotension;”
Quote in the paperSubstantial claim - Findingown data
Remimazolam likely decreases the risk of hypotension compared with propofol.
“(iv) remimazolam reduces the risk of respiratory depression, hypotension requiring treatment, and bradycardia, while likely decreasing the risk of hypotension;”
Quote in the paperSubstantial claim - Findingown data
Remimazolam and propofol probably offer comparable rates of patient satisfaction.
“(v) remimazolam and propofol provide comparable rates of endoscopist satisfaction, while probably offering comparable rates of patient satisfaction.”
Quote in the paperSubstantial claim - Findingown data
Remimazolam reduces the risk of bradycardia compared with propofol.
“(iv) remimazolam reduces the risk of respiratory depression, hypotension requiring treatment, and bradycardia, while likely decreasing the risk of hypotension;”
Quote in the paperSubstantial claim - Findingown data
For nausea/vomiting, the pooled risk ratio for remimazolam vs propofol was 1.00 (95% CI 0.86 to 1.16), p=0.99, I2=0%, with high-quality evidence.
“| Nausea/vomiting | 11 | 1759/1691 | RR 1.00 (0.86e1.16) | 0.99 | 0 | 4444 |”
Quote in the paperNot a substantial claim - Findingown data
For bradycardia, the pooled risk ratio for remimazolam vs propofol was 0.42 (95% CI 0.30 to 0.58), p<0.01, I2=0%, with high-quality evidence.
“| Bradycardia | 10 | 1328/1261 | RR 0.42 (0.30e0.58) | <0.01 | 0 | 4444 |”
Quote in the paperSubstantial claim - Findingown data
In a subgroup analysis by age range, there were no statistically significant differences between older and younger subgroups for most outcomes.
“We conducted a subgroup analysis by age range, revealing no statistically significant differences between the older and the younger subgroups for most outcomes.”
Quote in the paperSubstantial claim - Findingown data
For hypotension requiring treatment, the pooled risk ratio for remimazolam vs propofol was 0.25 (95% CI 0.12 to 0.52), p<0.01, I2=26%, with high-quality evidence.
“| Hypotension requiring treatment | 5 | 1024/768 | RR 0.25 (0.12e0.52) | <0.01 | 26 | 4444 |”
Quote in the paperSubstantial claim - Interpretationown data
Remimazolam has greater safety than propofol for sedation in gastrointestinal endoscopies.
“Remimazolam has clinically similar efficacy and greater safety when compared with propofol for sedation in gastrointestinal endoscopies.”
Quote in the paperSubstantial claim - Interpretationown data
Remimazolam has clinically similar efficacy to propofol for sedation in gastrointestinal endoscopies.
“Remimazolam has clinically similar efficacy and greater safety when compared with propofol for sedation in gastrointestinal endoscopies.”
Quote in the paperSubstantial claim - Interpretationown data
The consistent positive effects observed across both the younger and older populations underscore an additional advantage to remimazolam over propofol.
“The consistent positive effects observed across both the younger and older populations underscore an additional advantage to remimazolam over propofol.”
Quote in the paperSubstantial claim - Study design and conductown data
Sensitivity analyses identified the source of heterogeneity in some cases.
“Sixthly, some outcomes had a significant between-study heterogeneity; nonetheless, sensitivity analyses identified the source of heterogeneity in some cases, and leave-one-out sensitivity analyses showed that results were not dependent on individual studies in general.”
Quote in the paperNot a substantial claim - Interpretationown data
Remimazolam has similar clinical efficacy to propofol for sedation of adults in GI endoscopy.
“In conclusion, this systematic review and meta-analysis demonstrated similar clinical efficacy and better safety profile of remimazolam compared with propofol for sedation of adults in GI endoscopy, with similar results in both younger and older populations.”
Quote in the paperSubstantial claim - Interpretationown data
Remimazolam has a better safety profile than propofol for sedation of adults in GI endoscopy.
“In conclusion, this systematic review and meta-analysis demonstrated similar clinical efficacy and better safety profile of remimazolam compared with propofol for sedation of adults in GI endoscopy, with similar results in both younger and older populations.”
Quote in the paperSubstantial claim - Study design and conductown data
Leave-one-out sensitivity analyses showed that results were not dependent on individual studies in general.
“Sixthly, some outcomes had a significant between-study heterogeneity; nonetheless, sensitivity analyses identified the source of heterogeneity in some cases, and leave-one-out sensitivity analyses showed that results were not dependent on individual studies in general.”
Quote in the paperNot a substantial claim - Study design and conductown data
Some outcomes had significant between-study heterogeneity.
“Sixthly, some outcomes had a significant between-study heterogeneity; nonetheless, sensitivity analyses identified the source of heterogeneity in some cases, and leave-one-out sensitivity analyses showed that results were not dependent on individual studies in general.”
Quote in the paperNot a substantial claim - Interpretationown data
For induction time and hypotension, older age is associated with a tendency for no significant difference between remimazolam and propofol, lowering the magnitude of the effect of remimazolam relative to propofol.
“For both outcomes, older age was associated with a tendency for no significant difference between groups, that is, lowering the magnitude of the effect of remimazolam relative to propofol.”
Quote in the paperNot a substantial claim - Study design and conductown data
All included studies were conducted in China.
“Firstly, all included studies were conducted in China; whether this affects the generalisability of findings to non-Asian patients is unclear.”
Quote in the paperSubstantial claim - Premisecitation
Several studies have reported significantly higher rates of sedation-related adverse events in older patients than younger patients receiving propofol, even when a much lower dose of propofol was used.
“Several studies have compared its safety between older and younger patients, and they have reported significantly higher rates of sedation-related adverse events in the older group, even when a much lower dose of propofol was used.”
Quote in the paperSubstantial claim0 of 1 sources checked- cites 50e52
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
- Interpretationown data
The asymmetry in funnel plots for induction time and hypotension suggests publication bias.
“In contrast, on funnel plot analysis for induction time and hypotension, we observed asymmetry, which was confirmed by Egger's test (P<0.05),suggesting publication bias (Fig. 4; Supplementary Table S4).”
Quote in the paperNot a substantial claim - Interpretationown data
Results for remimazolam vs propofol are similar in both younger and older populations.
“In conclusion, this systematic review and meta-analysis demonstrated similar clinical efficacy and better safety profile of remimazolam compared with propofol for sedation of adults in GI endoscopy, with similar results in both younger and older populations.”
Quote in the paperSubstantial claim - Premisecitation
The collective findings of the three previous meta-analyses suggest that remimazolam possesses a more favourable combination of efficacy and safety profiles than midazolam for sedation during GI endoscopies.
“Although the three studies had some variations, their collective findings suggest that remimazolam possesses a more favourable combination of efficacy and safety profiles than midazolam for sedation during GI endoscopies.13e15”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites 13e15
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
- Premisecitation
The safety profile of propofol becomes even more concerning when administered to older individuals.
“Notably, the safety profile of propofol becomes even more concerning when administered to older individuals.”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites 50e52
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
- Study design and conductnone given
The absence of patient-level data precluded a more definitive assessment of patient characteristics potentially associated with the relative efficacy of remimazolam vs propofol.
“Finally, the absence of patient-level data precluded a more definitive assessment of patient characteristics potentially associated with the relative efficacy of remimazolam vs propofol.”
Quote in the paperNot a substantial claim - Study design and conductown data
All other RCTs showed a low risk of bias in all domains.
“All the other RCTs showed a low risk of bias in all domains.”
Quote in the paperNot a substantial claim - Study design and conductnone given
Most included studies did not evaluate postoperative delirium, a known adverse event of benzodiazepines, especially in older patients.
“Thirdly, most studies did not evaluate postoperative delirium, a known adverse event of benzodiazepines, especially in older patients.”
Quote in the paperNot a substantial claim - Premisecitation
The most common adverse events in the older population receiving propofol included hypoxaemia, hypotension, bradycardia, arrhythmia, and even cardiac/respiratory arrest.
“The most common adverse events in the older population included hypoxaemia, hypotension, bradycardia, arrhythmia, and even cardiac/respiratory arrest.50e52”
Quote in the paperSubstantial claim0 of 1 sources checked- cites 50e52
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
- Classified as probably not a substantial claim. 20
- May combine two claims. 18
- The quote only partly states this claim. 2
Probably not a substantial claim: may not pass S3 (load-bearing).
PremisecitationIn that prior meta-analysis, anaesthesia recovery time was shorter in the propofol group than in the midazolam group.
“However, the anaesthesia recovery time was shorter in the propofol group.”
Quote in the paperNot a substantial claim1 of 1 sources checked- cites [47] Dossa, 2020, Propofol versus midazolam with or without short-acting opioids for sedation in colonoscopy: a systematic review and meta-analysis of safety, satisfaction, and efficiency outcomes, Gastrointest Endosc source
Probably not a substantial claim: may not pass S3 (load-bearing).
PremisecitationIn a prior meta-analysis comparing propofol with midazolam for sedation in colonoscopies, there were no significant differences in cardiorespiratory outcomes (hypotension, hypoxia, and bradycardia) between the two sedative agents.
“In a prior meta-analysis comparing propofol with another benzodiazepine, midazolam, for sedation in colonoscopies, there were no significant differences in cardiorespiratory outcomes (encompassing hypotension, hypoxia, and bradycardia) between both sedative agents.”
Quote in the paperNot a substantial claim1 of 1 sources checked- cites [47] Dossa, 2020, Propofol versus midazolam with or without short-acting opioids for sedation in colonoscopy: a systematic review and meta-analysis of safety, satisfaction, and efficiency outcomes, Gastrointest Endosc source
May combine two claims.
Findingown dataThe subgroup analysis by type of short-acting opioid used showed no significant treatment interaction and little impact on heterogeneity within each subgroup for most outcomes.
“There was no significant treatment interaction based on the type of short-acting opioid used (test for subgroup differences with P!0.10), and there was little impact on heterogeneity within each subgroup for most outcomes (Supplementary Fig. S6)”
Quote in the paperNot a substantial claimMay combine two claims.
Findingown dataThere was a significant relationship between age and induction time (regression coefficient −0.37; P=0.02) and between age and hypotension (regression coefficient 0.02; P=0.01) in meta-regression.
“There was a significant relationship between age and the outcomes of induction time (regression coefficient [RC] e0.37; P¼0.02) and hypotension (RC 0.02; P¼0.01), as shown in Supplementary Figure S8.”
Quote in the paperNot a substantial claimMay combine two claims.
Findingown dataFunnel plot analysis for induction time and hypotension showed asymmetry, confirmed by Egger's test (P<0.05).
“In contrast, on funnel plot analysis for induction time and hypotension, we observed asymmetry, which was confirmed by Egger's test (P<0.05),suggesting publication bias (Fig. 4; Supplementary Table S4).”
Quote in the paperNot a substantial claimMay combine two claims.
Findingown dataRemimazolam exhibited a small increase in induction time compared with propofol in both age subgroups, and this effect was stronger in the younger subgroup.
“Remimazolam exhibited a small increase in induction time compared with propofol in both subgroups, and this effect was stronger in the younger subgroup.”
Quote in the paperNot a substantial claimMay combine two claims. The quote only partly states this claim.
Findingown dataFor endoscopist satisfaction, the pooled mean difference for remimazolam vs propofol was -0.31 (95% CI -0.65 to 0.04), p=0.08, I2=66%, with high-quality evidence.
“| Endoscopist satisfaction | 5 | 850/854 | MD e0.31 (e0.65 to 0.04) | 0.08 | 66 | 4444 |”
Quote in the paperNot a substantial claimMay combine two claims.
Findingown dataFor time to anaesthesia discharge, the pooled mean difference for remimazolam vs propofol was 0.29 min (95% CI -0.62 to 1.20), p=0.53, I2=88%, with moderate-quality evidence.
“| Time to anaesthesia discharge | 9 | 1285/986 | MD 0.29 (e0.62 to 1.20) | 0.53 | 88 | 444 |”
Quote in the paperNot a substantial claimMay combine two claims.
Findingown dataThe risk of hypotension was lower with remimazolam than with propofol in both age subgroups, with an even lower risk in the younger subgroup.
“Conversely, the risk of hypotension was lower with remimazolam than with propofol in both subgroups, with an even lower risk in the younger subgroup.”
Quote in the paperNot a substantial claimMay combine two claims.
Findingown dataFor patient satisfaction, the pooled mean difference for remimazolam vs propofol was 0.41 (95% CI -0.07 to 0.89), p=0.09, I2=88%, with moderate-quality evidence.
“| Patient satisfaction | 4 | 393/397 | MD 0.41 (e0.07 to 0.89) | 0.09 | 88 | 444 |”
Quote in the paperNot a substantial claimMay combine two claims.
Findingown dataFor induction time, the pooled mean difference for remimazolam vs propofol was 8.64 min (95% CI 4.34 to 12.93), p<0.01, I2=93%, with moderate-quality evidence.
“| Induction time | 11 | 1949/1698 | MD 8.64 (4.34e12.93) | <0.01 | 93 | 444 |”
Quote in the paperSubstantial claimMay combine two claims.
Findingown dataFor sedation success, the pooled risk ratio for remimazolam vs propofol was 0.99 (95% CI 0.98 to 1.00), p=0.01, I2=0%, with high-quality evidence.
“| Sedation success | 9 | 1295/978 | RR 0.99 (0.98e1.00) | 0.01 | 0 | 4444 |”
Quote in the paperSubstantial claimMay combine two claims.
Interpretationown dataThe choice of opioids in combination with remimazolam and propofol for sedation in GI endoscopies appears to be flexible, with fentanyl, alfentanil, and sufentanil all being suitable options.
“Therefore, the choice of opioids in combination with remimazolam and propofol for sedation in GI endoscopies appears to be flexible, with fentanyl, alfentanil, and sufentanil all being suitable options.”
Quote in the paperSubstantial claimProbably not a substantial claim: may not pass S3 (load-bearing).
Study design and conductnone givenThere was no statistical adjustment for multiple testing in the subgroup analyses.
“Seventhly, there was no statistical adjustment for multiple testing in the subgroup analyses; thus, these results should be viewed as exploratory.”
Quote in the paperNot a substantial claimProbably not a substantial claim: may not pass S3 (load-bearing).
Study design and conductnone givenIn the presence of high heterogeneity (I2 >50%), a leave-one-out sensitivity analysis was conducted.
“In the presence of high heterogeneity (I 2 >50%), we conducted a leave-one-out sensitivity analysis.”
Quote in the paperNot a substantial claimProbably not a substantial claim: may not pass S3 (load-bearing).
Study design and conductnone givenThe included studies mainly enrolled patients with ASA physical status 1 and 2.
“Secondly, the studies included mainly patients with ASA physical status 1 and 2.”
Quote in the paperNot a substantial claimMay combine two claims.
PremisecitationAcross those three previous meta-analyses, remimazolam demonstrated superiority in sedation success, time-related outcomes, and adverse event rates compared with midazolam.
“Across these studies, remimazolam demonstrated superiority in terms of sedation success, time-related outcomes, and adverse event rates.”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites 13e15
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
Probably not a substantial claim: may not pass S3 (load-bearing).
Study design and conductnone givenThe definitions of the outcomes were determined after completing data extraction, according to the definitions most used by the studies.
“Fourthly, we determined the definitions of the outcomes after completing the data extraction, according to the definitions most used by the studies.”
Quote in the paperNot a substantial claimMay combine two claims.
InterpretationreasoningThe marginally lower sedation success (RR 0.99) and slightly longer induction time (MD 9 s) with remimazolam relative to propofol do not represent clinically relevant effects.
“Notably, the marginally lower sedation success (RR 0.99) and slightly longer induction time (MD 9 s) with remimazolam relative to propofol do not represent clinically relevant effects.”
Quote in the paperSubstantial claimMay combine two claims.
Study design and conductown dataFor procedure duration, respiratory depression, bradycardia, and nausea/vomiting, studies occupied a symmetrical distribution according to weight and converged towards the pooled effect as the weight increased.
“For procedure duration, respiratory depression, bradycardia, and nausea/vomiting, studies occupied a symmetrical distribution according to weight and converged towards the pooled effect as the weight increased.”
Quote in the paperNot a substantial claimProbably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.
Study design and conductown dataTwo independent reviewers screened titles and abstracts and full-text articles, with a third author resolving disagreements.
“After excluding duplicates, two independent reviewers (ECB and PAES) screened the titles and abstracts, followed by fulltext articles, using the Zotero software (version 6.0.26;Corporation for Digital Scholarship, Vienna, VA, USA).A third author (GCM) solved disagreements.”
Quote in the paperNot a substantial claimMay combine two claims.
Interpretationown dataPatient and endoscopist satisfaction levels were similar between remimazolam and propofol groups.
“Furthermore, patient and endoscopist satisfaction levels were similar between both groups.”
Quote in the paperNot a substantial claimClassified as probably not a substantial claim.
Study design and conductown dataThe certainty of evidence for each outcome was assessed using the GRADE tool.
“We assessed the certainty of the evidence for each outcome using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) tool, 29 which evaluates the following parameters: (i) risk of bias of included studies; (ii) indirectness, inconsistency, and imprecision of the effect estimate; and (iii) other considerations, including risk of publication bias.”
Quote in the paperSubstantial claimProbably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.
Study design and conductown dataSubgroup analyses based on type of short-acting opioid and age range were prespecified.
“Based on a priori hypotheses to explain potential heterogeneity, we performed prespecified subgroup analyses based on the type of short-acting opioid used in the procedure and the age range for all outcomes, provided there were at least two studies in each subgroup.”
Quote in the paperNot a substantial claimProbably not a substantial claim: may not pass S3 (load-bearing).
Study design and conductnone givenThe study protocol was registered belatedly.
“Fifthly, we registered the study protocol belatedly.”
Quote in the paperNot a substantial claimProbably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.
Study design and conductcitationPublication bias was assessed using subjective and objective methods, with funnel plot and Egger's test, for outcomes with at least 10 studies.
“We assessed publication bias using subjective and objective methods, and only the outcomes with at least 10 studies were included in the evaluation, following Cochrane's guidelines.23 Subjectively, we used a funnel plot for visualisation, whereas objectively, we conducted Egger's test, where a P-value of <0.05 suggested the presence of possible publication bias.28”
Quote in the paperNot a substantial claimProbably not a substantial claim: may not pass S3 (load-bearing).
Study design and conductcitationIf included studies lacked mean and standard deviation, values were estimated using reported median and range based on Wan and colleagues and Luo and colleagues.
“If the included studies lacked mean and standard deviation, we estimated their values using the reported median and range based on Wan and colleagues 25 and Luo and colleagues 26 .”
Quote in the paperNot a substantial claim0 of 2 sources checked- cites Wan and colleagues 25
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
- cites Luo and colleagues 26
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
Probably not a substantial claim: may not pass S3 (load-bearing).
Study design and conductown dataTwo independent examiners evaluated five risk-of-bias domains for each outcome of the selected studies.
“two independent examiners (ECB and SB) evaluated five domains for each outcome of the selected studies: (i) bias in the randomisation process; (ii) bias as a result of deviations from intended interventions; (iii) bias as a result of missing data; (iv) bias in outcome measurement; and (v) bias in the selection of the reported results.”
Quote in the paperNot a substantial claimProbably not a substantial claim: may not pass S3 (load-bearing).
Study design and conductnone givenThe overall number of patients included in the meta-analysis was large.
“In addition, the overall number of patients included in the metaanalysis was large, and we used rigorous methods specified in the meta-analysis protocol.”
Quote in the paperNot a substantial claimThe quote only partly states this claim.
Interpretationown dataRemimazolam was associated with significantly lower rates of cardiopulmonary adverse events compared with propofol.
“Remimazolam was associated with significantly lower rates of cardiopulmonary adverse events.”
Quote in the paperSubstantial claimProbably not a substantial claim: may not pass S3 (load-bearing).
Study design and conductnone givenThe study was registered on PROSPERO (ID: CRD42023450487).
“This study was registered on PROSPERO (ID: CRD42023450487).”
Quote in the paperNot a substantial claimProbably not a substantial claim: may not pass S3 (load-bearing).
Study design and conductreasoningThe overall bias risk assessment for each trial outcome was derived from individual domain judgements.
“We derived the overall bias risk assessment for each trial outcome from individual domain judgements.”
Quote in the paperNot a substantial claimProbably not a substantial claim: may not pass S3 (load-bearing).
Study design and conductnone givenOutcome definitions were established per the criteria most used by the included studies, after completing data extraction.
“We established the definition of each evaluated outcome per the criteria most used by the studies included in the analysis (i.e.we determined the definitions after completing the data extraction).”
Quote in the paperNot a substantial claimClassified as probably not a substantial claim.
Study design and conductnone givenThe inclusion of randomised studies only minimises potential confounding factors frequently present in observational data.
“Our study has some strengths, particularly the inclusion of randomised studies only, which minimises potential confounding factors frequently present in observational data.”
Quote in the paperSubstantial claimProbably not a substantial claim: may not pass S3 (load-bearing).
PremisecitationThree previous meta-analyses have compared remimazolam with midazolam for GI endoscopy sedation.
“Three previous meta-analyses have compared remimazolam with midazolam for GI endoscopy sedation.”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites 13e15
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
Probably not a substantial claim: may not pass S3 (load-bearing).
Study design and conductnone givenThe meta-analysis used rigorous methods specified in the meta-analysis protocol.
“In addition, the overall number of patients included in the metaanalysis was large, and we used rigorous methods specified in the meta-analysis protocol.”
Quote in the paperNot a substantial claim
The paper relies on this without support.
Propofol has a favourable efficacy profile in gastrointestinal endoscopic procedures, but adverse events remain frequent.
“Propofol has a favourable efficacy profile in gastrointestinal endoscopic procedures, however adverse events remain frequent.”
The paper relies on this without support.
Emerging evidence supports the use of remimazolam in gastrointestinal endoscopy.
“Emerging evidence supports remimazolam use in gastrointestinal endoscopy.”
The paper relies on this without support.
No prior systematic review and meta-analysis compared remimazolam and propofol for sedation in GI endoscopies.
“To our knowledge, this is the first systematic review and meta-analysis comparing remimazolam and propofol for sedation in GI endoscopies.”
The paper relies on this without support.
Propofol causes dose-related cardiorespiratory depression.
“One of the main adverse events of propofol is dose-related cardiorespiratory depression.”
The paper relies on this without support.
Remimazolam can be used as a safe and effective alternative to other widely used sedatives, such as propofol and midazolam, for sedation of patients undergoing various procedures.
“Reported clinical data suggest that remimazolam can be used as a safe and effective alternative to other widely used sedatives, such as propofol and midazolam, for sedation of patients undergoing various procedures.”
Self-check
Percentages, sums and reported differences re-computed from the paper’s own numbers.
Sufentanil subgroup count is 30 patients too high
MinorThe four cited sufentanil studies have sample sizes of 76, 346, 216, and 132, totaling 770 patients rather than 800. The reported count also makes the opioid subgroup counts sum to 4546, exceeding the stated overall total of 4516 by 30.
Reported 800 · recomputed 770
“four studies sufentanil (800 [17.7%] patients), 33,39,40,42”
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“No statistically significant differences were observed in the procedure (31.5 ± 4.9 vs 32.1 ± 5.2), sedation (41.2 ± 5.2 vs 41.7 ± 5.3), and awake times (4[4,4] vs 4[4,4]) between the two groups (Table 2).”
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“47 This observed variation could be attributed to differences in the discharge criteria of PACUs among various medical centers.”
BackgroundOrtegal, G. H. P. C., Barbosa, E. C., Faria, P. C. C., et al. (2024) · Minerva Anestesiologica · doi:10.23736/s0375-9393.24.18203-x · Cited by 14 · see citing works
Self-citationInduction Agents for Tracheal Intubation in Critically Ill Patients
Kotani, Y., & Russotto, V. (2024) · Critical Care Medicine · doi:10.1097/ccm.0000000000006506 · Cited by 16 · see citing works
“Due to its hemodynamic tolerant property, remimazolam resulted in less frequent hypotension and bradycardia than propofol for sedation during endoscopic procedures in noncriti-cally ill settings (50).”
Lin, S., Wei, Y., Zhuo, Y., et al. (2024) · Clinical Interventions in Aging · doi:10.2147/cia.s490330 · Cited by 13 · see citing works
Hung, K.-C., Wang, W.-T., Liu, W.-C., Hsu, C.-W., Huang, Y.-T., Wu, J.-Y., & Chen, I.-W. (2024) · Systematic Reviews · doi:10.1186/s13643-024-02660-8 · Cited by 14 · see citing works
Remimazolam in children: a comprehensive narrative review
Hansen, T. G., & Engelhardt, T. (2025) · Anesthesiology and Perioperative Science · doi:10.1007/s44254-025-00090-w · Cited by 12 · see citing works
“Adult studies have consistently shown that remimazolam preserves hemodynamic parameters even at higher doses, indicating a broad therapeutic index [26–29].”
InfluentialKim, I. J., Choi, G. J., Oh, H., et al. (2025) · Digestive Endoscopy · doi:10.1111/den.15078 · Cited by 11 · see citing works
Effect of remimazolam on intra-operative hypotension
He, T.-Y., Zhong, R.-P., Zhong, W.-B., Huang, G.-M., & Liu, X.-C. (2024) · European Journal of Anaesthesiology · doi:10.1097/eja.0000000000002057 · Cited by 4 · see citing works
Shi, H., Zhang, J., Hu, Z., Hou, Q., Hu, Q., Dai, Z., Zhou, W., Qi, D., Li, Y., Wang, Q., et al. (2024) · Frontiers in Medicine · doi:10.3389/fmed.2024.1434767 · Cited by 12 · see citing works
Li, C., Wei, L., Gong, H.-Y., & Yuan, X. (2025) · BMC Anesthesiology · doi:10.1186/s12871-025-03018-w · Cited by 11 · see citing works
“E x c l u d e d –– – - response associated with complex surgical interventions likely contribute to these differences [66].”
Clinical experience with remimazolam in pediatric anesthesiology: An educational focused review
Tobias, J. D. (2024) · Paediatric anaesthesia · doi:10.1111/pan.14970 · Cited by 18 · see citing works
“22,23 In a cumulative analysis of 15 trials involving 4516 adult patients for GI endoscopy (colonoscopy, ERCP, endoscopic, or gastroscopy), the success rate was slightly lower with remimazolam when compared to propofol whereas there was no significant difference between the sedatives in other…”
Han, S. Y., Oh, D., Choe, J. W., et al. (2025) · Gastrointestinal Endoscopy · doi:10.1016/j.gie.2025.11.002 · Cited by 8 · see citing works
Esketamine as an adjuvant to propofol sedation for gastrointestinal endoscopy
Song, N., & Peng, K. (2024) · Anesthesiology and Perioperative Science · doi:10.1007/s44254-024-00067-1 · Cited by 7 · see citing works
“A recent meta-analysis showed that remimazolam, when compared to propofol, led to similar sedation efficacy and fewer episodes of respiratory depression, hypotension, and bradycardia [15].”
Xiaoming, X. U. E., Ma, X., Bing, Z. H. A. O., Bo, L. I. U., Zhang, J., Zhao, L., Li, H.-Z., Liu, X., & Zhao, S. (2025) · Minerva Anestesiologica · doi:10.23736/s0375-9393.24.18338-1 · Cited by 8 · see citing works
Chen, X., Zhao, W., Yu, B., Liu, Y., Ma, Y., Tang, C., Huang, Y., & Yan, M. (2025) · Drug Design Development and Therapy · doi:10.2147/dddt.s548418 · Cited by 8 · see citing works
“15,16 Moreover, remimazolam has been shown to reduce oxidative stress and inflammation in experimental models.”
Feng, Y., Xu, J., Ma, H., Wang, E., Bian, J., Fang, X., Shen, L., Zhu, T., Liu, K., Jiang, L., et al. (2025) · British Journal of Anaesthesia · doi:10.1016/j.bja.2025.09.038 · Cited by 7 · see citing works
Yang, W., Zhou, R., Zhou, X., et al. (2025) · Drug Design Development and Therapy · doi:10.2147/dddt.s527586 · Cited by 6 · see citing works
“28,29 In this study, the SpO 2 of the patients fluctuated between 94% and 100%, and no hypoxemia occurred.”
Barbosa, E. C., Aguirre, J. M., Bertoldi, P. F. E., et al. (2025) · Anaesthesia · doi:10.1111/anae.16563 · Cited by 6 · see citing works
“There has been growing interest in anaesthesia and sedation practices for gastrointestinal endoscopy [1 – 6].”
Self-citationLi, A., Zhou, Y., Wu, L.-J., & Hu, B.-L. (2025) · BMC Anesthesiology · doi:10.1186/s12871-025-03167-y · Cited by 5 · see citing works
“As a new type of benzodiazepine, remimazolam not only has a faster onset of action and metabolism [31], but also reduces the risk of postoperative nausea and vomiting and excessive sedation [32].”
Gong, F.-S., Gui, Q.-J., Lan, L.-H., Zhou, G., Wen, Q., Wei, Y.-J., Li, X.-P., & Cao, X.-H. (2025) · BMC Anesthesiology · doi:10.1186/s12871-025-03484-2 · Cited by 7 · see citing works
Koo, B., Na, H., Park, S.-H., et al. (2025) · Medicina · doi:10.3390/medicina61040646 · Cited by 5 · see citing works
“Emerging evidence from recent randomized trials and meta-analyses published be-tween 2022 and 2024 has broadened the understanding of the role of remimazolam beyond colonoscopy [7].”
Xu, Q., Qian, J., Zhang, S., Xia, F., Hu, H.-J., & Xiao, F. (2025) · Drug Design, Development and Therapy · doi:10.2147/dddt.s494426 · Cited by 5 · see citing works
“17 When combined with 4 μg/kg fentanyl and 0.15 mg cisatracurium, using a biased coin design method, Qu et al 18 determined that the effective dose (ED95) of remimazolam for inhibiting endotracheal intubation response in frail and non-frail elderly patients was found to be 0.297 mg/kg and 0.331…”
InfluentialElrosasy, A., Hindawi, M. D., Zeid, M. A., Awad, A. A., Abbas, A. W., Azzawi, M. A. D. A., Afifi, E., Amgad, A., Yasser, M., Sarhan, K., et al. (2025) · Naunyn-Schmiedeberg s Archives of Pharmacology · doi:10.1007/s00210-025-04557-2 · Cited by 4 · see citing works
Chudziński, K., Szuldrzynski, K. S., Jankowski, M., et al. (2025) · Journal of Clinical Medicine · doi:10.3390/jcm14186583 · Cited by 4 · see citing works
“Lidocaine, administered intravenously, has been shown to reduce propofol requirements by decreasing the pain response and enhancing sedation, while benzodiazepines such as midazolam can effectively reduce induction doses of propofol [57,58,60].”
Shintani, S., Mizuno, T., Matsubayashi, J., Okamoto, T., Hiroe, K., Nishida, A., Kitagawa, H., Inatomi, O., & Iwashita, T. (2025) · Journal of hepato-biliary-pancreatic sciences · doi:10.1002/jhbp.70018 · Cited by 4 · see citing works
“To date, most studies on the usefulness of remimazolam in endoscopic sedation have focused on screening procedures such as gastrointestinal endoscopy and colonoscopy [14].”
InfluentialMahendru, K., Kumar, A., Pandey, K., et al. (2025) · Anesthesia and Pain Medicine · doi:10.17085/apm.25203 · Cited by 4 · see citing works
Remimazolam: A Novel Frontier in Procedural Sedation for Emergency Medicine
Bradshaw, J. C., Lester, L., Greer, M. R., & Leon, D. A. (2025) · Journal of Emergency Medicine · doi:10.1016/j.jemermed.2025.09.031 · Cited by 5 · see citing works
Chen, I., Wang, W., Lai, P.-C., Ho, C.-N., Lin, C., Lin, Y., Huang, Y., & Hung, K. (2024) · Systematic Reviews · doi:10.1186/s13643-024-02707-w · Cited by 4 · see citing works
Yu, G., Zhou, C.-L., Zhu, M., et al. (2025) · Annals of Medicine · doi:10.1080/07853890.2025.2568985 · Cited by 3 · see citing works
“However, other previous reviews reported conflicting results that remimazolam had a reduced success rate of sedation during gastrointestinal endoscopy [31–33].”
Jin, O., Shao, W., Lai, J., et al. (2025) · Frontiers in Medicine · doi:10.3389/fmed.2025.1701785 · Cited by 3 · see citing works
Xu, L., Yin, Q., Liu, H., et al. (2026) · Frontiers in Medicine · doi:10.3389/fmed.2025.1713720 · Cited by 3 · see citing works
Xu, Y., Liu, Q., Yang, Z., et al. (2026) · European journal of medical research · doi:10.1186/s40001-026-04165-7 · Cited by 3 · see citing works
Τriantafyllou, Κ., Tziatzios, G., Tham, T., Beilenhoff, U., Lorenzo‐Zúñiga, V., Pouw, R. E., Roelandt, P. R., van Malenstein, H., Vilmann, P., Voiosu, T., et al. (2026) · Endoscopy · doi:10.1055/a-2898-6540 · Cited by 5 · see citing works
“Thus, the certainty the impact of distraction overall versus a specific type of distraction technique being utilized.”
Lu, X., Zhou, M., Lu, Y., et al. (2025) · Frontiers in Medicine · doi:10.3389/fmed.2025.1612779 · Cited by 2 · see citing works
Lv, Y., Duan, G., Wu, Y., Jiang, J., You, M., Wang, F., Wu, J., & Dai, H. (2025) · Journal of International Medical Research · doi:10.1177/03000605251372495 · Cited by 5 · see citing works
Liu, C., Li, J., He, J., Zhang, J., Bo, L., Yang, J., Ma, Y., Qin, J., Yang, Y., & Sun, Z. (2025) · Frontiers in Pharmacology · doi:10.3389/fphar.2025.1653593 · Cited by 2 · see citing works
Tang, L., Zhang, M., Guo, J., Zhang, M., Chen, W., Zhao, X., Huang, J., & Sheng, L. (2025) · Drug Design Development and Therapy · doi:10.2147/dddt.s564228 · Cited by 2 · see citing works
“…was no significant change in the dexmedetomidine and remimazolam groups, indicating that remimazolam can reduce the stress response and effectively maintain relative hemodynamic stability, which is consistent with the findings of Barbosa EC et al 17 on remimazolam in gastrointestinal microscopy.”
Youseif, A. L., Elmezayen, Z. W., Hammad, N., Younis, A. F., Ramadan, A. M., El-Khalifa, B. M., Saleh, A. R., Khalil, K. A., Hamouda, M. N., hamed, B., et al. (2026) · Digestive Diseases and Sciences · doi:10.1007/s10620-026-09678-z · Cited by 2 · see citing works
The hemodynamics of tracheal intubation in critically ill patients: a narrative review
Kotani, Y., Koroki, T., Hayashi, Y., et al. (2026) · Journal of Intensive Care · doi:10.1186/s40560-026-00877-4 · Cited by 2 · see citing works
“Remimazolam, a novel benzodiazepine, has shown a favorable hemodynamic profile in perioperative and cardiac surgical populations [18, 19], but evidence in ICU patients is still scarce.”
Yang, X., Pan, J.-Y., Gong, X., Lv, A., Liang, F., Liu, J., Li, D., Fu, S.-Z., Pan, A., Yu, L., et al. (2026) · Intensive Care Medicine · doi:10.1007/s00134-026-08381-x · Cited by 3 · see citing works
Chen, Y., Li, S., Wang, D., Zhang, W., Jiang, C., Su, N., & Bi, C. (2026) · Journal of Anesthesia · doi:10.1007/s00540-026-03722-y · Cited by 2 · see citing works
Lu, Y., Wang, X., Zou, H., et al. (2026) · Drug Design Development and Therapy · doi:10.2147/dddt.s609835 · Cited by 2 · see citing works
Lu, D.-Y., Zeng, Q., Zhang, A., Wei, W., Huang, H., Chen, W.-Q., Li, J., Yao, Y.-H., & Gu, Y. (2024) · BMJ Open · doi:10.1136/bmjopen-2024-089650 · Cited by 2 · see citing works
“13 25 26 Case reports suggest that remimazolam may be a viable choice for anaesthesia in surgery with neurophysiological monitoring because of its minimal effect on evoked potentials.”
Anesthetic considerations for outpatient interventional radiology procedures for cancer patients
Simon, N. B., Serafin, J., Shah, S. H., & Barnett, K. M. (2025) · Current Opinion in Anaesthesiology · doi:10.1097/aco.0000000000001515 · Cited by 2 · see citing works
Hong, Y. N., Meng, S., Liu, J., Zhao, Q., Peng, J., & Chen, Y. (2025) · Perioperative Medicine · doi:10.1186/s13741-025-00588-8 · Cited by 1 · see citing works
“Additionally, its sedative effects can be quickly reversed by flumazenil, making it safe and controllable (Barbosa et al. 2024).”
Zheng, J.-L., Sun, J., Han, Q., Shi, S.-R., Zhou, J., Wang, W.-L., Huang, X.-D., & Zhou, Z.-F. (2025) · Frontiers in Pharmacology · doi:10.3389/fphar.2025.1692105 · Cited by 2 · see citing works
Procedural sedation in high-risk patients
Robles, C. R. F., & Oprea, A. D. (2025) · Best practice & research. Clinical anaesthesiology · doi:10.1016/j.bpa.2025.10.005 · Cited by 1 · see citing works
Meng, Y., Song, Y., Gao, C., et al. (2025) · Drug Design Development and Therapy · doi:10.2147/dddt.s537897 · Cited by 1 · see citing works
Fukano, K., Fukuda, Y., Chiba, Y., et al. (2026) · BMJ Open · doi:10.1136/bmjopen-2025-109137 · Cited by 1 · see citing works
“18 Continuous infusion is generally preferred for procedures requiring stable and sustained sedation, such as prostate biopsy; however, supporting evidence remains limited.”
Huang, L., Xu, L.-N., Kuai, L.-Y., Gui, W.-H., Liu, L.-L., Lv, J., Ji, F., & Peng, K. (2026) · Annals of Medicine · doi:10.1080/07853890.2026.2622743 · Cited by 1 · see citing works
Zhang, D.-L., Liu, Y., Zhang, T., Shang, Y., Dong, H., & Niu, X.-G. (2026) · Frontiers in Medicine · doi:10.3389/fmed.2026.1819593 · Cited by 1 · see citing works
“These results are consistent with observations from prior clinical trials (31, 32), suggesting that the remimazolam-based regimen may be associated with less pronounced hemodynamic depression, possibly due to its minimal effects on vascular tone and myocardial contractility (33).”
Gu, Y.-L., Liu, P.-P., Sun, Y., Wang, Y.-T., Zheng, J.-J., & Shen, Y. (2026) · Paediatric anaesthesia · doi:10.1002/pan.70303 · Cited by 1 · see citing works
Perioperative remimazolam: A potential tool to prevent intraoperative hypotension?
Spence, J. D. (2024) · Journal of Clinical Anesthesia · doi:10.1016/j.jclinane.2024.111606 · Cited by 1 · see citing works
Time to Wake Up to Remimazolam’s Potential
Allen, M. B., & Goettel, N. (2024) · Journal of Neurosurgical Anesthesiology · doi:10.1097/ana.0000000000001009 · Cited by 1 · see citing works
Filipovic, M. G., & Guensch, D. P. (2025) · Journal of Cardiothoracic and Vascular Anesthesia · doi:10.1053/j.jvca.2025.01.010 · Cited by 1 · see citing works
Wen, X., Li, S., Wang, J., Bi, L., Sun, Y., Wang, X., Du, Y., Liang, Z., & Wei, C. (2025) · Anesthesia & Analgesia · doi:10.1213/ane.0000000000007614 · Cited by 1 · see citing works
Novotny, D., Páleník, J., Tyll, T., et al. (2025) · Clinical Endoscopy · doi:10.5946/ce.2024.347 · Cited by 1 · see citing works
“22,23 Recently evaluated alternative sedation protocols include the use of dexmedetomidine, 24 dexmedetomidine with ketamine, 25 remimazolam, 26 lidocaine, 27 or ciprofol.”
Shen, T., An, X., Yin, X., et al. (2024) · British Journal of Anaesthesia · doi:10.1016/j.bja.2024.04.059
Remimazolam in the perioperative setting: an answer in search of an ideal question
Derry, K. L., & Wijeysundera, D. N. (2024) · Canadian Journal of Anesthesia/Journal canadien d anesthésie · doi:10.1007/s12630-024-02899-8
“Indeed, several meta-analyses comparing the efficacy and safety of remimazolam vs propofol for these indications have been published, 3,4 as well as RCTs comparing it against sevoflurane for GA. 5,6 The present trial is only the second evaluating remimazolam among patients undergoing TAVI, 7 and the…”
Goktas, A. T., Muhtaroğlu, A., Kuloğlu, E., et al. (2025) · Medical Science and Discovery · doi:10.36472/msd.v12i3.1266
Liu, H., Zhou, M.-X., Chen, X., Esmaeili, E., Sun, M., & Wu, Z.-L. (2025) · PLoS ONE · doi:10.1371/journal.pone.0319044
“A multitude of clinical trials have showcased its safety and efficacy during induction and maintenance of general anesthesia, in comparison with propofol [9,10].”
Remimazolam: back to the future
Romagnoli, S., & Filippo, A. D. (2025) · Minerva Anestesiologica · doi:10.23736/s0375-9393.24.18665-8
Anesthésie pour endoscopie digestive
Abbas, L., Weiss, E., & Tanaka, S. (2025) · Le Praticien en Anesthésie Réanimation · doi:10.1016/j.pratan.2025.04.003
Safety of remimazolam versus propofol in elderly patients undergoing gastrointestinal endoscopy
Li, X.-M., Zhao, Z.-M., & Li, Y.-N. (2025) · Asian Journal of Surgery · doi:10.1016/j.asjsur.2025.02.245
Shang, J., Ma, X., Xin, Z., et al. (2025) · Respiratory Medicine · doi:10.1016/j.rmed.2025.108186
Snooze but don't lose: Remimazolam for sedation in gastrointestinal endoscopy
Nakai, Y. (2025) · Digestive Endoscopy · doi:10.1111/den.15063
“Those results were in line with previous reports 4 suggesting the safety of remimazolam.”
Ma, B., Zhang, N., Huang, R., et al. (2025) · PLoS ONE · doi:10.1371/journal.pone.0326043
Cha, B.-Z., Hu, S. H., Chen, N., et al. (2025) · BMC Anesthesiology · doi:10.1186/s12871-025-03235-3
Qian, Y., Hou, W., Yang, L., et al. (2025) · BMC Anesthesiology · doi:10.1186/s12871-025-03290-w
“Current evidence has indicated that remimazolam anesthesia has significant safety advantages in short-duration surgeries, with lower incidences of hypotension, intervention-required hypotension, and bradycardia compared to propofol anesthesia [23].”
Guo, N., Liu, Y., Li, M., et al. (2025) · Research Square · doi:10.21203/rs.3.rs-7344122/v1
Abdallfatah, A., Beshay, B., Nasseem, M., Tahhan, I., Kloub, M. N., Machchhar, R., Daoud, S., Hamed, M., & Abosheaishaa, H. (2025) · Perioperative Care and Operating Room Management · doi:10.1016/j.pcorm.2025.100569
Xu, L., Yin, Q., Liu, H., et al. (2025) · Research Square · doi:10.21203/rs.3.rs-7472714/v1
Sun, P., Tan, Z., Liang, L., et al. (2025) · Frontiers in Pharmacology · doi:10.3389/fphar.2025.1685312
Liu, M. T., Greer, D., Chou, I., et al. (2025) · Side effects of drugs annual · doi:10.1016/bs.seda.2025.08.015
Asgari, G., Amini, A., Vahedi, P., Tabatabavakili, Y., Mužı́k, J., Nazari, E., & Aldaghi, T. (2025) · Journal of Cellular & Molecular Anesthesia · doi:10.5812/jcma-166293
Jg, L., Li, B., Xu, G., et al. (2026) · BMC Medical Education · doi:10.1186/s12909-025-08562-0
“However, the increasing use of new drugs such as remimazolam, along with the application of high-flow nasal oxygen, suggests potential enhancements in sedation safety [31, 32].”
Vijayasimha, M., & Srikanth, M. (2026) · Journal of Anesthesia · doi:10.1007/s00540-026-03669-0
“…context: in procedural sedation for gastrointestinal endoscopy, pooled data indicate lower hypotension risk versus propofol, while in hypertensive patients undergoing neurosurgery, remimazolam and propofol showed broadly comparable hypotension incidence with nuanced time-point differences [4, 5].”
Update on total intravenous anesthesia in children
Quintão, V. C., Carlos, R. V., & von Ungern-Sternberg, B. S. (2026) · Current Opinion in Anaesthesiology · doi:10.1097/aco.0000000000001635
Niu, K., Li, L., Wu, X., et al. (2026) · BMC Anesthesiology · doi:10.1186/s12871-026-03793-0
“Currently, propofol is often combined with remimazolam, esketamine, and opioids for procedural sedation, improving both safety and patient comfort [28– 30].”
Sasaki, K., Ishikawa, C., Kondo, Y., et al. (2026) · British Journal of Anaesthesia · doi:10.1016/j.bja.2026.02.028
Zhou, Y.-K., Wu, W., Zhang, Y., Peng, Y., Jiang, W.-C., Zhang, X.-J., Ju, F., & Xie, A. (2026) · Frontiers in Medicine · doi:10.3389/fmed.2026.1793528 · Cited by 2 · see citing works
“Across all published meta-analyses, remimazolam demonstrates significantly reduced respiratory depression compared with propofol, with risk ratios ranging from 0.35 to 0.47 (9–12, 53 ).”
InfluentialJiang, H., Xie, Y., Qin, X., Liu, Q., Zhang, Y., Ge, C., & Mamtili, I. (2026) · Frontiers in Pharmacology · doi:10.3389/fphar.2026.1740424 · Cited by 1 · see citing works
“In addition, remimazolam-opioid regimens also demonstrated a favourable safety profile, particularly in relation to hypotension and bradycardia (Barbosa et al., 2024).”
Xu, Z., Lu, J., Saeed, S., et al. (2026) · European Journal of Pharmacology · doi:10.1016/j.ejphar.2026.178859
Song, J., Ge, T., Liu, J., et al. (2026) · Frontiers in Pharmacology · doi:10.3389/fphar.2026.1796709
“Similarly, remimazolam was found associated with significantly lower rates of respiratory depression and hypotension for sedation in gastrointestinal endoscopic procedures (Barbosa et al., 2024).”
Xie, W., Fang, X., Shi, Z., et al. (2026) · BMC Anesthesiology · doi:10.1186/s12871-026-03870-4
“Similarly, studies in endoscopic sedation reported a lower incidence of respiratory depression and cardiovascular instability with remimazolam [18].”
InfluentialMeng, J., Deng, X.-S., Han, R., et al. (2026) · BMC Anesthesiology · doi:10.1186/s12871-026-03909-6
“Remimazolam is a novel ultrashort-acting benzodiazepine characterised by rapid onset (1–2 min), short duration of action, and predictable recovery (10–40 min) [12–14].”
Xu, S., Wan, Q., Li, T., Shu, Y., Guo, Y., & Li, J. (2026) · BMC Gastroenterology · doi:10.1186/s12876-026-04961-9 · Cited by 1 · see citing works
“Remimazolam is an ultra-short-acting benzodiazepine, and has shown promise in reducing adverse events, including respiratory depression and hypotension, in procedures like gastrointestinal endoscopy and general anesthesia [10, 11].”
Bonura, G. F., Soriani, P., Gualandi, N., et al. (2026) · Journal of Clinical Medicine · doi:10.3390/jcm15114281
“In addition, five meta-analyses, three of which specifically focused on elderly populations, have consistently reported comparable efficacy between remimazo-lam and propofol, with a superior safety profile for remimazolam, particularly regarding respiratory and hemodynamic adverse events [39–43].”
Zhang, Y., Song, Q., Xie, K.-J., Ou, Z.-J., & Mo, L. (2026) · Perioperative Medicine · doi:10.1186/s13741-026-00713-1
“A systematic review and meta-analysis involving 3,450 participants also demonstrated no significant difference in PONV (Barbosa et al. 2024).”
de Amorim, D. R. S. G., Valerio, F. G., Silva, R. P., et al. (2026) · Journal of Neurosurgical Anesthesiology · doi:10.1097/ana.0000000000001128
Wang, T., Wang, Y., Liao, Z., et al. (2026) · BMC Anesthesiology · doi:10.1186/s12871-026-04018-0
Safety Signals of Remimazolam Require Procedure-Specific Interpretation
Qiu, L., Tang, J., & Yue, C.-C. (2026) · Digestive Diseases and Sciences · doi:10.1007/s10620-026-10074-w
- Authors
- Barbosa, E. C., Espírito Santo, P. A., Baraldo, S., & Meine, G. C.
- Affiliations
- Universidade Evangelica de Goiás (BR)
- Hospital de Câncer de Barretos (BR)
- Universidade Feevale (BR)
- Corresponding author
- Meine, Gilmara Coelho
- Venue
- British Journal of Anaesthesia
- Publisher
- Elsevier BV
- Published
- 2024-06
- Volume
- 132
- Issue
- 6
- Pages
- 1219-1229
- ISSN
- 0007-0912 (ISSN-L)
- OpenAlex
- W4392383825
- Cited by
- 111
- References
- 55
- Citations by year
- 2026: 40 · 2025: 52 · 2024: 19
- FWCI
- 12.53
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Licence
- Locations
- British Journal of Anaesthesia (publishedVersion)
- PubMed (publishedVersion)
- Funders
- Brigham and Women's Hospital
- Topics
- Health Sciences › Medicine › Anesthesiology and Pain Medicine › Anesthesia and Sedative Agents
- Health Sciences › Veterinary › Small Animals › Veterinary Pharmacology and Anesthesia
- Health Sciences › Medicine › Anesthesiology and Pain Medicine › Airway Management and Intubation Techniques
- Keywords
- remimazolam, propofol, procedural sedation, gastrointestinal endoscopy, short-acting opioids, respiratory depression, hypotension, bradycardia, sedation success rate, induction period, patient satisfaction, endoscopist satisfaction, drug safety comparison, opioid-sparing sedation, meta-regression
- MeSH terms
- Benzodiazepines, Humans, Hypnotics and Sedatives, Propofol, Randomized Controlled Trials as Topic, Endoscopy, Gastrointestinal
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Claims read by deepseek-v4.1-flash under definition version 3 (extract-v3) on 2026-10-11.
Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-10-11.
Cited sources are checked by gpt-6-sol.
Statistics and arithmetic are recomputed, not judged.
Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.
What counts as a claim ›How we measure confidence ›How we check this ›
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