Remimazolam for Precision Sedation and Anaesthesia in Vulnerable Populations: A Narrative Review of Pharmacological Mechanisms, Stratified Clinical Evidence, and Individualised Perioperative Strategies
- 1Department of Anesthesiology, The Second Affiliated Hospital of Dalian Medical University, Dalian, 116027, People’s Republic of China
- 2Department of Anesthesiology, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Shandong Institute of Anesthesia and Respiratory Critical Medicine, Shandong Provincial Clinical Research Center for Anesthesiology, Jinan, 250014, People’s Republic of China
Abstract
Sedation and anaesthesia in vulnerable populations are complicated by altered pharmacokinetics, variable pharmacodynamic sensitivity, and limited physiological reserve. The extent of these differences depends on the underlying condition, disease severity, comorbidity, and treatment setting. These issues are common in older adults, patients with obesity or obstructive sleep apnoea, organ dysfunction, cardiovascular vulnerability, critical illness, and neurological or psychiatric comorbidity. Conventional sedatives may be poorly tolerated in these settings. Propofol can cause hypotension and respiratory depression. Midazolam may lead to delayed recovery and accumulation. Dexmedetomidine may be limited by bradycardia and slow onset. Remimazolam is an ultra-short-acting benzodiazepine that undergoes rapid carboxylesterase-mediated hydrolysis and can be antagonised with flumazenil. This narrative review examines its pharmacology, clinical evidence, and practical use across nine vulnerable populations. The synthesis prioritised population-specific clinical studies, pharmacokinetic studies, comparative trials, systematic reviews, and major guidelines. For short procedures, the most consistent evidence concerns older adults and haemodynamically vulnerable patients, in whom remimazolam has often been associated with less hypotension than propofol and faster recovery than midazolam. These findings are based mainly on short-term physiological and recovery outcomes. Evidence in mild to moderate hepatic or renal dysfunction is supportive but remains sparse in severe disease. Data for obesity or obstructive sleep apnoea, prolonged ICU sedation, paediatric care, obstetrics, and neurological or psychiatric vulnerability are limited or indirect. Remimazolam should therefore be considered according to the clinical objective, the expected duration and depth of sedation, opioid exposure, airway risk, and organ reserve. Its pharmacological advantages have not yet been shown to improve delirium, cognition, mechanical ventilation, functional recovery, or long-term safety. Further studies should focus on population-specific dosing models and patient-centred outcomes.
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BibTeX
@article{wu2026remimazolam,
title = {{Remimazolam for Precision Sedation and Anaesthesia in Vulnerable Populations: A Narrative Review of Pharmacological Mechanisms, Stratified Clinical Evidence, and Individualised Perioperative Strategies}},
author = {Guanghan Wu and Jiaxue Zhang and Yufei Li and Yitong Zhou and Jianbo Wu and Zhaoyang Xiao},
journal = {Drug Design, Development and Therapy},
year = {2026},
month = oct,
doi = {10.2147/dddt.s637421},
url = {https://doi.org/10.2147/dddt.s637421},
note = {CC BY-NC 4.0},
}
RIS
TY - JOUR
TI - Remimazolam for Precision Sedation and Anaesthesia in Vulnerable Populations: A Narrative Review of Pharmacological Mechanisms, Stratified Clinical Evidence, and Individualised Perioperative Strategies
AU - Guanghan Wu
AU - Jiaxue Zhang
AU - Yufei Li
AU - Yitong Zhou
AU - Jianbo Wu
AU - Zhaoyang Xiao
PY - 2026
DA - 2026/10/30
JO - Drug Design, Development and Therapy
DO - 10.2147/dddt.s637421
UR - https://doi.org/10.2147/dddt.s637421
AB - Sedation and anaesthesia in vulnerable populations are complicated by altered pharmacokinetics, variable pharmacodynamic sensitivity, and limited physiological reserve. The extent of these differences depends on the underlying condition, disease severity, comorbidity, and treatment setting. These issues are common in older adults, patients with obesity or obstructive sleep apnoea, organ dysfunction, cardiovascular vulnerability, critical illness, and neurological or psychiatric comorbidity. Conventional sedatives may be poorly tolerated in these settings. Propofol can cause hypotension and respiratory depression. Midazolam may lead to delayed recovery and accumulation. Dexmedetomidine may be limited by bradycardia and slow onset. Remimazolam is an ultra-short-acting benzodiazepine that undergoes rapid carboxylesterase-mediated hydrolysis and can be antagonised with flumazenil. This narrative review examines its pharmacology, clinical evidence, and practical use across nine vulnerable populations. The synthesis prioritised population-specific clinical studies, pharmacokinetic studies, comparative trials, systematic reviews, and major guidelines. For short procedures, the most consistent evidence concerns older adults and haemodynamically vulnerable patients, in whom remimazolam has often been associated with less hypotension than propofol and faster recovery than midazolam. These findings are based mainly on short-term physiological and recovery outcomes. Evidence in mild to moderate hepatic or renal dysfunction is supportive but remains sparse in severe disease. Data for obesity or obstructive sleep apnoea, prolonged ICU sedation, paediatric care, obstetrics, and neurological or psychiatric vulnerability are limited or indirect. Remimazolam should therefore be considered according to the clinical objective, the expected duration and depth of sedation, opioid exposure, airway risk, and organ reserve. Its pharmacological advantages have not yet been shown to improve delirium, cognition, mechanical ventilation, functional recovery, or long-term safety. Further studies should focus on population-specific dosing models and patient-centred outcomes.
SN - 1177-8881
ER -