Efficacy and safety of remimazolam in endoscopic sedation-A systematic review and meta-analysis
Open accessAbstract
Background: The aim of this systematic review and meta-analysis was to investigate the efficacy and safety of remimazolam in clinical endoscopic procedure sedation. Methods: The authors searched the databases of PubMed, Embase, and Cochrane Library for studies published until January 2, 2021, that reported remimazolam sedation for endoscopic procedures. The sedative efficiency and the incidence of adverse events were assessed as outcomes. Cochrane Review Manager Software 5.3 was used to perform the statistical analyses. Results: Seven relevant studies involving a total of 1,996 patients were identified. We conducted a meta-analysis of the different controls used in the studies, that is, the placebo, midazolam, and propofol. The results demonstrated that remimazolam had a strong sedative effect, and its sedative efficiency was significantly higher than that of placebo [OR = 0.01, 95% CI: (0.00, 0.10), I2 = 30%, p <0.00001]. The sedative efficiency of remimazolam was significantly higher than that of midazolam [OR = 0.12, 95% CI: (0.08, 0.21), I2 = 0%, p < 0.00001] but lesser than that of propofol [OR = 12.22, 95% CI: (1.58, 94.47), I2 = 0%, p = 0.02]. Regarding the adverse events, remimazolam is associated with a lower incidence of hypotension than placebo and midazolam. Similarly, remimazolam was associated with a lower incidence of hypotension and hypoxemia than propofol. Conclusions: Remimazolam is a safe and effective sedative for patients undergoing endoscopic procedures. The sedative efficiency of remimazolam was significantly higher than that of midazolam but slightly lower than that of propofol. However, the respiration and circulation inhibitory effects of remimazolam were weaker than those of midazolam and propofol.
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Numerous published clinical experiments have shown the safety and efficacy of remimazolam as an anesthetic during sedative procedures and general anesthesia compared with midazolam or propofol.
“Compared with midazolam or propofol, numerous published clinical experiments have shown the safety and efficacy of remimazolam as an anesthetic during sedative procedures and general anesthesia (9,10).”
From Hemodynamic Influences of Remimazolam Versus Propofol During the Induction Period of General Anesthesia: A Systematic Review and Meta-analysis of Randomized Controlled Trials (2023) · cites this paper as [9]
The Abstract and Results report multiple endoscopic-sedation studies comparing remimazolam with midazolam or propofol, and the Discussion reports favorable efficacy and safety findings. The Discussion mentions one study of remimazolam as a general anesthetic compared with propofol; it does not establish that numerous clinical experiments showed those findings in general anesthesia. (LLM, conf=0.82)
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“However, no statistically significant difference was observed between both the intervention groups for the adverse effects as reported in the previous two meta-analyses except for the incidence of hypotension, for which remimazolam had a better outcome [16-17].”
BackgroundResultZhou, S., Yu, S. C., Bi, Y., Zhang, T., Pan, R., Yan, T., Deng, J., & Xu, A. (2025) · BMC Anesthesiology · doi:10.1186/s12871-025-03108-9 · Cited by 19 · see citing works
“While effective, its use is associated with some limitations, such as cardiovascular depression and pain injection [9, 10].”
New sedatives and analgesic drugs for gastrointestinal endoscopic procedures
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“Although the sedative efficiency of remimazolam is higher than that of midazolam, it is slightly lower than that of propofol.(25) In a meta-analysis comparing remimazolam and midazolam, the remimazolam group showed excellent results in terms of procedure success rates, proper sedation maintenance, and use of antagonis…”
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“The conclusions indicate no significant differences in induction time [21] or the depth of sedation achieved with remimazolam [22, 23].”
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“Another meta-analysis comparing the safety and efficacy of remimazolam and midazolam for endoscopic sedation, including five RCTs from the United States and two RCTs from China, was not performed the racial subgroup analysis either ( Zhu et al., 2021 ).”
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“13,14 Clinical evidence consistently demonstrates remimazolam’s superior hemodynamic stability compared to propofol, 15–19 with specific studies showing equivalent sedation efficacy but significantly reduced hemodynamic and respiratory complications when combined with opioids for elderly…”
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“Such result aligns with that reported by Zhu X, et al. who suggesting the weak impacts on inhibiting circulation and respiration compared with midazolam [27].”
ResultSelf-citationConsiderations for Satisfactory Sedation during Dental Implant Surgery
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“Additionally, it is safer to use than midazolam and propofol because of its minimal effects on respiratory and circulatory depression [97].”
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“Hypotension is less frequent when patients receive remimazolam compared to propofol and midazolam (5, 6).”
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“21 When comparing the reviews, five trials were included in both, but risk of bias in these trials were assessed differently.”
BackgroundInfluentialLi, 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
“However, despite its efficacy, propofol use is associated with adverse effects, including pain on injection, dose-dependent respiratory depression, hemodynamic instability, and, particularly in elderly patients, a potential increased risk of postoperative delirium (POD) [8].”
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
Xie, Z., Liao, Y., Chen, Q., Zhang, C.-M., Luo, J., Cao, H., Lin, Y., Lan, H., Huang, X., & Guan, X. (2025) · Annals medicus · doi:10.1080/07853890.2025.2534850 · Cited by 4 · see citing works
“…procedures [4,5] and general anesthesia [6–8] with the following characteristics of ideal anesthetic and sedative drugs: rapid onset and rapid offset [9,10], lower incidence of respiratory and circulatory depression [5–7, 11 ], and no Remifentanil is a novel ultrashort-acting opioid analgesic.”
InfluentialZhou, L., Huang, Y., Zhou, R., & Liu, S. (2024) · Medical Science Monitor · doi:10.12659/msm.944632 · Cited by 4
“More importantly, it has little effect on the cardiovascular sys-tem and spontaneous respiration [14,15].”
BackgroundRemimazolam for procedural sedation: a future sedative potential in the emergency department?
van der Have, A. J., Harmsen, B. L. T., van Leeuwen, B. V., Stollman, J., & Alexandridis, G. (2024) · Emergency Medicine Journal · doi:10.1136/emermed-2023-213805 · Cited by 4
Advantages of Remimazolam in Pediatric Anesthesia: A Narrative Review
Vittori, A., Fabio, C. D., Francia, E., Mascilini, I., Tarquini, R., Cecchetti, C., Marchetti, G., Marinangeli, F., Capitello, T. G., & Cascella, M. (2026) · Children · doi:10.3390/children13030348 · Cited by 3
“Compared with propofol, remimazolam was also associated with a significantly lower incidence of hypotension and greater overall hemodynamic stability [28,30].”
A randomized controlled study of remimazolam in preschool children undergoing adenotonsillectomy
Wu, Y., Wang, F., Zhu, K., Ling, L., & Zhang, W.-P. (2025) · Frontiers in Pharmacology · doi:10.3389/fphar.2025.1678650 · Cited by 2
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
Chen, J.-M., Li, X., Hu, Z., Zheng, Y., Mai, Y., & Zhang, Z.-Q. (2024) · Frontiers in Medicine · doi:10.3389/fmed.2024.1385998 · Cited by 2
“When used for procedural sedation, the sedative efficiency of RMZ was less than that of propofol as a novel IV sedative drug (17, 18).”
BackgroundSelf-citationQiao, X., Zhou, J., Zheng, X., Li, C., & Du, W. (2026) · Drug Design, Development and Therapy · doi:10.2147/dddt.s613603 · Cited by 1
“30 Recent randomized controlled trials have confirmed this finding.”
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
Sakurai, H., Miyazaki, K., Nakayama, A., Sasaki, M., Oowada, M., Sugawara, M., Kubo, Y., Mizobe, R., Katsumi, A., Ishizawa, M., et al. (2026) · JGH Open · doi:10.1002/jgh3.70351 · Cited by 1
Liu, J., Lu, K.-K., Chen, J.-H., Chen, W.-W., Pang, H., Song, J.-J., & Wang, Y. (2026) · PeerJ · doi:10.7717/peerj.21505
Hu, X., Fu, C., 毕国荣, Tan, Q., Ying, Y., Zhao, W., Cai, X., Yin, N., Wang, X., Liu, H. R., et al. (2026) · Annals of Medicine · doi:10.1080/07853890.2026.2700794
“…to its rapid onset, short emergence time, hepatic-and renal-independent metabolism, inactive metabolites, minimal accumulation during continuous infusion, limited respiratory and circulatory effects, and the availability of a specific antagonist, it is widely used in clinical anesthesia [6,7].”
Lúcio, M. J., Ferreira, S., Pereira, M., Barata, C., Correia, J., Mota, L., Abreu, T., Semedo, J., & Aljazeeri, J. (2026) · Pulmonology · doi:10.1080/25310429.2026.2691458
Lee, S. C., Chung, C., Ma, S., Choi, S., Park, S. Y., & Lee, T. (2026) · Anesthesia and Pain Medicine · doi:10.17085/apm.24154
“Remarkably low scores were recorded in the physical comfort and emotional state domains of the QoR-15, whereas previous studies comparing the recovery states of remimazolam TIVA and propofol TIVA observed no significant differences in physical status or emotional state [13,21,22].”
Yamamoto, T., Inoue, T., Yoshida, M., Seki, S., Kishimoto, N., & Seo, K. (2026) · Journal of Maxillofacial and Oral Surgery · doi:10.1007/s12663-025-02925-2
“Remimazolam was initially introduced for use in general anesthesia [4], but its application has expanded to include procedural sedation [5–12] and dental sedation [ 13 –19].”
A multi-site service evaluation on remimazolam for dental conscious sedation.
Yeo, X., Doshi, M., Clough, S., & Shehabi, Z. (2025) · British Dental Journal · doi:10.1038/s41415-025-8717-0
Remimazolam as a Novel Option for Procedural Sedation: A Narrative Review
Ziembicki, H., Skrzypska, N., Wróblewska, J., Zagaja, K., Wasilewska, P., & Wojtczak, O. (2025) · Cureus · doi:10.7759/cureus.91962
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Zhao, T.-Y.-M. (2024) · Asploro Journal of Biomedical and Clinical Case Reports · doi:10.36502/2024/asjbccr.6349
Hasnain, N., Khalid, M. A., Sadiq, M., Siddiqui, M. J., Anjum, A., Munaf, U., A.Budhwani, L., Haque, I., & Afshan, G. (2024) · F1000Research · doi:10.12688/f1000research.140834.1
Ma, Q.-R. (2025) · Advances in Clinical Medicine · doi:10.12677/acm.2025.15123670
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“Special Issue 3, 2022 Indian Journal of Pharmaceutical Sciences 130 sedative role[13,14].”
Background
- Authors
- Zhu, X., Wang, H., Yuan, S., Li, Y., Jia, Y., Zhang, Z., Yan, F., & Wang, Z.
- Affiliations
- The Central Hospital of Enshi Tujia and Miao Autonomous Prefecture (CN)
- Chinese Academy of Medical Sciences & Peking Union Medical College (CN)
- Corresponding author
- Yan, Fuxia
- Wang, Zaiping
- Venue
- Frontiers in Medicine
- Publisher
- Frontiers Media SA
- Published
- 2021-07-26
- Volume
- 8
- Pages
- 655042-655042
- ISSN
- 2296-858X (ISSN-L)
- PMC
- PMC8350069
- OpenAlex
- W3184472250
- Cited by
- 75
- References
- 36
- Citations by year
- 2026: 7 · 2025: 15 · 2024: 24 · 2023: 16 · 2022: 12
- FWCI
- 3.55
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Licence
- Locations
- Frontiers in Medicine (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
- Informationszentrum Lebenswissenschaften (ZB MED) (submittedVersion, cc-by)
- Funders
- National Natural Science Foundation of China (81760257)
- Chinese Academy of Medical Sciences
- Topics
- Health Sciences › Medicine › Anesthesiology and Pain Medicine › Anesthesia and Sedative Agents
- Health Sciences › Veterinary › Small Animals › Veterinary Pharmacology and Anesthesia
- Health Sciences › Medicine › Oncology › Colorectal Cancer Screening and Detection
- Keywords
- remimazolam, procedural sedation, endoscopy, sedation efficacy, adverse events, hypotension, hypoxemia, midazolam, propofol, benzodiazepines, respiratory depression
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