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Table 3 Classification, dose, and side effects of reversal agents

From: Neuromuscular blockers and their reversal: have we finally found the on-off switches?

Class of reversal agent Name of drug
Duration of action
Dose Side effects Remarks
Carbamate group AntiAch esterase (Ganapati et al. 2016) Neostigmine
0.5–2 h
TOF count < 1: do NOT give neostigmine Residual block, muscarinic S/E, (bradycardia, arrhythmias, salivation, bronchospasm, increased airway secretions, nausea, vomiting, diarrhea, micturition) Does not cross blood-brain barrier
MG treatment
Paralytic ileus
Urinary retention
TOF count 2–4 (tactile/visual fade; TOFR < 0.4): 0.05–0.07 mg/kg
TOF count = 4 (no tactile/visual fade; TOFR = 0.4–0.9): 0.02–0.03 mg/kg
TOFR is ≥0.9: do NOT give neostigmine
Pyridostigmine
3–6 h
   MG treatment
Alcohol group AntiAch esterase Edrophonium
5-15 min
   MG diagnosis
Gamma Cyclodextrin Sugammadex
Renal excretion after 24 h
TOF count = T2: 2mg/kg Marked bradycardia and cardiac arrest, coagulopathy, anaphylaxis, contraceptive failure Approved in Europe (2008), Japan (2010), Australia, Middle East, US (2015)
Post-tetanic count = 1–2: 4 mg/kg
3 min post-IV rocuronium (1.2 mg/kg): 16 mg/kg
Non-essential amino acid l-Cysteine
Adduct-hydrolysis 300 min: gantacurium 60 min: CW002 60 min: CW011
10–50 mg/kg 1 min after 8× ED95 gantacurium   
Cucurbit[n]urils Calabadion-1
90% renal; 1 h
60 mg/kg (rocuronium rat)
120 mg/kg (cisatra; rat)
Not significant  
Calabadion-2
69% and 42% renal excretion after 1 h
5–10 mg/kg (rat)
40–80 mg/kg (rat)
Not significant Not yet available for clinical use
  1. IV intravenous, MG Myasthenia gravis, S/E side effects, TOF train of four, TOFR train of four ratio