The Cyclodextrin Sugammadex and Anaphylaxis to Rocuronium: Is Rocuronium Still Potentially Allergenic in the Inclusion Complex Form?
B. A. Baldo,
N. J. McDonnell,
N. H. Pham.
Rocuronium, a non-depolarizing neuromuscular blocking drug has a rapid onset of action, a comparatively low
potency and, with a more favourable side effects profile than succinylcholine, it has become a popular alternative to that
drug for rapid sequence inductions in anaesthesia. The rocuronium-binding cyclodextrin derivative sugammadex,
prepared by per-6 substitution of the primary hydroxyls of γ-cyclodextrin with thiol ether-linked propionic acid side
chains to extend the hydrophobic cavity to accommodate rocuronium, is used to reverse neuromuscular blockade by
encapsulating the drug as an inclusion complex and removing it from the neuromuscular junction to the plasma. It has
recently been suggested that sugammadex might also be of value in the management of rocuronium-induced anaphylaxis
and this has been potentially supported by recent case reports. However, before sugammadex can be recommended for
this purpose, it is important to establish whether or not the allergenic substituted ammonium groups at each end of the
rocuronium molecule in the inclusion complex are masked within the cavity or left exposed for interaction with
rocuronium-reactive IgE antibodies in the sera of rocuronium-allergic patients. Detailed experimental strategies and
experimental protocols to investigate the allergenic potential of the sugammadex-rocuronium inclusion complex are
presented and a possible explanation of the apparently rapid and successful reversal of anaphylaxis by administration of
sugammadex is advanced and discussed.
Keywords: Sugammadex, perioperative anaphylaxis, cyclodextrins, drug allergy, rocuronium, drug-specific IgE.
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