• P-J de Kam, H Nolte, S Good, M Yunan, D E Williams-Herman, J Burggraaf, C Kluft, N F Adkinson, C Cullen, P S Skov, J H Levy, D J van den Dobbelsteen, E L G M van Heumen, F C M van Meel, D Glassner, T Woo, K C Min, and Peeters P A M PAM MSD, Oss, The Netherlands..
• Merck & Co., Inc., Kenilworth, NJ, USA.
• Br J Anaesth. 2018 Oct 1; 121 (4): 758-767.

BackgroundWe investigated potential for hypersensitivity reactions after repeated sugammadex administration and explored the mechanism of hypersensitivity.MethodsIn this double-blind, placebo-controlled study (NCT00988065), 448 healthy volunteers were randomised to one of three arms to receive three repeat i.v. administrations of either sugammadex 4 mg kg-1, 16 mg kg-1, or placebo. Primary endpoint was percentage of subjects with hypersensitivity (assessed by an independent adjudication committee). Secondary endpoint of anaphylaxis was classified per Sampson and Brighton criteria. Exploratory endpoints included skin testing, serum tryptase, anti-sugammadex antibodies [immunoglobulin (Ig) E/IgG], and other immunologic parameters.ResultsHypersensitivity was adjudicated for 1/148 (0.7%), 7/150 (4.7%), and 0/150 (0.0%) subjects after sugammadex 4 mg kg-1, 16 mg kg-1, and placebo, respectively. After sugammadex 16 mg kg-1, one subject met Sampson criterion 1 and Brighton level 1 (highest certainty) anaphylaxis criteria; two met Brighton level 2 criteria. After database lock it was determined that certain protocol deviations could have introduced bias in the reporting of hypersensitivity signs/symptoms in a subject subset. Objective laboratory investigations indicated that potential underlying hypersensitivity mechanisms were unlikely to have been activated; the results suggest that most of the observed hypersensitivity reactions were unlikely IgE/IgG-mediated.ConclusionDose-dependent hypersensitivity or anaphylaxis reactions to sugammadex were observed when administered without prior neuromuscular blocking agent. Laboratory investigations do not suggest prevalent allergen-specific IgE/IgG-mediated immunologic hypersensitivity. Because it could not be fully excluded that estimates of hypersensitivity/anaphylaxis incidence were unbiased, an additional study was conducted to characterise the potential for hypersensitivity reactions and is described in a companion report.Clinical Trial Registrationhttp://www.clinicaltrials.gov NCT00988065; Protocol number P06042.Copyright © 2018 British Journal of Anaesthesia. All rights reserved.

This article appears in the collection: Sugammadex anaphylaxis: all that glitters?.

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