The safety and efficacy of remimazolam, ciprofol, and propofol anesthesia in endoscopy: a systematic review and network meta-analysis.

Background

While propofol remains widely used for endoscopic sedation, its cardiovascular depression and injection pain limitations have prompted exploration of novel agents (remimazolam, ciprofol). This study aimed to compare their safety and efficacy profiles systematically.

Methods

We conducted a network meta-analysis to evaluate remimazolam, ciprofol, and propofol for gastrointestinal endoscopy. Bayesian random-effects models were used to estimate relative risks (RR) and mean differences (MD) with 95% credible intervals(CrI).

Results

Forty-two randomized controlled trials (N = 10,540 patients) were included. Remimazolam demonstrated superior cardiovascular safety (RR = 0.44, 95%CrI 0.35-0.54 vs propofol) and lowest respiratory depression risk (RR = 0.36, 0.28-0.46). Propofol showed faster recovery (MD -14.22 min, -2.35 to -30.83 vs remimazolam). Both remimazolam (RR = 0.045) and ciprofol (RR = 0.054) significantly reduced injection pain versus propofol.

Conclusion

Remimazolam should be prioritized for high-risk patients (cardiovascular/respiratory comorbidities) despite slightly longer recovery times. Propofol remains suitable for low-risk procedures requiring rapid turnover, while ciprofol offers balanced efficacy for endoscopy.

Trial registration

The study was registered with the UK National Institute for Health Research's PROSPERO platform (CRD42024569405; https://www.crd.york.ac.uk/prospero/ ).

COI Statement

Declarations. Ethics approval and consent to participate: The study was registered with the UK National Institute for Health Research's PROSPERO platform (CRD42024569405; https://www.crd.york.ac.uk/prospero/ ). Consent for publication: Not applicable. Competing interests: The authors declare no competing interests.

References:

• Sharif S, et al. “Pharmacological agents for procedural sedation and analgesia in the emergency department and intensive care unit: a systematic review and network meta-analysis of randomised trials,” (in eng). Br J Anaesth. 2024;132(3):491–506. 10.1016/j.bja.2023.11.050.
• Stogiannou D, Protopapas A, Protopapas A, Tziomalos K. “Is propofol the optimal sedative in gastrointestinal endoscopy?,” (in eng). Acta Gastroenterol Belg. 2018;81(4):520–4.
• Zhang F, Sun HR, Zheng ZB, Liao R, Liu J. “Dexmedetomidine versus midazolam for sedation during endoscopy: A meta-analysis,” (in eng). Exp Ther Med. 2016;11(6):2519–24. 10.3892/etm.2016.3186.
• Kalsotra S, Khan S, McKee C, Tobias JD. “Remimazolam as the Primary Agent for Sedation During Cardiac Catheterization in Three Patients With Comorbid Cardiac Conduction Abnormalities,” (in eng). Cardiol Res. 2023;14(1):86–90. 10.14740/cr1477.
• Kothari D, et al. “An open-access endoscopy screen correctly and safely identifies patients for conscious sedation,” (in eng). Gastroenterol Rep (Oxf). 2016;4(4):281–6. 10.1093/gastro/gow020.