Sugammadex versus neostigmine for routine reversal of rocuronium block in adult patients: A cost analysis

J Clin Anesth. 2020 Dec;67:110027. doi: 10.1016/j.jclinane.2020.110027. Epub 2020 Sep 25.


Study objective: This report analyzes the comparative costs, efficacy and side effects of a newer, more expensive reversal drug, sugammadex, with its generic counterpart, neostigmine combined with glycopyrrolate, or no reversal agent when used routinely to reverse rocuronium-induced neuromuscular blockade in adult patients.

Design: Cost analysis.

Methods: We constructed a decision model to analyze the costs associated with the choice of reversal drug and differences in reversal time, occurrence of postoperative nausea or vomiting (PONV), and residual blockade requiring unplanned postoperative mechanical ventilation (UPMV). We selected variables that demonstrated meaningful differences in meta-analyses of published studies and/or had significant associated costs. We used data from local hospital system information, meta-analysis of published studies, and the general literature to construct base-case scenarios and sensitivity analyses. We performed the analysis from the perspective of a single hospital system. Costs were in 2019 U.S. dollars.

Results: Cost analysis suggested that reversal with sugammadex is preferable to neostigmine or no reversal drug when operating room (OR) time was valued at ≥$8.60/min (base case $32.49/min). Net costs of sugammadex were less than no treatment or neostigmine reversal when the probability of UPMV exceeded 0.019 and 0.036, respectively. Neither sugammadex nor neostigmine reversal was preferable to no treatment in a base-case analysis that considered the effect of the reversal agent on only drug and PONV costs, disregarding costs of OR time or UPMV.

Conclusions: Routine reversal with sugammadex is preferable to choosing neostigmine or no reversal drug when accounting for potential savings in OR time. Sugammadex might also be a reasonable choice for patients at high risk of UPMV. If the cost of OR time is not considered, the analysis does not support the routine use of sugammadex in patients with perceived increased risk or solely to reduce PONV.

Keywords: Adult; Cost analysis; Gamma-cyclodextrins; Neostigmine; Neuromuscular blocking agents; Sugammadex.

Publication types

  • Meta-Analysis

MeSH terms

  • Adult
  • Cholinesterase Inhibitors / adverse effects
  • Costs and Cost Analysis
  • Humans
  • Neostigmine / adverse effects
  • Neuromuscular Blockade* / adverse effects
  • Neuromuscular Nondepolarizing Agents* / adverse effects
  • Rocuronium
  • Sugammadex / adverse effects
  • gamma-Cyclodextrins* / adverse effects


  • Cholinesterase Inhibitors
  • Neuromuscular Nondepolarizing Agents
  • gamma-Cyclodextrins
  • Sugammadex
  • Neostigmine
  • Rocuronium