CLINICAL CASES FOR ANESTHESIA PROFESSIONALS

GENERIC SUGAMMADEX, A GAME-CHANGER

Richard Novak, MD Oct 7, 2026 0 Comments

Anesthesia professionals are often unaware of the cost of the drugs they administer, but costs are relevant to the institutions where we work. The muscle relaxant reversal agent sugammadex (Bridion) is the most significant advance in anesthesiology in the past 15 years. Sugammadex reverses the paralysis of muscle relaxants such as rocuronium in seconds. Sugammadex forms a complex with rocuronium, resulting in a reduction in the amount of the rocuronium available to bind to the neuromuscular junction. A past problem with sugammadex was its high acquisition cost of $160 for a 200 mg vial, compared to the lower cost of administering the alternative slower-acting combination of generic neostigmine/glycopyrrolate to reverse rocuronium. As of July 2026, the acquisition cost of sugammadex is only $9.50 per 200 mg vial at the multispecialty surgery center in California where I’m the Medical Director. This 94% discount makes the quick and reliable reversal of rocuronium paralysis inexpensive. Clinicians can now acutely paralyze a patient with 0.6 – 1.0 mg/kg of intravenous rocuronium, see muscle relaxation within 1 minute, and if needed they can reverse this paralysis in seconds with an inexpensive dose of generic sugammadex.

This change makes succinylcholine even more of a dinosaur. Succinylcholine has the advantage of being an ultrafast paralytic drug useful for airway emergencies, but succinylcholine has more than 10 significant side effects, including postoperative muscle pain, the risk of hyperkalemia in susceptible patients, and the risk of malignant hyperthermia. For decades no responsible anesthesia professional would start a case without succinylcholine being available, should he or she need to acutely paralyze a patient for airway management. To control an airway with acute paralysis, nothing was faster or shorter acting than succinylcholine, but few drugs had as many side effects.

Succinylcholine remains an important drug in the emergency setting of pediatric laryngospasm, where a tiny patient can become hypoxic during mask induction in seconds if their vocal cords clamp together. When there’s no IV in place, an intramuscular dose of succinylcholine 4 mg/kg will affect paralysis and relieve laryngospasm. But intramuscular rocuronium 1 mg/kg has been described as a rapid and effective alternative to intramuscular succinylcholine to treat pediatric laryngospasm.

What about the emergency anesthetic on a patient with a full stomach who requires a rapid-sequence induction with cricoid pressure and intubation? For years anesthesia professionals were taught that succinylcholine was the appropriate muscle relaxant, because of its ultra-short onset time and its short offset time. But note that the offset time of paralysis after a 0.6 mg/kg paralysis dose of succinylcholine is 4 to 6 minutes. If one is unable to intubate the patient and is unable to do successful mask ventilation, a patient may become hypoxic in 4 – 6 minutes time. The dogma that short-acting succinylcholine will wear off in time for a patient to begin breathing on their own is flawed, because after 4 to 6 minutes of hypoxia a patient may incur irreversible brain anoxia.

An alternative approach for rapid sequence induction at present is to administer rocuronium 1.2 mg/kg (85 mg for a 70 kg patient). https://pmc.ncbi.nlm.nih.gov/articles/PMC7808042/ If one is unable to intubate the patient and is unable to do successful mask ventilation, one can completely reverse the rocuronium paralysis with a dose of 16 mg/kg of sugammadex, (1120 mg for a 70-kilogram patient). A 1120 mg dose of sugammadex would be six 200 mg ampules, at a cost of 6 X $9.50 = $57, a trivial cost. At the previous cost of 6 X $160 = $960, many facilities simply would not condone purchasing large quantities of sugammadex to make this approach possible.

What about the rare but serious issue of sugammadex-induced anaphylaxis? In a study of 19 case reports and series, 25 cases of anaphylaxis were confirmed via allergy testing to be caused by sugammadex or sugammadex-rocuronium complex, for a total incidence between 0.02% and 0.04% (one in 500 to 1 in 250). A 2018 study showed only one case of anaphylaxis to sugammadex out of 64,000 patients, for an incidence of 0.0016%. Additional population studies are needed to get a more accurate global incidence rate. A PubMed search for “lethal sugammadex anaphylaxis” yields zero cases.

Sugammadex does not reverse the neuromuscular block of cisatracurium, atracurium, or mivacurium, reducing the utility of these drugs.

For practitioners who still favor using succinylcholine, may someone administer that drug to you for your next anesthetic and surgery. Let me know how it feels to have succinylcholine-induced myalgias the following day. Patients tell me it feels like they were hit by a bus.

I’d advise we all stick with rocuronium, especially now that inexpensive sugammadex is available for reversal.