Hemodynamic safety of remimazolam vs propofol in elderly patients

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.

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.

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 I ² test.

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; I ² = 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.

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.