Please provide the most current information related to utilization of remimazolam over propofol or midazolam for procedural sedation and if it is cost effective compared to traditional therapies.

Comment by InpharmD Researcher

Current evidence suggests that remimazolam is a promising alternative to propofol and midazolam for procedural sedation, particularly in endoscopy and bronchoscopy. Although sedation success rates were generally comparable across agents, differences in induction time, sedation duration, and other procedural outcomes were observed, potentially reflecting variations in dosing protocols and concomitant opioid use. Remimazolam appears to offer a more favorable safety profile, particularly regarding hemodynamic stability and respiratory depression, with some studies also reporting faster recovery and earlier discharge. Overall, remimazolam may be a viable alternative, especially in older adults and patients at increased risk of hemodynamic or respiratory complications. However, robust U.S.-based cost-effectiveness data remain limited, and additional high-quality comparative studies are needed to further define its role in routine clinical practice.

A literature search of PubMed and Google Scholar was conducted using combinations of the terms remimazolam, propofol, midazolam, procedural sedation, cost effective, and pharmacoeconomic analysis.

Background

A 2026 American Society for Gastrointestinal Endoscopy (ASGE) clinical practice update suggests that remimazolam combined with an opioid is a safe and effective regimen for minimal to moderate sedation during gastrointestinal endoscopy. Based on published literature and expert consensus, the update summarizes a meta-analysis of 15 randomized trials involving 4,516 patients: pooled sedation success was slightly lower with remimazolam than propofol (98.2% vs 99.1%; p= 0.01), whereas remimazolam was associated with lower risks of respiratory depression (risk ratio [RR] 0.41; 95% confidence interval [CI] 0.30 to 0.56), hypotension (RR 0.43; 95% CI 0.35 to 0.51), and bradycardia (RR 0.42; 95% CI 0.30 to 0.58), without significant differences in time to full alertness or anesthesia discharge. Compared with midazolam, a 205-patient randomized colonoscopy trial using concomitant fentanyl reported shorter time to discharge with remimazolam (29.9 vs 35.0 minutes; p= 0.012). Regarding cost-effectiveness, the update notes substantially higher acquisition costs than propofol, limited economic evidence, and no published US cost-effectiveness studies; although a Danish analysis suggested savings compared with midazolam and propofol, the authors emphasize that the economic relevance of modest recovery-time reductions remains uncertain and recommend pragmatic studies incorporating cost analyses. [1]

Several literature reviews and expert opinions have reported promising efficacy and safety outcomes with remimazolam for procedural sedation, attributed to its rapid onset, short duration of action, predictable recovery profile, ability to be titrated, and availability of flumazenil as a reversal agent. Evidence has primarily evaluated colonoscopy, upper gastrointestinal endoscopy, and bronchoscopy procedures. However, remimazolam has not been broadly incorporated into all procedural sedation guidelines, and long-term post-marketing data and cost-effectiveness analyses remain limited. [2], [3], [4], [5], [6]

A 2026 meta-analysis of 37 randomized controlled trials (RCTs; N= 8,533) evaluated the efficacy and safety of remimazolam versus propofol for sedation during gastrointestinal endoscopic procedures. Outcomes included sedation efficacy, procedural and recovery times, and adverse events. There were no significant differences in induction time, procedure time, sedation success, recovery time, or time to discharge. However, remimazolam was associated with a modestly longer total sedation time (mean difference [MD] 1.84 minutes; 95% CI, 0.61–3.07; p= 0.0033). Remimazolam demonstrated a significantly more favorable safety profile, with lower risks of hypotension (RR 0.42), bradycardia (RR 0.42), respiratory depression (RR 0.37), hypoxemia (RR 0.42), and injection pain (RR 0.11) compared with propofol. Patient satisfaction was higher with remimazolam, while endoscopist satisfaction was comparable. Subgroup analyses identified longer induction times with remimazolam during gastroscopy and colonoscopy, despite comparable sedation success rates; no significant differences were observed in ERCP procedures. Despite heterogeneity related to dosing regimens, sedation protocols, and outcome definitions, findings suggest that remimazolam provides comparable sedation efficacy with fewer hemodynamic and respiratory adverse events than propofol, supporting its use as an alternative for gastrointestinal endoscopic sedation, particularly in patients at risk of cardiovascular or respiratory compromise. [7]

A 2026 meta-analysis synthesized data from 9 RCTs (N= 1,251) of patients undergoing gastrointestinal (GI) endoscopy, comparing remimazolam and midazolam for moderate sedation. Key outcomes evaluated were sedation success, induction time, time to full alertness, recovery time, discharge time, procedure duration, and adverse event rates. Results demonstrated that sedation success rates were comparable between remimazolam and midazolam (risk ratio [RR] 1.49; 95% CI 0.95 to 2.32; p= 0.08), albeit with substantial heterogeneity (I²= 91%). However, remimazolam was associated with significantly reduced sedation induction (MD t4.39 minutes; p= 0.04), shorter time to full alertness (MD 4.65 minutes; p= 0.012), faster recovery time (MD 15.66 minutes; p<0.001), and earlier discharge (MD 7.62 minutes; p= 0.04). Patient satisfaction scores favored remimazolam (standardized MD [SMD] 0.34; p<0.01), while endoscopist satisfaction did not differ significantly. Subgroup analyses revealed that remimazolam’s advantages in sedation success and induction time were more pronounced in patients receiving concomitant opioids, reflecting synergistic sedation effects. Safety analysis showed that remimazolam significantly decreased the odds of hypotension (OR 0.47; p<0.001) and bradycardia (OR 0.59; p= 0.037) compared with midazolam, with no differences in other adverse events such as respiratory depression or hypoxemia. Despite some heterogeneity and variability in study designs, remimazolam’s ultrashort-acting pharmacokinetic profile translated into faster onset and offset of sedation, improving procedural efficiency and safety in GI endoscopic sedation. [8]

A 2026 meta-analysis of 13 RCTs involving 2,002 adults evaluated remimazolam versus propofol, midazolam, or dexmedetomidine for sedation during bronchoscopy, with searches conducted through May 14, 2025. Compared with propofol, remimazolam showed no significant difference in procedural success, defined as completion without rescue or alternative sedation (OR 0.55; 95% CI 0.11 to 2.61), but was associated with lower odds of hypotension (OR 0.35; 95% CI 0.23 to 0.55); patient satisfaction did not differ significantly, and wake-up time comparisons were inconclusive because of substantial heterogeneity. Compared with midazolam, remimazolam was associated with higher procedural success (OR 3.65; 95% CI 1.40 to 9.49) and shorter wake-up time (MD −4.72 minutes; 95% CI −8.05 to −1.39), with no significant differences in hypotension, hypoxemia, or tachycardia. Sedation onset and procedure duration did not differ significantly from propofol or midazolam. Interpretation was limited by substantial heterogeneity in several outcomes, few trials for some comparisons, and unavailable procedural success data from three propofol trials. Costs and cost-effectiveness were not evaluated. [9]

A 2025 meta-analysis of 14 randomized controlled trials involving 3,290 adults compared the safety and efficacy of remimazolam versus propofol for colonoscopy sedation, with searches conducted through January 2025. Remimazolam significantly reduced the risks of hypotension (relative risk 0.44; 95% CI 0.39 to 0.51), bradycardia (RR 0.36; 95% CI 0.25 to 0.53), respiratory depression (relative risk 0.32; 95% CI 0.22 to 0.45), and injection pain (relative risk 0.14; 95% CI 0.09 to 0.24). Procedure success rates did not differ significantly (97.4% vs 99.6%; RR 0.99; 95% CI 0.97 to 1.00; p= 0.0958). Remimazolam required longer to achieve target sedation (MD 15.97 seconds) but was associated with shorter emergence time (MD −0.91 minutes) and postprocedural unit stay (MD −2.20 minutes); however, heterogeneity was substantial for these outcomes (I²= 95% to 99%), and evidence certainty was low for emergence time and postprocedural stay. The analysis did not evaluate cost-effectiveness or directly compare remimazolam with midazolam; the authors identified higher remimazolam costs and limited availability as potential barriers and recommended further economic evaluation. [10]

A 2026 meta-analysis of 9 RCTs (N= 1,164) compared the efficacy and safety of remimazolam versus propofol for sedation during hysteroscopy. The analysis focused on procedural outcomes such as sedation success, recovery duration, total procedure time, as well as adverse events. The results revealed no significant differences between remimazolam and propofol in terms of sedation success (RR 0.99; 95% CI 0.86 to 1.13; p= 0.83), recovery duration (SMD 0.95; 95% CI –0.01 to 1.91; p= 0.05), or total procedural duration (SMD -0.13; 95% CI -0.27 to 0.01; p= 0.07). However, remimazolam demonstrated a superior safety profile by significantly reducing the incidence of injection pain (RR 0.07; 95% CI 0.02 to 0.20; p= 0.001), hypotension (RR 0.33; 95% CI 0.22 to 0.50; p= 0.001), and low SpO2/respiratory depression (RR 0.26; 95% CI 0.18 to 0.38; p= 0.001) compared to propofol. Conversely, remimazolam was associated with a markedly increased risk of hiccough (RR= 10.37; 95% CI 2.94 to 36.62; p= 0.001). No significant differences were observed in bradycardia, body movement, or postoperative nausea and vomiting (PONV) rates. Subgroup analyses suggested that an induction dose of 0.2 mg/kg remimazolam may optimize safety outcomes without compromising efficacy. The review highlighted limitations including single-center designs, all Chinese patient populations, variable opioid co-administration, and heterogeneous outcome definitions, underscoring the need for further multinational, well-controlled trials to confirm generalizability and refine dosing strategies. [11]

A 2026 meta-analysis examined the efficacy and safety of Remimazolam compared to Propofol, Dexmedetomidine, and Midazolam for sedation in adult patients undergoing flexible bronchoscopy. The analysis included 11 RCTs encompassing 1,884 patients, with 1,057 receiving Remimazolam and 827 assigned to comparator sedatives. Primary outcomes assessed were hypotension, bradycardia, and intraprocedural opioid consumption, while secondary outcomes included respiratory depression, hypoxia, patient satisfaction, sedation success, induction time, and recovery time. The meta-analysis found that Remimazolam significantly reduced the incidence of hypotension (RR 0.61; p= 0.0289), bradycardia (RR 0.39; p= 0.0069), respiratory depression (RR 0.44; p= 0.0002), and hypoxia (RR 0.60; 0.0227) compared to pooled sedatives, with moderate to low certainty of evidence. Compared to Propofol, Remimazolam notably decreased hypotension (RR 0.42; p<0.0001 and respiratory depression (RR 0.41; p= 0.0005) but was associated with a modestly increased induction time (MD 0.61 min; p= 0.002). Compared to Dexmedetomidine, Remimazolam improved patient satisfaction (SMD 0.23; p= 0.004), shortened recovery (MD -1.79 min; p<0.001) and induction times (MD -2.21 min; p<0.001), and reduced hypoxia incidence (RR 0.49; p= 0.0162). Compared to Midazolam, Remimazolam demonstrated higher sedation success rates (RR 2.03; p= 0.0002), shorter induction (MD -0.69 min; p= 0.047), and quicker recovery times (MD -4.49 min; p<0.001). No significant differences were observed in intraprocedural opioid consumption across groups. Despite these positive findings, substantial heterogeneity was noted in some outcomes, predominantly driven by methodological variations in two studies, and most data originated from trials conducted in China, which may limit generalizability. The analysis underscores Remimazolam's favorable safety and efficacy profile in flexible bronchoscopy sedation but highlights the need for further diverse, large-scale RCTs to confirm these results and standardize dosing strategies. [12]

A 2025 systematic review and meta-analysis compared remimazolam and propofol for procedural sedation and general anesthesia across 27 RCTs involving 8,315 patients (mostly from China, with some from Korea and Japan). The primary outcome was sedation/general anesthesia success rate, while secondary outcomes included time to awakening, discharge time, hypotension, hypoxemia, postoperative nausea/vomiting (PONV), and injection pain. Results showed no significant difference in sedation or anesthesia success rates (RR 0.99; 95% CI 0.97 to 1.00; p= 0.10; n= 4,858). However, remimazolam had lower risks of hypotension (RR 0.48; 95% CI 0.42 to 0.55; p<0.00001) and injection pain (RR 0.06; 95% CI 0.03 to 0.11; p<0.00001) compared to propofol. It also reduced hypoxemia during procedural sedation (RR 0.36; 95% CI 0.23 to 0.55; p<0.00001), though this was not significant in general anesthesia due to limited data. Awakening time was longer with remimazolam (mean difference [MD] 1.61 minutes; 95% CI 0.36 to 2.86; p= 0.01), but discharge times were similar (MD –0.01 minutes; 95% CI –5.46 to 8.65; p= 1.00). Incidences of PONV were comparable (RR 0.92; 95% CI 0.58 to 1.48; p= 0.74). [13]

Across additional pooled data, remimazolam demonstrated a safety and efficacy profile generally comparable to propofol in adults undergoing general anesthesia or procedural sedation. Remimazolam did not significantly increase emergence agitation, postoperative delirium, PONV, intraoperative awareness, or hypoxemia compared with propofol. Cognitive outcomes were also similar or favorable with remimazolam, with one meta-analysis reporting better postoperative Mini-Mental State Examination scores and no increased risk of postoperative delirium. In contrast, remimazolam consistently demonstrated greater hemodynamic stability, with lower risks of postinduction and intraoperative hypotension and, in elderly patients, lower rates of bradycardia and injection pain. PONV incidence was similar to propofol but lower when compared against volatile anesthetics. Although induction may be slower with remimazolam, emergence and extubation times were generally comparable to propofol. Notably, administration of flumazenil may shorten emergence and extubation times with remimazolam, whereas prolonged recovery may occur without antagonist administration. Overall, these findings suggest that remimazolam provides comparable anesthetic and recovery outcomes to propofol, with a potential advantage in hemodynamic stability, particularly in older or hemodynamically vulnerable patients. However, remimazolam may be associated with a higher risk of postoperative delirium in patients with American Society of Anesthesiologists (ASA) physical status III-IV, warranting further evaluation in this population. [14], [15], [16], [17], [18]

A 2025 review evaluated the use of remimazolam in cardiovascular anesthesia and procedural sedation across catheterization laboratory and cardiac operating room settings. In the catheterization laboratory, randomized and observational studies suggested that remimazolam provided effective anesthesia with greater hemodynamic stability and less vasopressor use than desflurane and propofol during radiofrequency catheter ablation, while flumazenil administration was associated with faster emergence and extubation compared with propofol. Preliminary evidence from cardiac catheterization and transcatheter aortic valve implantation (TAVI) also suggested effective sedation, rapid recovery, and generally favorable hemodynamic outcomes, although some TAVI data reported increased respiratory depression and vasopressor use with higher remimazolam doses. In the cardiac operating room, randomized controlled trials generally demonstrated less hypotension and vasopressor requirement during induction compared with propofol, with similar or favorable recovery outcomes, although higher remimazolam doses may increase hemodynamic fluctuations. Limited observational and case-based evidence also supported its use during cardiac surgery with cardiopulmonary bypass, including in elderly and high-risk patients, with no clear increase in postoperative delirium. Overall, the review concluded that remimazolam is a promising option for cardiovascular anesthesia because of its rapid onset and offset, reversibility with flumazenil, and favorable hemodynamic profile. However, evidence remains limited for several cardiac procedures, and additional high-quality studies are needed to establish optimal dosing, comparative efficacy and safety, and long-term outcomes. [19]

A 2024 systematic review and cost analysis synthesized 50 studies, including 29 RCTs, 6 cohort studies, and 15 case series, evaluating intravenous conscious sedation for prolonged oral surgery procedures such as dental extractions and implant surgeries in adults. The sedative agents included midazolam, dexmedetomidine, propofol, and remimazolam. Mean procedure durations were 31.3 minutes for extractions and 79.4 minutes for implant surgeries. Based on British National Formulary pricing and study-averaged dosages, midazolam was the least costly agent at <£0.10 per procedure, followed by remimazolam at £4.92, dexmedetomidine at £7.90, and propofol at £46.39. [20]

The risk of bias varied across studies, with blinding deficiencies being a common concern. Due to heterogeneity in sedation protocols and outcome reporting, a meta-analysis could not be performed. Instead, a comparative network approach was used to assess relative efficacy and satisfaction. Dexmedetomidine, propofol, and remimazolam generally provided greater patient and operator satisfaction, improved sedation quality, and shorter recovery times than midazolam, although at a higher cost. Dexmedetomidine demonstrated favorable outcomes compared with midazolam both alone and with fentanyl. No direct comparisons between dexmedetomidine and remimazolam were identified. [20]

Overall, all four agents demonstrated clinical safety and efficacy for prolonged oral surgery. Midazolam may be preferred when cost is a priority, while dexmedetomidine or remimazolam may be favored when patient experience and rapid recovery are prioritized. Propofol may be less practical because of its higher cost and need for specialized training. Further comparative research, particularly between dexmedetomidine and remimazolam, is warranted. [20]

Literature Review

A search of the published medical literature revealed 7 studies investigating the researchable question:

Please provide the most current information related to utilization of remimazolam over propofol or midazolam for procedural sedation and if it is cost effective compared to traditional therapies.

Level of evidence

A - Multiple high-quality studies with consistent results Read more→

Please see Tables 1-7 for your response.

Safety And Efficacy Of Remimazolam Compared With Placebo And Midazolam For Moderate Sedation During Bronchoscopy
Design	Prospective, double-blind, randomized, multicenter, parallel-group trial N= 431
Objective	To evaluate the safety and effectiveness of remimazolam for moderate sedation during flexible bronchoscopy.
Study Groups	Group 1: Placebo (n= 60) Group 2: Remimazolam (n= 303) Group 3: Midazolam (n= 68)
Inclusion Criteria	Patients aged 18 years or older, scheduled to undergo a diagnostic or therapeutic flexible bronchoscopy, BMI less than or equal to 45 kg/m^2, SpO2 greater than or equal to 90% in ambient air or with no more than 2L/min of O2 support, a negative result for pregnancy.
Exclusion Criteria	Known sensitivity to benzodiazepines, flumazenil, opioids, naloxone, or a medical condition in which these agents are contraindicated, medical ventilation, tracheal stenosis, positive drugs of abuse screen or a history of drug or ethanol abuse within the last 2 years.
Methods	Eligible patients were randomized (5:1:1) to receive an initial dose of 25 to 75 ug of fentanyl and a single intravenous (IV) dose of 5.0 mg of remimazolam or an equal volume of placebo or 1 to 1.75 mg of midazolam as an additional open-label arm. Bronchoscopy was started when adequate sedation (MOAA/S score, 3) was achieved. In case of insufficient sedation after the first dose of trial medication, patients could receive a maximum of five remimazolam or placebo doses in any 15-min window, or a maximum of three doses of midazolam in any 12-min window in the open-label arm at intervals of > 2 min, as per the package insert. If sedation was still insufficient to begin the procedure, treatment failure was declared.
Duration	The study duration was < 28 days. Patients were screened within 21 days of bronchoscopy, with a follow-up telephone interview 4 to 7 days postprocedure.
Outcome Measures	Primary outcomes: Composite endpoint including the completion of the procedure, no requirement for rescue sedative. Secondary outcomes: Time to start of the procedure, time to peak sedation, time to ready for discharge, time to fully alert, recovery times, and procedural recall.
Baseline Characteristics		Placebo (n=59)	Remimazolam (n=303)	Midazolam (n=69)	p-value (Remimazolam vs Placebo)
	Age, years	63	62.7 ± 12.09	64	p=0.270
	Female	35 (59.3%)	164 (54.1%)	34 (49.3%)	-
	Ethnicity White Black or African American	46 (78%) 10 (16.9%)	263 (86.8%) 33 (10.9%)	49 (71%) 19 (27.5%)	- p=0.187
	Height, cm	167.1 ± 10.0	168.6 ± 9.50	170.0 ±9.87	p=0.272
	Weight, kg	77.7 ± 21.17	80.9 ± 20.21	83.0 ± 22.10	p=0.270
	BMI, kg/m2	27.9 ± 7.09	28.4 ± 6.39	28.0 ± 5.79	p=0.589
	The durations of bronchoscopy were 10.84 (± 10.45) min in the midazolam arm, 11.14 (± 12.31) min in the placebo arm, and 12.8 (±11.59) min in the remimazolam arm.
Results	Primary outcomes	Placebo	Remimazolam	Midazolam	p-value (vs Placebo)
	Procedure success (composite endpoint)	4.8%	80.6%	32.9%	p<0.0001
	Completion of the bronchoscopy	95.2%	97.1%	93.2%	-
	No administration of rescue sedative medication	9.5%	84.2%	46.6%	-
	No more than five total doses of study medication within any 15-min interval	84.1%	95.5%	86.3%	-
	Secondary outcomes	Placebo (Mean [95% CI])	Remimazolam (Mean [95% CI])	Midazolam (Mean [95% CI])	p-value (vs Placebo)
	Time from end of preocedure to fully alert, min	13.6 (8.1-24.0)	6.0 (5.2-7.1)	12 (5.0-15.0)	p=0.0001
	Time to fully alert from last dose of IMP/rescue, min	20 (15.3-31.0)	11.6 (10.0-12.8)	18 (15.0-20.1)	p=0.0001
	Time to ready for discharge from end of procedure, min	81 (70.0-100.0)	60 (57.0-63.0)	66 (62.0-72.0)	p=0.0004
	Time to ready for discharge from last dose of IMP/rescue, min	93 (75.0-107.0)	64 (62.0-68.8)	70 (67.0-87.0)	p=0.0002
	Time from end of study medication to back to normal, h	15.6 (7.7-20.3)	6.7 (5.7-8.5)	7.4 (5.2-16.8)	p=0.1165
	Bronchoscopy was started sooner in the remimazolam arm (mean, 6.4 ± 5.82 min) compared with placebo (17.2 ±4.15 min; P < 0.0001) and midazolam (16.3 ± 8.60 min). Remimazolam registered superior restoration of neuropsychiatric function compared with placebo and midazolam.
Adverse Events	Safety was comparable among all three arms, and 5.6% of the patients in the remimazolam group had serious treatment-emergent adverse events as compared with 6.8% in the placebo group.
Study Author Conclusions	Remimazolam administered under the supervision of a pulmonologist was effective and safe for moderate sedation during flexible bronchoscopy. In an exploratory analysis, it demonstrated a shorter onset of action and faster neuropsychiatric recovery than midazolam.
InpharmD Researcher Critique	The study was well developed using a double-blinded, randomized, multicenter study design. However, the trial endpoints were compared with placebo in terms of statistical significance rather than with the open-label midazolam arm. Thus, the statistical comparisons between remimazolam and midazolam are exploratory.

Table 1 References:
[21] Pastis NJ, Yarmus LB, Schippers F, et al. Safety and efficacy of remimazolam compared with placebo and midazolam for moderate sedation during bronchoscopy. Chest. 2019;155(1):137-146. doi:10.1016/j.chest.2018.09.015.

A Phase III Study Evaluating the Efficacy and Safety of Remimazolam (CNS 7056) Compared with Placebo and Midazolam in Patients Undergoing Colonoscopy
Design	Prospective, randomized, placebo and active-controlled, multicenter, parallel-group study comparing remimazolam to placebo in a double-blind manner, with an open-label midazolam arm. N= 458
Objective	To evaluate the sedative effect of remimazolam plus fentanyl versus fentanyl alone versus midazolam plus fentanyl.
Study Groups	Remimazolam (n= 296) Placebo (n= 60) Midazolam (n= 102)
Inclusion Criteria	Aged 18, scheduled to undergo a diagnostic or therapeutic colonoscopy, American Society of Anesthesiologists Physical Status (ASA-PS) Classification System risk class 1-3, body mass index 40 kg/m2, negative result of pregnancy test.
Exclusion Criteria	Known sensitivity to benzodiazepines, flumazenil, opioids, naloxone, or a medical condition such that these agents are contraindicated, chronic use of benzodiazepines and opioids for any indication, positive drugs of abuse screen or positive serum ethanol at baseline, a history of drug or ethanol abuse within the past 2 years.
Methods	Eligible patients were randomized into 1 of 3 groups: remimazolam, placebo, or open-label midazolam in a ratio of 30:6:10. Study medications were administered under the supervision of the endoscopist, without any involvement of an anesthesia specialist. Patients were given 50 to 75 mg of fentanyl before receiving study medications. Patients were randomized to receive an initial single intravenous dose of remimazolam 5.0 mg or an equal volume of placebo over 1 minute in a blinded manner, and colonoscopy was initiated when adequate sedation (MOAA/S score 3) was achieved. Sedation was maintained by injection of further top-up doses of remimazolam 2.5 mg (1 mL) or an equal volume of placebo not more than 2 minutes apart after assessment of the sedative effect. Patients who failed to achieve adequate sedation in any arm were rescued with midazolam dosed at the investigator’s discretion.
Duration	April 2015 and April 2016.
Outcome Measures	Primary outcome: Success of procedure as measured by completion of colonoscopy and no requirement for an alternative sedative and, in the case of remimazolam and placebo, no requirement for more than 5 top-ups of study medication within any 15-minute period. In the case of midazolam, no requirement for more than 3 doses in any 12-minute window. Secondary outcomes: Recovery times.
Baseline Characteristics		Remimazolam (n=296)	Placebo (n=60)	Midazolam (n=102)
	ASA-PS score I II III	95 179 22	11 45 4	37 61 4
	The mean age for the entire population was 54.4 (±10.12) years, and 50.3% were female. There were no significant differences between the study groups for any demographic factor.
Results	Endpoint	Remimazolam	Placebo	Midazolam
	Procedural success	91.3%	1.70%	25.2%
	Colonoscopy completed	97.7%	98.3%	98.1%
	No more than 5 “top-ups” in any 15 minute interval (for midazolam, 3 top-ups in any 12-minute interval)	94.0%	26.7%	45.6%
	Comparison	Difference in rates	95% Confidence Interval (95% CI)	p-value
	Remimazolam vs placebo	0.8961	(0.8505, 0.9416)	p< 0.0001
	Remimazolam vs midazolam	0.6603	(0.5705, 0.7501)	-
	Recovery times were consistently shorter for remimazolam compared with placebo (p < 0.001). The reported mean time from the end of the procedure to patients feeling completely back to normal was 3.2 hours in the remimazolam group, compared with 5.8 hours with placebo (hazard ratio of 1.750; 95% CI, 1.311-2.336; P < 0.0001). Mean recovery time was 6.1 hours in the midazolam group.
Adverse Events	The incidence of hypotension was 61.8% with midazolam, 41.7% for placebo, and 38.9% for remimazolam. The incidence of hypotension was the principal contributor to the main differences observed in treatment-emergent adverse events between remimazolam and midazolam. The rates of treatment-emergent adverse events with remimazolam, placebo, and midazolam were 73.6%, 78.3%, and 91.2%, respectively (p < 0.0001, remimazolam vs midazolam).
Study Author Conclusions	Remimazolam can be administered safely under the supervision of endoscopists for outpatient colonoscopy, and it allows faster recovery of neuropsychiatric function compared with placebo (midazolam rescue) and midazolam.
InpharmD Researcher Critique	Fentanyl plus remimazolam resulted in adequate sedation for outpatient colonoscopy. The authors explained that the study administered midazolam according to the instructions in the U.S. midazolam package insert which used a slower and more cautious administration of midazolam regimen than is commonly used in clinical practice. Thus, the times to achieve various sedation endpoints in this study are likely prolonged in the midazolam arm and may overstate the advantages of remimazolam with regard to the onset of sedation. However, the results likely understate the advantages of remimazolam for recovery because midazolam generally is administered more rapidly and in higher doses in clinical practice. The statistical comparisons between remimazolam and midazolam are only exploratory.

Table 2 References:
[22] Rex DK, Bhandari R, Desta T, et al. A phase III study evaluating the efficacy and safety of remimazolam (CNS 7056) compared with placebo and midazolam in patients undergoing colonoscopy. Gastrointest Endosc. 2018;88(3):427-437.e6. doi:10.1016/j.gie.2018.04.2351.

Remimazolam Besylate Versus Propofol for Procedural Sedation in Patients Undergoing Electrical Cardioversion: A Prospective, Noninferiority Cohort Study
Design	Prospective observational study N= 60
Objective	To assess the safety, feasibility, and clinical advantages of remimazolam compared to propofol for procedural sedation during electrical cardioversion
Study Groups	Remimazolam (n= 30) Propofol (n= 30)
Inclusion Criteria	Medical patients aged ≥18 years admitted to the electrophysiology (EP) Department for electrical cardioversion (ECV) for atrial arrhythmia, with sedation using either propofol or remimazolam
Exclusion Criteria	Critically ill patients, those with circulatory shock requiring vasopressors, or those who declined to participate
Methods	Patients received either propofol or remimazolam besylate for sedation. Propofol was administered as an initial bolus of 0.5 mg/kg, with additional doses of 10-20 mg every 2 minutes. Remimazolam was given as an initial bolus of 5 mg, with additional doses of 2.5 mg every 2 minutes. Sedation was monitored using bispectralindex (BIS) and Modified Observer’s Alertness/Sedationscale (MOAA/S) scale. The procedure included standard monitoring and was performed in the EP laboratory.
Duration	May 2024 to September 2024
Outcome Measures	Primary: Time to loss of consciousness Secondary: Adequacy of sedation, hemodynamic variations, time to recovery of consciousness, adverse drug events
Baseline Characteristics		Overall (N = 60)	Propofol (n = 30)	Remimazolam Besylate (n = 30)	p-value
	Age, years	70.50 [65.00-76.25]	70.50 [64.25-77.75]	70.50 [66.25-75.50]	0.935
	Male sex	39 (65.0%)	20 (66.7%)	19 (63.3%)	1
	BMI, kg/m²	25.86 [22.88-28.33]	26.90 [23.10-28.86]	25.00 [22.84-27.10]	0.252
	Active smoking	11 (18.3%)	7 (23.3%)	4 (13.3%)	0.505
	NYHA class 0	1 (1.7%)	1 (3.4%)	0 (0.0)	0.652
	NYHA class 1	41 (69.5%)	19 (65.5%)	22 (73.3%)	0.652
	NYHA class 2	9 (15.3%)	5 (17.2%)	4 (13.3%)	0.652
	NYHA class 3	7 (11.9%)	3 (10.3%)	4 (13.3%)	0.652
	NYHA class 4	1 (1.7%)	1 (3.4%)	0 (0.0)	0.652
	Chronic renal failure	6 (10.0%)	5 (16.7%)	1 (3.3%)	0.197
	Hypertension	36 (60.0%)	18 (60.0%)	18 (60.0%)	1
	History of stroke/TIA	2 (3.3%)	2 (6.7%)	0 (0.0)	0.472
	History of myocardial infarction	7 (11.7%)	2 (6.7%)	5 (16.7%)	0.421
	Dialysis	1 (1.7%)	0 (0.0)	1 (3.3%)	1
	Pacemaker	4 (6.7%)	1 (3.3%)	3 (10.0%)	0.605
	ICD	3 (5.0%)	1 (3.3%)	2 (6.7%)	1
	Diabetes	7 (11.7%)	2 (6.7%)	5 (16.7%)	0.421
	COPD	4 (6.7%)	2 (6.7%)	2 (6.7%)	1
	Previous cardiac surgery	14 (23.3%)	8 (26.7%)	6 (20.0%)	0.760
	Oral anticoagulation	46 (78%)	25 (86.2%)	21 (70%)	0.263
	Amiodarone	19 (31.7%)	9 (30.0%)	10 (33.3%)	1
	Propafenone	1 (1.7%)	1 (3.3%)	0 (0.0)	1
	Sotalol	4 (6.7%)	2 (6.7%)	2 (6.7%)	1
	b-Blockers	29 (48.3%)	16 (53.3%)	13 (43.3%)	0.605
	Flecainide	4 (6.7%)	3 (10.0%)	1 (3.3%)	0.605
	Antihypertensive drugs	41 (68.3%)	20 (66.7%)	21 (70%)	0.294
	Previous benzodiazepine use	2 (3.3%)	0 (0.0)	2 (6.7%)	0.472
	Previous ECV	28 (47.5%)	16 (53.3%)	12 (41.4%)	0.510
	Baseline EF, %	51.50 [37.75-56.00]	52.00 [49.00-56.50]	47.00 [35.00-55.00]	0.154
	Concomitant valvular disease	43 (69.6%)	24 (79.3%)	19 (59.3%)	0.466
Results		Overall (N = 60)	Propofol (n = 30)	Remimazolam Besylate (n = 30)	p-value
	Total dose administered, mg	—	50 [40], [41], [42], [43], [44], [45], [46], [47], [48], [49], [50]	5 [5]	—
	Need for antagonization of the sedative agent	0 (0.0)	0 (0.0)	0 (0.0)	NA
	Crossover	1 (1.7%)	0 (0.0)	1 (3.3%)	1
	Time to shock, min	2.20 [1.36-3.31]	2.25 [1.30-3.15]	2.12 [1.40-3.84]	0.446
	Time to ROC, min	10.0 [4.75-11]	8.5 [4.5-10]	10.50 [5.5-13.25]	0.163
	Effective ECV	51 (86.4)	26 (86.7)	25 (86.2)	1
	Total ECV attempts				0.767
	1	50 (83.3%)	25 (83.3%)	25 (83.3%)
	2	7 (11.7%)	4 (13.3%)	3 (10.0%)
	3	2 (3.3%)	1 (3.3%)	1 (3.3%)
	4	1 (1.7%)	0 (0.0)	1 (3.3%)
	Early recurrence of AF	5 (8.3%)	4 (13.3%)	1 (3.3%)	0.350
Adverse Events	Overall, adverse events occurred in 11 (18.3%) patients, with 6 (20%) in the propofol group and 5 (17%) in the remimazolam group. Desaturation was the most frequent adverse event, occurring in 11.7% of patients, with 10% in the propofol group and 13.3% in the remimazolam group. Three patients in the propofol group required emergent ventilation, while no patients in the remimazolam group required ventilation. One case of hiccups and 1 case of postoperative recall were observed in the remimazolam group.
Study Author Conclusions	Remimazolam was associated with similar sedation adequacy but more favorable hemodynamics over time compared to propofol when used for procedural sedation in adults undergoing electrical cardioversion for atrial arrhythmias.
Critique	The study provides valuable insights into the use of remimazolam for procedural sedation, demonstrating its noninferiority to propofol with a more favorable hemodynamic profile. However, the small sample size limits the generalizability of the findings, and the lack of randomization may introduce selection bias. Further large-scale, randomized controlled trials are needed to confirm these findings and explore potential superiority differences.

Table 3 References:
[23] D'Andria Ursoleo J, Bottussi A, Agosta VT, et al. Remimazolam Besylate Versus Propofol for Procedural Sedation in Patients Undergoing Electrical Cardioversion: A Prospective, Noninferiority Cohort Study. J Cardiothorac Vasc Anesth. 2026;40(2):546-553. doi:10.1053/j.jvca.2025.10.044

Multidisciplinary Team Quality Improvement Project: Working Towards Safety, Quality, And Effectiveness on Prevention of Atrial Fibrillation After Cardiac Surgery
Design	Nonrandomized, comparative service evaluation N=48
Objective	To assess the impact of introducing remimazolam to an existing nurse-led direct current cardioversion service using midazolam on time to patient discharge, patient safety, satisfaction, and efficiency-related cost savings
Study Groups	Remimazolam (n= 29) Midazolam (n= 19)
Inclusion Criteria	Patients routinely selected for nurse-led direct current cardioversion
Exclusion Criteria	Not specified
Methods	Remimazolam sedation was introduced into a nurse-led direct current cardioversion service at a large dedicated cardiac hospital. Patients received remimazolam when anesthetic support was available and midazolam on alternate days. A remimazolam administration standard operating procedure was developed, and the service progressed from anesthetic-led administration to an autonomous nurse-led service during the evaluation. Using a case report form, the investigators recorded time from drug administration to cardioversion, recovery milestones, discharge, pre- and postprocedure physiology, patient satisfaction, and adverse events. Satisfaction and adverse events were evaluated using the Iowa Sedation Questionnaire and World Society of Intravenous Anaesthesia adverse-event reporting tool, respectively. A cost analysis was also performed. The median total doses administered were 4 mg of remimazolam and 5 mg of midazolam.
Duration	Nine-month project period; patients were followed from sedation administration through hospital discharge
Outcome Measures	Time from drug administration to direct current cardioversion, becoming alert, discharge from recovery, and hospital discharge; patient satisfaction; adverse events; and efficiency-related cost savings
Baseline Characteristics	Baseline characteristics were reported as similar between the remimazolam (n=29) and midazolam (n=19) groups, although numerical demographic and clinical characteristics were not disclosed. The median total sedative doses were 4 mg and 5 mg, respectively.
Results	Median times from drug administration to cardioversion, becoming alert, and discharge from recovery were shorter with remimazolam versus midazolam: 2 versus 7 minutes, 7 versus 11 minutes, and 15 versus 26 minutes, respectively. Median time to hospital discharge was 101 versus 168 minutes, representing a 67-minute difference (95% confidence interval [CI] 51 to 86; p< 0.001); all patients in both groups expressed satisfaction with their care.
Adverse Events	Three events occurred in the remimazolam group: brief self-resolving apnea without associated desaturation (n= 1), partial airway obstruction requiring jaw thrust (n= 1), and partial recall (n= 1). Adverse events in the midazolam group were not reported.
Study Author Conclusions	In this evaluation, remimazolam was associated with a reduction in time to onset and offset of sedation for elective DCCV and time to discharge (as compared with midazolam). The small number of adverse events reinforced the need for effective sedation training for nurse-led services. Remimazolam for nurse-led DCCV offers an alternative to midazolam that was associated with reduced time to patient discharge and an opportunity for cost saving while maintaining patient satisfaction and safety.
Critique	This service evaluation provides a direct, procedure-specific comparison with midazolam in a real-world nurse-led cardioversion service and assessed clinically relevant recovery, discharge, satisfaction, and safety outcomes. However, its small, nonrandomized cohorts, assignment according to anesthetic availability and alternate-day scheduling, limited baseline reporting, and lack of comparative statistical testing for most outcomes restrict assessment of confounding and comparative safety.

Table 4 References:
[24] Verma M, Lendrum R, Butcher C, Fhadil S, Comer K, Lees M. Remimazolam for direct current cardioversion. Br J Anaesth. 2024;133:712. doi:10.1016/j.bja.2024.06.016

Economic benefits of remimazolam compared to midazolam and propofol for procedural sedation in colonoscopies and bronchoscopies
Design	Cost analysis using a micro-costing approach
Objective	To estimate the economic benefits of introducing remimazolam for procedural sedation in colonoscopies and bronchoscopies in hospitals in Scandinavia
Methods	A cost model was developed using a micro-costing approach, comprising cost components affected by differences in the efficacy of remimazolam, midazolam, and propofol. The model estimated the cost per successful colonoscopy and bronchoscopy using these sedatives. Data from clinical studies on remimazolam informed the model, which included stages representing the patient journey during endoscopies. Costs included drug acquisition, healthcare personnel time, utensils, and patient-incurred costs. Sensitivity analyses were performed to identify contributors to uncertainty. Of note, all costs were in Danish krone (DKK) as this study was conducted in Denmark.
Duration	Not applicable
Outcome Measures	Total cost per successful procedure using remimazolam, midazolam, or propofol
Results		Remimazolam	Midazolam	Propofol
	Total cost per colonoscopy (DKK)	1200	1320	1255
	Incremental saving per colonoscopy (DKK)	-120	-55
	Total cost per bronchoscopy (DKK)	1353	1724	N/A
	Incremental saving per bronchoscopy (DKK)	-372	N/A
Study Author Conclusions	Procedural sedation with remimazolam is associated with economically meaningful savings compared to midazolam and propofol in colonoscopies and to midazolam in bronchoscopies. The main drivers of savings are reduced preparation and recovery times, and reduced need for healthcare personnel during procedures.
Critique	The study effectively demonstrates the economic benefits of remimazolam using a detailed cost model. However, the reliance on clinical expert input for some model parameters and the lack of direct clinical trial data for propofol in bronchoscopies may limit the generalizability of the findings. Additionally, the study does not account for potential variations in clinical practice across different settings and countries.

Table 5 References:
[25] Pedersen MH, Dan A, Englev E, Kattenhj L, Munk E. Economic benefits of remimazolam compared to midazolam and propofol for procedural sedation in colonoscopies and bronchoscopies. Curr Med Res Opin. 2023;39(5):691-699. doi:10.1080/03007995.2023.2196198

Remimazolam Enables Faster Sedation Induction and Recovery Compared With Midazolam in Diagnostic Upper Gastrointestinal Endoscopy: A Multicenter Randomized Controlled Trial
Design	Multicenter, single-blind, randomized, positive-control, superiority, investigator-initiated phase III trial N= 132
Objective	To evaluate the efficacy and safety of remimazolam compared with those of midazolam in diagnostic upper gastrointestinal endoscopy
Study Groups	Remimazolam group (n= 66) Midazolam group (n= 66)
Inclusion Criteria	Scheduled for diagnostic upper gastrointestinal endoscopy under sedation, age 19-60 years, ASA score of 1 or 2, BMI ≥18.5 kg/m2 and < 30 kg/m2
Exclusion Criteria	Suspected pathological conditions requiring therapeutic endoscopy, history of respiratory diseases affecting breathing during sedation, Mallampati score ≥3, uncontrolled hypertension, severe hepatic dysfunction or chronic kidney disease, history of drug or alcohol abuse within the past year, hypersensitivity to benzodiazepines, pregnancy, participation in other clinical trials within 1 month prior to screening
Methods	Participants at seven South Korean academic hospitals were randomized 1:1, with patients blinded to treatment. Initial IV doses were remimazolam 5 mg or midazolam 2 mg, administered over >1 minute. Endoscopy began at a Modified Observer’s Assessment of Alertness and Sedation (MOAA/S) score ≤3. Supplemental remimazolam 2.5 mg or midazolam 1–2 mg could be administered at intervals ≥2 minutes, up to five times within 15 minutes. Inadequate sedation after these doses prompted investigator-selected rescue medication and constituted sedation failure. Opioids were not routinely coadministered. Full recovery required MOAA/S=5 on three consecutive assessments; discharge required an Aldrete score >9. Flumazenil was permitted for delayed recovery >30 minutes after the last dose. An independent research nurse recorded procedural times; adverse events were monitored until discharge, when patient satisfaction was assessed.
Duration	April 2023 to January 2024
Outcome Measures	Primary: Total procedure time (duration from first sedative administration to discharge) Secondary: Sedation success rate, recovery time, induction time, total endoscopy time, discharge time, sedation time, patient satisfaction, incidence rates of hypotension, respiratory depression, tachycardia, bradycardia, and paradoxical reaction
Baseline Characteristics		Remimazolam (n= 64)	Midazolam (n= 65)
	Age, years, median (IQR)	42.0 (15.5)	39.0 (15.0)
	Male	27 (42.2%)	22 (33.8%)
	Height, cm, median (IQR)	165.2 (10.00)	164.0 (13.8)
	Weight, kg, median (IQR)	62.9 (21.10)	61.0 (17.8)
	Median BMI, kg/m2	23.1 (4.5)	22.9 (5.2)
	ASA score 1 2	62 (96.9%) 2 (3.1%)	62 (95.4%) 3 (4.6%)
	Mallampati score 1 2	36 (56.3%) 28 (43.7%)	38 (58.5%) 27 (41.5%)
	Current smoker	10 (15.6%)	7 (10.8%)
	Current alcohol drinker	33 (51.6%)	43 (66.2%)
	Systolic blood pressure, mmHg	119.9 ± 13.5	124.5 ± 14.9
	Diastolic blood pressure, mmHg	73.3 ± 10.9	78.9 ± 12.0
	Pulse rate, times/min, median (IQR)	76.0 (22.0)	76.0 (18.0)
	Oxygen saturation, median (IQR)	99.0 (2.0%)	98.0 (2.0%)
	Abbreviations: IQR, interquartile range.
Results		Remimazolam (n= 64)	Midazolam (n= 65)	p-value
	Total procedure time, min	30.3 (6.8)	48.5 (12.5)	<0.001
	Success rate of sedation	64 (100%)	63 (97%)	0.496
	Recovery time, min, median (range)	13.0 (4.0–31.0)	28.2 (2.0–57.0)	<0.001
	Discharge time, min	23.5 ± 7.2	38.8 ± 13.0	<0.001
	Sedation time, min	16.9 (6.5)	33.7 (12.6)	< 0.001
	Induction time, min, median (range)	1.9 (1.0–13.0)	3.0 (1.0–17.0)	< 0.001
	Total endoscopy time, min, median (range)	4.0 (1.3–7.0)	4.0 (1.9–10.8)	0.724
Adverse Events	The incidence of adverse events did not significantly differ between the groups. Hypotension was less frequent in the remimazolam group (33.3% vs. 48.5%). Bradycardia occurred less frequently in the remimazolam group (15.2% vs. 27.3%). No cases of respiratory depression were identified in either group. Two cases of transient hypoxemia in the remimazolam group resolved immediately with oxygen administration.
Study Author Conclusions	In conclusion, this study confirmed that compared with midazolam, the use of remimazolam in diagnostic upper gastrointestinal endoscopy allows for faster sedation induction and recovery, more rapid discharge, and higher patient satisfaction compared with previous sedation experiences, while maintaining a safety profile similar to that of midazolam.
Critique	Multicenter randomization and standardized timing strengthen the comparison, but the single-blind design, restriction to relatively healthy adults undergoing brief diagnostic procedures, and follow-up only through discharge limit generalizability and safety assessment. The study demonstrates shorter sedation-related times versus midazolam but provides neither a direct propofol comparison nor economic data to establish cost-effectiveness.

Table 6 References:
[26] Park Y, Lee JK, Lee KH, et al. Remimazolam Enables Faster Sedation Induction and Recovery Compared With Midazolam in Diagnostic Upper Gastrointestinal Endoscopy: A Multicenter Randomized Controlled Trial. United European Gastroenterol J. 2026;14(1):e70147. doi:10.1002/ueg2.70147

Discharge Readiness After Remimazolam Versus Propofol for Colonoscopy: A Randomised, Double-Blind Trial
Design	Prospective, single-centre, randomised, double-blind, parallel-group noninferiority trial N= 132
Objective	To test the hypothesis that remimazolam could provide a noninferior discharge time to propofol for ambulatory colonoscopy
Study Groups	Remimazolam (n= 66) Propofol (n= 66)
Inclusion Criteria	Participants aged 18 to 65 years with an ASA physical status of I to II scheduled for ambulatory colonoscopy
Exclusion Criteria	Weight <40 kg or BMI >30 kg/m², obstructive sleep apnoea, chronic use of opioids or benzodiazepines, inability to ambulate without assistance, preexisting cognitive impairment, suspected or diagnosed disorder of the lower gastrointestinal tract requiring advanced therapeutic endoscopy, history of drug or ethanol abuse, pregnancy or lactating, inability to communicate in Mandarin Chinese
Methods	Participants were randomly assigned to receive either 0.2 mg/kg remimazolam or 1 mg/kg propofol for sedation. Sufentanil (5 µg) was administered intravenously before the sedative drugs. Colonoscopy started once the MOAA/S sedation score was ≤3. Top-up boluses of 3 mL (remimazolam 6 mg or propofol 30 mg), at least 2 minutes apart, kept MOAA/S below 4. All patients breathed spontaneously with oxygen at 3 L/min by nasal cannula. Monitoring included noninvasive arterial blood pressure, pulse oximetry, and ECG during the procedure.
Duration	July 2021 to October 2021
Outcome Measures	Primary: Discharge time after colonoscopy Secondary: Induction time, emergence time, extent of recovery (modified Aldrete score) upon arrival in the PACU, fatigue (0–10 numerical rating scale), endoscopist and patient satisfaction (0–10), adverse events
Baseline Characteristics		Remimazolam (n= 66)	Propofol (n= 66)	p-value
	Age, median (IQR), years	49 (41-56)	48 (39-56)	0.776
	Female	37 (56%)	32 (49%)	0.384
	BMI, median (IQR), kg/m²	22.4 (19.8-24.6)	22.0 (20.1-25.3)	0.562
	ASA physical status I II	36 (55%) 30 (45%)	32 (49%) 34 (51%)	0.486
	Mean arterial pressure, mmHg	82 ± 13	85 ± 12	0.174
	Oxygen saturation, median (IQR), %	99 (98-100)	100 (98-100)	0.318
	Heart rate, beats/min	75 ± 11	73 ± 14	0.578
	Duration of colonoscopy, median (IQR), min	12 (10-14)	12 (9-14)	0.494
	Preexisting conditions Hypertension Diabetes Cardiovascular disorder	9 (14%) 4 (6%) 4 (6%)	11 (17%) 6 (9%) 1 (2%)	0.627 0.511 0.365
Results		Remimazolam (n= 66)	Propofol (n= 66)	p-value
	Discharge time, median (IQR), min	24 (21-26)	21 (20-24)	0.018
	Induction time, median (IQR), s	90 (74–106)	78 (70–92)	0.003
	Emergence time, median (IQR), s	134 (102–222)	138 (91–252)	0.864
	Extent of recovery (modified Aldrete score), median (IQR), s	5.5 (5.0–9.0)	6.5 (5.0–8.3)	0.993
	Fatigue score, median (IQR)	5 (2–6)	3 (0–6)	0.476
	Endoscopist satisfaction score, median (IQR)	9 (7–10)	9 (8–10)	0.322
	Patient satisfaction score, median (IQR)	9 (8–10)	8 (7–9)	0.001
	Injection pain	11 (17%)	32 (49%)	<0.001
	Hypotension	13 (20%)	31 (47%)	<0.001
	Bradycardia	4 (6%)	13 (20%)	0.019
	Hypoxaemia (SpO₂ <92%)	8 (12%)	11 (17%)	0.457
	PONV	0 (0%)	2 (3%)	0.496
	Hiccups	2 (3%)	0 (0%)	0.496
Adverse Events	See results section.
Study Author Conclusions	For sedation in ambulatory colonoscopy, compared with propofol, remimazolam provides a noninferior discharge time. Furthermore, remimazolam is associated with less injection pain, lower risks of hypotension and bradycardia, and improved patient satisfaction.
Critique	The study's strengths include its randomised, double-blind design and clear demonstration of noninferiority in discharge times. However, the single-centre setting and specific patient population may limit generalisability. The study did not explore dose-response relationships for remimazolam, which could provide further insights into its optimal use.

Table 7 References:
[27] Yao Y, Guan J, Liu L, Fu B, Chen L, Zheng X. Discharge readiness after remimazolam versus propofol for colonoscopy: A randomised, double-blind trial. Eur J Anaesthesiol. 2022;39(12):911-917. doi:10.1097/EJA.0000000000001715