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[Pharmacology](https://durgical.com/en/pharmacology/) · Class

# Neuromuscular block reversal agents

Drugs that restore muscle strength at the end of surgery after a non-depolarising blocker: sugammadex and neostigmine.

Updated 2026-11-01

## What they are

Two strategies: acetylcholinesterase inhibitors (neostigmine) raise acetylcholine at the end plate so it wins the competition; sugammadex, a cyclodextrin, encapsulates rocuronium or vecuronium in plasma and pulls it away from the neuromuscular junction.

## Mechanism of action

Neostigmine inhibits acetylcholinesterase: acetylcholine builds up and displaces the competitive blocker; because it also stimulates muscarinic receptors, it is given with atropine or glycopyrronium. Sugammadex forms a very stable complex with rocuronium or vecuronium; their free concentration falls and the blocker leaves the end plate down its gradient.

Target: Acetylcholinesterase (neostigmine); free rocuronium and vecuronium (sugammadex)

## Key points

- Sugammadex reverses only aminosteroids (rocuronium, vecuronium), even a deep block; it does not work on suxamethonium or benzylisoquinolines.
- Neostigmine needs some spontaneous recovery already present and is always given with an antimuscarinic to prevent bradycardia.
- Sugammadex can cause anaphylaxis and marked bradycardia; it reduces the effect of hormonal contraceptives for 7 days.
- Neostigmine only antagonises competitive blockers: it does not reverse the phase I block of suxamethonium.
- After any reversal, ventilation is watched: the block can come back.

## Drugs in this class

- [**Sugammadex** Reverses rocuronium and vecuronium muscle block within minutes by encapsulating them in the blood. It can cause… Free rocuronium and vecuronium in plasma (it does not act on a receptor)](https://durgical.com/en/pharmacology/sugammadex/)

## Others in the class

- Neostigmine
- Edrophonium
- Glycopyrronium (paired with neostigmine)

## Test yourself

Think of the answer, then tap the question to see it.

## Why is glycopyrronium or atropine given with neostigmine?

To block the muscarinic effects of the accumulated acetylcholine, above all bradycardia, salivation and bronchospasm.

## Which blockers does sugammadex reverse?

The aminosteroids rocuronium and vecuronium, which it encapsulates; it has no effect on suxamethonium, atracurium or cisatracurium.

## What should a patient using hormonal contraception know after receiving sugammadex?

That sugammadex can bind the progestogen: it counts as a missed dose, and an additional non-hormonal method is needed for 7 days.

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Educational content on how drugs work; not a prescribing guide and no substitute for a health professional's advice. No doses are given.

Sources: [DailyMed - SUGAMMADEX injection, solution](https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=c451d4dc-03f8-48d9-a848-6b2905122aa4) (DailyMed (U.S. National Library of Medicine), 2026); [DailyMed - NEOSTIGMINE METHYLSULFATE injection](https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=7a9d996f-aecb-455f-95fc-1010e461d75d) (DailyMed (U.S. National Library of Medicine), 2026); Goodman & Gilman's The Pharmacological Basis of Therapeutics, 14th ed., ch. 13 (McGraw Hill, 2023).

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Representative model, for educational purposes only.

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License: CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). Cite as: DurgiPedia (durgical.com), https://durgical.com/en/pharmacology/classes/neuromuscular-block-reversal-agents/