Anesthetic efficacy with remimazolam compared with propofol: a systematic review and meta-analysis of randomized controlled trials

Background: Remimazolam is a novel, ultra-short-acting benzodiazepine. This systematic review and meta-analysis compared the anesthetic efficacy and safety of remimazolam versus propofol for procedural sedation and general anesthesia. Method: A comprehensive search of PubMed, EMBASE, Web of Science, and the Cochrane Central Register of Controlled Trials was conducted through 26 July 2024. Randomized controlled trials comparing remimazolam and propofol for procedural sedation or general anesthesia were included. The primary outcome was the success rate of sedation or general anesthesia. Data were analyzed using fixed and random-effects models to calculate pooled risk ratios (RRs), mean differences, 95% confidence intervals (CIs), and P values. Results: Twenty-seven studies involving 7,283 patients met the inclusion criteria. Sedation and general anesthesia success rates were comparable between remimazolam and propofol (RR: 0.99; 95% CI: 0.97–1.00; P = 0.10; N = 4,858). While remimazolam had a longer time to awake, it was associated with significantly lower rates of hypotension and injection pain. Rates of nausea, vomiting, and discharge times were similar between the drugs. Subgroup analyses revealed that during procedural sedation, remimazolam resulted in longer awakening times and a reduced risk of hypoxemia. However, these effects were not observed in general anesthesia. Conclusion: Remimazolam and propofol achieved comparable success rates for sedation and general anesthesia. Remimazolam reduced hypoxemia risk but prolonged awakening times during procedural sedation. It also lowered the incidence of hypotension and injection pain across both procedural sedation and general anesthesia. Additional studies are needed to further clarify its role, particularly in general anesthesia.