Remimazolam Tolerance in Long-term Benzodiazepine Users: A Case Report of 2 Cases

Abstract

A 60-year-old woman with a 5-year history of anxiolytic use, a diazepam-equivalent daily dose of 15 mg, was scheduled for esophageal stent removal. She was given remimazolam (0.5 mg/kg) but remained fully alert. She only lost consciousness with propofol (40 mg). A 61-year-old man with a 1-year history of anxiolytic use, diazepam-equivalent daily dose of 20 mg, was scheduled for hand tumor resection. He was given remimazolam (0.3 mg/kg) but remained fully alert. He only lost consciousness after desflurane inhalation. In a patient with a history of long-term benzodiazepine use, anesthetic or sedative agents aside from remimazolam should be considered.

Quality of Recovery After General Anesthesia with Remimazolam in Patients’ Undergoing Urologic Surgery: A Randomized Controlled Trial Comparing Remimazolam with Propofol

“… 5 Cases about remimazolam tolerance have been reported in benzodiazepine long-term users. 33 Our study showed the reduction in the quality of recovery in remimazolam group was in terms of physical comfort and emotional state, which reminded us to concern patients’ mental conditions.…”

Remimazolam: Non-Clinical and Clinical Profile of a New Sedative/Anesthetic Agent

“…Indeed, Io et al ( Io et al, 2021 ) observed tolerance to the effects of remimazolam over a 28 days dosing period in the pig, but note that the tolerance observed (assessed by the requirement to increase the dose to maintain the same sedative effect) was less than that seen with midazolam. As might be predicted, a reduced sedative effect of remimazolam has been observed in subjects with an existing tolerance to benzodiazepines resulting from long-term use equivalent to 15–20 mg diazepam per day ( Yoshikawa et al, 2021 ).…”

Successful recording of direct cortical motor-evoked potential from a pediatric patient under remimazolam anesthesia: a case report

“…Certain indicators to estimate the level of remimazolam anesthesia are required to make the minimum infusion rate compatible with avoiding intraoperative awareness. Long-term benzodiazepine use for seizure control, frequently observed among patients with intracranial legions, is another concern; otherwise, the patient might show remimazolam tolerance [ 24 ], and reversal with flumazenil may cause a seizure. Thus, at present, eliminating the incidences of intraoperative hypotension or PRIS is the most rational reason for considering remimazolam-based anesthesia for pediatric supratentorial surgery under MEP monitoring.…”