Pharmacology · Neuromuscular block reversal agents
Sugammadex !
Reverses rocuronium and vecuronium muscle block within minutes by encapsulating them in the blood. It can cause anaphylaxis and bradycardia.
Updated 2026-11-01
Also called: Sugammadex sodium
Mechanism of action
Sugammadex is a modified gamma-cyclodextrin: a ring-shaped molecule whose cavity traps rocuronium or vecuronium and forms a very stable complex. As the free concentration of the blocker in plasma falls, the blocker leaves the neuromuscular junction down its gradient and the nicotinic receptors are freed for acetylcholine. It does not act on acetylcholinesterase, so it has no muscarinic effects.
- Its ring traps rocuronium or vecuronium in plasma
- The free concentration of the blocker falls
- The blocker leaves the motor end plate down its gradient
- Acetylcholine activates the receptor again: strength returns
Pharmacokinetics
- Metabolism
- Not metabolised or excreted by the liver.
- Elimination
- Kidney, almost all unchanged and as the complex; severe renal impairment retains it for days.
- Half-life
- About 2 hours with normal kidney function; much longer in renal impairment.
Indications
- Reversal of moderate or deep rocuronium or vecuronium block at the end of surgery
- Immediate reversal after a high dose of rocuronium
Adverse effects
Common
- Nausea and vomiting
- Pain
- Hypotension
- Headache
- Dysgeusia (altered taste)
Contraindications
- Hypersensitivity to sugammadex or its components
Key interactions
- Hormonal contraceptives (oral and non-oral)
- It binds the progestogen: equivalent to a missed dose; an additional non-hormonal method is needed for 7 days.
- Toremifene
- Displaces rocuronium or vecuronium from the complex and delays recovery.
- Anticoagulants (vitamin K antagonists, heparins, rivaroxaban, dabigatran)
- Small, transient prolongation of aPTT and PT/INR.
- Drugs that enhance neuromuscular block, given after surgery
- Risk that the block recurs.
What is monitored
- Train-of-four before and after reversal
- Heart rate and blood pressure in the following minutes
- Ventilation and saturation until adequate spontaneous breathing is assured
- Signs of anaphylaxis
Administration and safety
- Intravenous bolus; have atropine and anaphylaxis medicines available.
- Reverses only rocuronium and vecuronium; it does not work after suxamethonium, atracurium or cisatracurium.
- Not recommended in severe renal impairment or dialysis.
Nursing care
- Watch heart rate and blood pressure: with significant bradycardia, report it and prepare atropine.
- Keep ventilatory support until adequate spontaneous breathing and a patent airway are confirmed.
- Teach patients on hormonal contraception to use an additional non-hormonal method for 7 days.
- Watch for signs of recurrent block after extubation (weakness, shallow breathing, desaturation).
Pregnancy and breastfeeding
There are not enough data in pregnancy; its interaction with progestogens reduces the efficacy of hormonal contraceptives in the following days.
Test yourself
Think of the answer, then tap the question to see it.
Why does sugammadex not need atropine or glycopyrronium the way neostigmine does?
Because it does not inhibit acetylcholinesterase: it does not raise acetylcholine at muscarinic receptors; even so, it can cause bradycardia, so atropine is kept at hand.
Which organ eliminates the sugammadex-rocuronium complex?
The kidney; that is why it is not recommended in severe renal impairment.
What should a patient on oral contraceptives do after receiving sugammadex?
Follow the product's missed-dose advice and use an additional non-hormonal method for 7 days.
Related drugs
← Back to the class: Neuromuscular block reversal agents
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 (DailyMed (U.S. National Library of Medicine), 2026); Goodman & Gilman's The Pharmacological Basis of Therapeutics, 14th ed., ch. 13 (McGraw Hill, 2023); ATCDDD - ATC/DDD Index (WHO Collaborating Centre for Drug Statistics Methodology, 2026).
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