Sir, intravenous (IV) sedation is frequently used in dentistry for treating adult patients with dental phobia or conditions which are aggravated by stress. Midazolam is currently the drug of choice in the UK for this procedure but recently remimazolam (Byfavo, Paion) following its approval by the UK Medicines & Healthcare products Regulatory Agency (MHRA) in June 2021 is being considered by clinicians as a more effective alternative pending the establishment of official guidance.
Remimazolam is an ultra-short-acting benzodiazepine with approved use in the US, China and the EU for procedural sedation. Unlike midazolam, remimazolam is metabolised by non-specific tissue esterases so does not rely on the cytochrome-dependent pathways of the liver meaning dose adjustments are not required in patients with either hepatic or renal impairment.1,2 Remimazolam can, like midazolam, be reversed with flumazenil, but its onset and offset is more rapid, offering faster induction and recovery times for patients as well as a more predictable duration of action and a superior safety profile to midazolam.3
The Society for the Advancement of Anaesthesia in Dentistry (SAAD) has called on the Intercollegiate Advisory Committee for Sedation in Dentistry (IACSD) to issue updated guidance to include remimazolam.4 Its last guidance was in 2020 which predates the approval of remimazolam use in the UK and without this specific guidance its use is yet to be implemented into clinical settings. We look forward to clearer guidance being provided and the implementation of remimazolam into routine IV dental sedation.
References
Stöhr T, Colin P J, Ossig J et al. Pharmacokinetic properties of remimazolam in subjects with hepatic or renal impairment. Br J Anaesth 2021; 127: 415-423.
Electronic Medicines Compendium (EMC). Byfavo 20 mg powder for solution for injection. Available at https://www.medicines.org.uk/emc/product/12746/smpc (accessed December 2022).
Kim K M. Remimazolam: pharmacological characteristics and clinical applications in anesthesiology. Anesth Pain Med (Seoul) 2022; 17: 1-11.
The Dental Faculties of the Royal Colleges of Surgeons and the Royal College of Anaesthetists. Standards for conscious sedation in the provision of dental care (V1.1). Report of the intercollegiate Advisory Committee for Sedation in Dentistry 2020. Available at: https://www.rcseng.ac.uk/dental-faculties/fds/publications-guidelines/standards-for-conscious-sedation-in-the-provision-of-dental-care-and-accreditation/ (accessed January 2023).
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Wootton, J., Forrest, M. Awaiting remimazolam guidance. Br Dent J 234, 73 (2023). https://doi.org/10.1038/s41415-023-5475-8
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DOI: https://doi.org/10.1038/s41415-023-5475-8