Remimazolam versus propofol for endoscopy sedation in elderly patients: a systematic review, meta-analysis and trial sequential analysis

INTRODUCTION: Procedural sedation is crucial in gastrointestinal endoscopy, where propofol is commonly used but may lead to cardiovascular and respiratory side effects. Remimazolam, a new drug, offers advantages such as rapid onset and recovery. The sedation protocols for this population vary, requiring tailored titration of sedatives. The comparative safety of these drugs in elderly patients undergoing procedural sedation remains unclear, as previous studies primarily focus on the general population. We aimed to compare the safety profiles of remimazolam and propofol in this context. in elderly patients undergoing procedural sedation for gastrointestinal endoscopy. EVIDENCE ACQUISITION: We searched MEDLINE, EMBASE and Cochrane Library for randomized controlled trials (RCTs) comparing propofol with remimazolam in elderly patients undergoing procedural sedation. Our outcomes were the incidence of adverse effects. A trial sequential analysis (TSA) was conducted on all outcomes to assess the adequacy of the sample size in supporting our findings. EVIDENCE SYNTHESIS: We selected 7 RCTs including 1499 patients, of whom 764 (50.96%) were randomized to receive remimazolam. Remimazolam exhibited a significantly lower risk of adverse events, including hypoxemia, respiratory depression, hypotension, bradycardia, and injection pain, compared to propofol. Incidences of PONV, dizziness and headache, did not significantly differ between the groups. The findings of the TSA indicated that our sample size was sufficiently large to render further studies inconsequential for most outcomes. CONCLUSIONS: Our findings suggest that in elderly patients having gastrointestinal endoscopy, remimazolam could be safer than propofol. This population may benefit from remimazolam's lower risk of adverse events, notably hypoxemia and respiratory depression.