Comparison of Remimazolam and Midazolam for Sedation During Endoscopic Retrograde Cholangiopancreatography‐Related Procedures

TL;DR

This study compares remimazolam and midazolam for sedation during ERCP procedures, finding that remimazolam allows patients to wake up and be discharged faster.

Contribution

The study provides new evidence on the faster recovery time and reduced antagonist use with remimazolam compared to midazolam for ERCP sedation.

Findings

Remimazolam resulted in a significantly shorter time to patient awakening and readiness for discharge compared to midazolam.

The rate of antagonist use for awakening was significantly lower with remimazolam than with midazolam.

Sedation success and adverse event rates were not significantly different between the two drugs.

Abstract

Remimazolam is an ultra‐short‐acting benzodiazepine recently approved for endoscopic procedures in Japan as a sedative agent. We aimed to compare the efficacy and safety of remimazolam and midazolam for endoscopic retrograde cholangiopancreatography (ERCP)‐related procedures.

ERCP‐related procedures performed under sedation with remimazolam (between August 2025 and November 2025) and midazolam (between April 2025 and July 2025) were retrospectively reviewed. The primary outcome was the time from the end of the procedure to patient awakening and readiness for discharge. The secondary outcomes included sedation success throughout the procedure, time from the initial dose to achieving sedation, dosage, rate of antagonist use for awakening, and sedation‐related adverse events.

Eighty‐eight patients underwent ERCP‐related procedures with remimazolam and 86 with midazolam. The median times from the end of the procedure to patient awakening and readiness for discharge with remimazolam and midazolam were 2 min (interquartile range [IQR], 1–3) and 4 min (IQR, 3–5), respectively. Sedation with remimazolam required a shorter time to awaken than sedation with midazolam (p < 0.01). Furthermore, the rate of antagonist use for awakening was significantly lower with remimazolam than with midazolam (p < 0.01). The success rate of sedation, median time from the initial dose to achieving sedation, and rate of sedation‐related adverse events were not significantly different between groups (p = 0.49, 0.13, and 0.27, respectively).

Remimazolam demonstrated significantly shorter time to patient awakening, suggesting a safer and more efficient discharge process after ERCP‐related procedures.

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