Hemodynamic safety of remimazolam vs propofol in elderly patients

doi:10.4292/wjgpt.120256

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World Journal of Gastrointestinal Pharmacology and Therapeutics

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2150-5349

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Baishideng Publishing Group Inc, 7041 Koll Center Parkway, Suite 160, Pleasanton, CA 94566, USA

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Meta-Analysis

Copyright: ©Author(s) 2026. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution-NonCommercial (CC BY-NC 4.0) license. No commercial re-use. See permissions. Published by Baishideng Publishing Group Inc.

World J Gastrointest Pharmacol Ther. Sep 5, 2026; 17(3): 120256
Published online Sep 5, 2026. doi: 10.4292/wjgpt.120256

Hemodynamic safety of remimazolam vs propofol in elderly patients

Nawal Tahir, Adil Khan, Sidra Faryal, Muhammad Faizan, Ayesha Irshad, Umer Iqbal, Muaaz Wasay, Syed A Arsal, Aashish Kumar, Inibehe I Okon, Shafin Bin Amin

Nawal Tahir, Ayesha Irshad, Department of Medicine, Dow Medical College, Karachi 74200, Sindh, Pakistan

Adil Khan, Department of General Surgery, Nowshera Medical College, Nowshera 24171, Khyber Pakhtunkhwa, Pakistan

Sidra Faryal, Muaaz Wasay, Department of General Medicine, Aziz Fatimah Medical and Dental College, Faisalabad 38000, Punjab, Pakistan

Muhammad Faizan, Department of General Surgery, Karachi Medical and Dental College, Karachi 74700, Sindh, Pakistan

Umer Iqbal, Department of Anesthesiology, Pain Management and Surgical Intensive Care, The Indus Hospital, Korangi Campus, Karachi 75190, Sindh, Pakistan

Syed A Arsal, Department of Pediatric Emergency, The Indus Hospital (Korangi Campus), Karachi 75190, Sindh, Pakistan

Aashish Kumar, Department of Pediatrics, The Indus Hospital, Korangi Campus, Karachi 75190, Sindh, Pakistan

Inibehe I Okon, Department of Research, Medical Research Circle (MedRec), Bukavu 50 Goma, Congo

Shafin Bin Amin, Department of General Surgery, Jinnah Postgraduate Medical Centre, Karachi 75510, Pakistan

Author contributions: All authors contributed to the study conception and design. Tahir N, Faizan M, Irshad A and Khan A contributed to material preparation, literature screening, data collection and analysis, as well as the preparation of supplementary tables and manuscript tables; Irshad A, Faryal S, Khan A, Iqbal U, Wasay M and Faizan M contributed to writing the original draft of the manuscript; and all authors contributed to commenting on previous versions of the manuscript; Arsal SA, Kumar A, Okon II and Iqbal U contributed to citation management, thorough manuscript review, editing and English language polishing, as well as study supervision, result validation and data visualization. All authors read and approved the final manuscript, with correspondence addressed to Iqbal U.

AI contribution statement: We confirm that no AI writing tools were used in the preparation, writing, or revision of this manuscript. The manuscript was written, revised, and edited entirely by the authors. Only Grammarly was used for small grammatical errors throughout the manuscript (for example: Commas and full stop placement, use of articles at appropriate places, etc.).

Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.

PRISMA 2009 Checklist statement: The authors have read the PRISMA 2009 Checklist, and the manuscript was prepared and revised according to the PRISMA 2009 Checklist.

Corresponding author: Umer Iqbal, Academic Fellow, Department of Anesthesiology, Pain Management and Surgical Intensive Care, The Indus Hospital, Korangi Campus, Plot C-76, Sector 31/5, Opposite Crossing, Darussalam Society Sector 39 Korangi, Karachi 75190, Sindh, Pakistan. umer.iqbal@tih.org.pk

Received: February 24, 2026
Revised: May 31, 2026
Accepted: June 18, 2026
Published online: September 5, 2026
Processing time: 188 Days and 4.2 Hours

Abstract

BACKGROUND

Endoscopy and colonoscopy are gastrointestinal procedures which are frequently performed in diagnosing conditions like gastrointestinal inflammatory disorders, strictures, or malignancy. Sedation in these procedures is necessary for patient comfort and successful completion of the procedure, especially in elderly people. This meta-analysis compares the efficacy and safety profiles of two commonly used sedatives, propofol and remimazolam, a new agent with a potentially safer profile.

AIM

To compare the efficacy and safety profiles of two commonly used sedatives in the elderly population, propofol and remimazolam, a new agent with a potentially safer profile.

METHODS

PubMed, Google Scholar, and Cochrane Library databases were searched from inception until 2025 to identify studies comparing remimazolam to propofol in elderly patients undergoing gastrointestinal endoscopic procedures. Statistical analyses were performed using RevMan with a random-effects model. Heterogeneity was assessed using the I² test.

RESULTS

Our study involved 10 randomized controlled trials with a total of 1994 patients, 997 (50.0%) of whom were in the remimazolam group and 997 (50.0%) were in the propofol group. Hypotension, the primary outcome, occurred significantly less often in patients receiving remimazolam (risk ratio = 0.48, 95% confidence interval: 0.38-0.61; P < 0.00001; I² = 52%). Other outcomes, including bradycardia, respiratory depression, and pain at the injection site, were also significantly lower with remimazolam. No significant difference was found between the groups in terms of nausea and vomiting and time to recovery outcome.

CONCLUSION

Remimazolam appears to be a safer alternative to propofol for elderly patients undergoing gastrointestinal endoscopy. Remimazolam was associated with a lower incidence of hypotension, bradycardia, respiratory depression, and injection-site pain. The recovery time and incidence of nausea and vomiting were similar after administration of either drug. Further high-quality trials are warranted to confirm these findings.

Keywords: Remimazolam; Propofol; Endoscopy; Colonoscopy; Procedural sedation

Core Tip: This meta-analysis of 10 randomized controlled trials involving 1994 elderly patients establishes the superior hemodynamic safety of remimazolam over propofol during gastrointestinal endoscopy. Remimazolam reduced the risk of hypotension by more than half compared to propofol, while significantly lowering incidences of bradycardia, respiratory depression, and injection pain. Crucially, these safety advantages were achieved without compromising recovery times or increasing post-operative nausea. These quantitative findings demonstrate that remimazolam serves as a safer, highly stable sedative alternative for mitigating cardiorespiratory risks in vulnerable older populations.