Bridion (Sugammadex)
Selective Relaxant Binding Agent — Reversal of Neuromuscular Blockade
Bridion (sugammadex) is a selective relaxant binding agent used to reverse neuromuscular blockade induced by rocuronium or vecuronium during surgery. It works by encapsulating these muscle relaxants, allowing patients to resume spontaneous breathing rapidly after an operation. Bridion is administered intravenously by an anaesthesiologist and is approved for use in adults and paediatric patients from birth.
Quick Facts
Key Takeaways
- Bridion (sugammadex) is a selective reversal agent that specifically reverses neuromuscular blockade caused by rocuronium and vecuronium, enabling faster post-operative recovery
- It works in as little as 1.5 to 3 minutes depending on the dose, making it significantly faster than traditional reversal agents such as neostigmine
- Common side effects include cough, airway complications of anaesthesia, and procedural hypotension; severe allergic reactions are uncommon but possible
- Bridion can reduce the effectiveness of hormonal contraceptives — additional barrier contraception is recommended for 7 days after administration
- It is not recommended for patients with severe renal impairment (CrCl < 30 ml/min) because it is eliminated primarily through the kidneys
What Is Bridion and What Is It Used For?
Bridion contains the active substance sugammadex, a modified gamma-cyclodextrin that acts as a selective relaxant binding agent. Unlike traditional reversal agents that work by inhibiting the enzyme acetylcholinesterase, sugammadex has a unique mechanism of action: it directly encapsulates (wraps around) the neuromuscular blocking agents rocuronium bromide and vecuronium bromide, forming a tight water-soluble complex. This complex is then excreted by the kidneys, effectively removing the muscle relaxant from the body.
During certain types of surgical procedures, general anaesthesia includes neuromuscular blocking agents (NMBAs) that cause complete muscle relaxation. This paralysis makes it easier for the surgeon to operate, particularly during abdominal, thoracic, and orthopaedic procedures. However, because these drugs also paralyse the respiratory muscles, patients require mechanical ventilation (artificial breathing support) throughout the operation and into the recovery period until they can breathe on their own.
Bridion is used to speed up the recovery of muscle function after surgery so that patients can resume spontaneous breathing more quickly. By selectively binding to rocuronium or vecuronium molecules in the bloodstream, sugammadex rapidly reduces the free concentration of these blocking agents at the neuromuscular junction. This results in a much faster and more predictable reversal of paralysis compared to the conventional approach of waiting for the drug to wear off naturally or using older reversal agents such as neostigmine combined with glycopyrrolate.
The drug is approved for use in adults when either rocuronium or vecuronium has been used as the neuromuscular blocking agent. For the paediatric population (neonates, infants, children and adolescents from birth to 17 years), sugammadex is recommended only for routine reversal of rocuronium-induced blockade. Bridion was first approved by the European Medicines Agency (EMA) in 2008 and subsequently by the U.S. Food and Drug Administration (FDA) in 2015, and it has since become widely used in perioperative medicine worldwide.
Available Brands
Several brands and generic versions of sugammadex are available internationally, including Bridion (the original brand by MSD), Sugammadex Noridem, Sugammadex Mylan, Sugammadex Baxter, Sugammadex Teva, Sugammadex Zentiva, Sugammadex Reddy, and Sugammadex Amomed. All contain the same active substance at 100 mg/ml concentration.
What Should You Know Before Receiving Bridion?
Contraindications
Bridion must not be given to anyone who has a known allergy (hypersensitivity) to sugammadex sodium or any of the excipients in the formulation. If you have previously experienced an allergic reaction to sugammadex, it is essential to inform your anaesthesiologist before any future surgical procedure, as re-exposure could trigger a more severe reaction. Hypersensitivity reactions to sugammadex, including anaphylaxis, have been documented in both clinical trials and post-marketing surveillance.
Warnings and Precautions
Before receiving Bridion, speak with your anaesthesiologist if any of the following conditions apply to you:
- Kidney disease: Bridion is excreted through the kidneys. It is not recommended for patients with severe renal impairment (creatinine clearance below 30 ml/min), including those on dialysis. Patients with mild to moderate kidney problems may still receive it, but closer monitoring may be needed.
- Liver disease: Although sugammadex is not metabolised or excreted by the liver, patients with severe hepatic impairment should be treated with particular caution. If liver disease is accompanied by coagulopathy, the bleeding risk considerations below also apply.
- Fluid retention (oedema): Conditions associated with prolonged circulation time, such as oedema or cardiovascular disease, may delay recovery time after sugammadex administration.
- Bleeding disorders or anticoagulant therapy: Sugammadex can cause transient, limited prolongation of activated partial thromboplastin time (aPTT) and prothrombin time (PT/INR). These effects are generally short-lived (under 30 minutes) and not clinically significant for most patients. However, an increased risk of bleeding cannot be excluded in patients with hereditary coagulation factor deficiencies, existing coagulopathies, those taking coumarin derivatives with INR above 3.5, or those receiving the 16 mg/kg dose.
Healthcare professionals should be prepared for the possibility of drug hypersensitivity reactions, including anaphylaxis, and take necessary precautions. Symptoms may include flushing, urticaria, erythematous rash, severe hypotension, tachycardia, tongue or throat swelling, bronchospasm, and airway obstruction. Severe reactions can be life-threatening.
Drug Interactions
Certain medications can affect how Bridion works, or Bridion may affect other medications. It is particularly important to tell your anaesthesiologist if you have recently taken:
- Toremifene (used to treat breast cancer) — has relatively high binding affinity for sugammadex and may displace rocuronium or vecuronium from the sugammadex complex, potentially prolonging recovery time.
- Fusidic acid (an antibiotic, given intravenously) — pre-operative use may prolong the time to recovery of the T4/T1 ratio to 0.9.
Effect on Hormonal Contraceptives
Bridion can reduce the effectiveness of hormonal contraceptives, including combined oral contraceptive pills, progestogen-only pills, vaginal rings, implants, and hormonal intrauterine devices. The interaction results from sugammadex binding to progestogen, reducing its plasma concentration. The effect is calculated to be equivalent to one missed oral contraceptive pill.
If you take a combined or progestogen-only pill on the same day as receiving Bridion, follow the missed pill instructions in your contraceptive leaflet. If you use a non-oral hormonal method (vaginal ring, implant, or hormonal IUD), use an additional non-hormonal contraceptive method (such as a condom) for the following 7 days.
Pregnancy and Breastfeeding
There are no adequate data on the use of sugammadex in pregnant women. Animal studies have not shown direct or indirect harmful effects on pregnancy, embryo-foetal development, parturition, or postnatal development. Sugammadex should be used during pregnancy only when the clinical benefit justifies the potential risk, and the decision should be made in consultation with the treating anaesthesiologist.
It is unknown whether sugammadex is excreted in human breast milk. Animal studies have shown excretion into breast milk, but oral absorption of cyclodextrins is generally low, and no effect on a breastfed infant is expected after a single dose. A decision should be made by the treating physician, weighing the benefit of breastfeeding for the child against the benefit of treatment for the mother.
Sodium Content
Bridion contains up to 9.7 mg sodium per millilitre, corresponding to 0.5% of the WHO recommended maximum daily intake of 2 grams of sodium for adults. This should be considered for patients on a sodium-restricted diet.
How Does Bridion Interact with Other Drugs?
Drug interactions with sugammadex can be categorised into two distinct mechanisms. The first involves displacement interactions, where other medications can displace the neuromuscular blocking agent from the sugammadex complex, potentially leading to recurrence of neuromuscular blockade. The second involves complex-forming interactions, where sugammadex itself binds to other drugs, reducing their effectiveness.
Displacement Interactions (Affecting Sugammadex Efficacy)
When certain medications are administered after sugammadex, they could theoretically cause rocuronium or vecuronium to be displaced from the sugammadex molecule. If this occurs, the neuromuscular blocking effect may return, requiring ventilatory support and possible re-dosing of sugammadex. Patients should be monitored for signs of recurrence of blockade for up to 15 minutes if another drug is administered parenterally within 7.5 hours of sugammadex.
Complex-Forming Interactions (Affecting Other Drugs)
Sugammadex may bind to certain other drugs administered concurrently, thereby reducing their free plasma concentration and clinical effect. The most clinically relevant example is the interaction with hormonal contraceptives, particularly progestogens.
| Interacting Drug | Interaction Type | Clinical Significance | Recommendation |
|---|---|---|---|
| Toremifene | Displacement | May prolong recovery from NMB; recurrence possible | Extended monitoring; inform anaesthesiologist if taken same day as surgery |
| Fusidic acid (IV) | Displacement | May prolong T4/T1 recovery time | Post-operative monitoring; recurrence not expected in recovery phase |
| Hormonal contraceptives | Complex-forming | 34% reduction in progestogen AUC (equivalent to one missed pill) | Follow missed pill instructions or use barrier contraception for 7 days |
| Vitamin K antagonists | Pharmacodynamic (in vitro) | Transient aPTT and PT prolongation (≤ 30 min) | Not clinically relevant for routine postoperative anticoagulant prophylaxis |
| Heparins (UFH/LMWH) | Pharmacodynamic (in vitro) | Transient coagulation parameter changes | Caution in patients with pre-existing coagulopathies |
| Rivaroxaban, Dabigatran | Pharmacodynamic (in vitro) | Transient aPTT and PT prolongation observed in vitro | Not clinically relevant for routine use; caution with therapeutic anticoagulation |
Re-Administration of Neuromuscular Blocking Agents
If neuromuscular blockade is required again after reversal with sugammadex, specific waiting times must be observed before re-administering rocuronium or vecuronium. These waiting times depend on the dose of sugammadex given and the desired dose of the neuromuscular blocking agent.
| Minimum Waiting Time | NMBA and Dose | Notes |
|---|---|---|
| 5 minutes | Rocuronium 1.2 mg/kg | Onset may be prolonged by ~4 min; duration shortened by ~15 min |
| 4 hours | Rocuronium 0.6 mg/kg or Vecuronium 0.1 mg/kg | Standard re-dosing with normal onset and duration |
| 24 hours | Rocuronium 0.6 mg/kg or Vecuronium 0.1 mg/kg | Recommended for patients with mild-moderate renal impairment |
| 24 hours | Any dose of rocuronium or vecuronium | After immediate reversal with 16 mg/kg sugammadex |
If neuromuscular blockade is needed before the recommended waiting time has elapsed, a non-steroidal neuromuscular blocking agent (such as cisatracurium) should be used instead. Note that the onset of a depolarising agent (succinylcholine) may be slower than expected if a significant proportion of nicotinic receptors are still occupied by the original blocking agent.
What Is the Correct Dosage of Bridion?
Bridion should only be administered by, or under the supervision of, an anaesthesiologist. The use of a neuromuscular monitoring technique is recommended to assess the depth of blockade and determine the appropriate timing and dose. All doses are calculated based on actual body weight, including in patients with obesity (BMI ≥ 40 kg/m²).
Adults
Routine Reversal — Moderate Blockade (Reappearance of T2)
Dose: 2 mg/kg intravenous bolus
Administered when spontaneous recovery has reached the reappearance of T2 (second twitch of train-of-four) after rocuronium or vecuronium-induced blockade. Median time to recovery of T4/T1 ratio to 0.9 is approximately 2 minutes.
Routine Reversal — Deep Blockade (1–2 PTC)
Dose: 4 mg/kg intravenous bolus
Administered when recovery has reached at least 1–2 post-tetanic counts (PTC) after rocuronium or vecuronium-induced blockade. Median time to recovery of T4/T1 ratio to 0.9 is approximately 3 minutes.
Immediate Reversal of Rocuronium (Adults Only)
Dose: 16 mg/kg intravenous bolus
For clinical situations requiring immediate reversal following a bolus of 1.2 mg/kg rocuronium bromide. When 16 mg/kg is administered 3 minutes after rocuronium, median recovery time to T4/T1 ratio 0.9 is approximately 1.5 minutes. There are insufficient data to recommend sugammadex for immediate reversal of vecuronium.
Children (Birth to 17 Years)
Sugammadex is approved for routine reversal of rocuronium-induced blockade in paediatric patients from birth to 17 years of age. The weight-based dosing is the same as for adults:
- 2 mg/kg at reappearance of T2 (routine reversal of moderate blockade)
- 4 mg/kg at 1–2 PTC (routine reversal of deep blockade)
For paediatric patients, Bridion 100 mg/ml may be diluted to 10 mg/ml with 0.9% sodium chloride to improve dosing accuracy, particularly in neonates and infants where small volumes are critical.
Immediate reversal (16 mg/kg) has not been studied in the paediatric population. Only routine reversal of rocuronium is recommended for patients under 18. Reversal of vecuronium has not been studied in paediatric patients.
Elderly Patients
Conditions associated with prolonged circulation time, including advanced age, may be associated with longer recovery times. While the dose recommendations are the same as for other adults, elderly patients may experience slightly slower reversal. No dose adjustment is required, but monitoring should be performed as with any patient.
Renal Impairment
Sugammadex is primarily excreted renally. It is not recommended for patients with severe renal impairment (creatinine clearance < 30 ml/min) or those requiring dialysis. For patients with mild or moderate renal impairment, the standard dose can be used; however, the waiting time before re-administering rocuronium (0.6 mg/kg) or vecuronium (0.1 mg/kg) should be extended to 24 hours.
Patients with Obesity
For patients with obesity, including morbid obesity (BMI ≥ 40 kg/m²), the dose should be calculated using actual body weight. The same dosing recommendations as for other adults apply. Clinical studies in patients with morbid obesity have confirmed that this approach provides adequate reversal.
Overdose
In clinical studies, one case of accidental overdose at 40 mg/kg was reported without significant adverse effects. In a human tolerability study, doses up to 96 mg/kg were administered with no dose-related serious adverse effects. Sugammadex can be removed by haemodialysis using a high-flux filter (up to 70% plasma concentration reduction after 3–6 hours), but not with a low-flux filter.
What Are the Side Effects of Bridion?
Like all medicines, Bridion can cause side effects, although not everybody gets them. Because Bridion is administered alongside other anaesthetic agents and neuromuscular blocking agents in the surgical setting, establishing a clear causal relationship can be challenging. The safety of sugammadex has been evaluated in over 3,500 subjects in pooled Phase I–III studies.
Common Side Effects
May affect up to 1 in 10 patients
- Cough — may occur as the patient begins to emerge from anaesthesia
- Airway complications of anaesthesia — including bronchospasm against the endotracheal tube, light bronchospasm, and awakening reactions during the operation
- Light anaesthesia — the patient may begin to wake up from deep sleep and require additional anaesthetic; this can manifest as movement or coughing at the end of the procedure
- Procedural complications — changes in heart rate, coughing, or movement related to the surgical procedure
- Procedural hypotension — a decrease in blood pressure related to the surgical procedure
Uncommon Side Effects
May affect up to 1 in 100 patients
- Bronchospasm — shortness of breath caused by muscle spasm in the airways, reported more frequently in patients with a history of pulmonary disease
- Hypersensitivity reactions — including skin rash, flushing, swelling of the tongue and/or throat, shortness of breath, changes in blood pressure or heart rate. Severe allergic or anaphylactic reactions can be life-threatening. These were reported more frequently in conscious healthy volunteers
- Recurrence of neuromuscular blockade — return of muscle paralysis after initial reversal, observed with an incidence of 0.20% when doses were used for deep blockade reversal
Frequency Not Known
Cannot be estimated from available data
- Severe bradycardia — marked slowing of the heart rate that may progress to cardiac arrest. Isolated cases have been observed within minutes of sugammadex administration during post-marketing surveillance
Additional Side Effects in Healthy Volunteers
In Phase I studies with healthy conscious subjects (where effects could be directly reported rather than being masked by anaesthesia), the following additional side effects were identified as common or very common compared to placebo:
- Dysgeusia (altered taste) — 10.1%
- Headache — 6.7%
- Nausea — 5.6%
- Urticaria (hives) — 1.7%
- Pruritus (itching) — 1.7%
- Dizziness — 1.6%
- Vomiting — 1.2%
- Abdominal pain — 1.0%
Hypersensitivity: Detailed Information
In a dedicated randomised, double-blind study in healthy volunteers receiving up to 3 doses, the incidence of adjudicated hypersensitivity was 1.3% in the placebo group, 6.6% in the sugammadex 4 mg/kg group, and 9.5% in the sugammadex 16 mg/kg group. Verified anaphylaxis occurred in one subject at the 16 mg/kg dose (incidence 0.7%). In an earlier study of similar design, three verified cases of anaphylaxis were reported, all at 16 mg/kg (incidence 2.0%). There was no evidence of increased frequency or severity with repeated dosing.
Post-marketing experience has identified hypersensitivity to both sugammadex alone and to the sugammadex-rocuronium complex. Reactions have occurred in patients with no prior exposure to sugammadex.
Special Populations
Pulmonary patients: Bronchospasm has been reported as a possibly related adverse reaction in patients with a history of pulmonary complications. Clinicians should be vigilant for this possibility.
Paediatric patients: In studies from birth to 17 years, the safety profile at doses up to 4 mg/kg was generally similar to that in adults.
Patients with morbid obesity: A dedicated clinical study confirmed that the safety profile was generally similar to the overall adult population.
ASA class 3–4 patients: In a study of patients with severe systemic disease, the adverse event profile was generally similar to the pooled adult data.
How Should Bridion Be Stored?
Bridion storage is handled by healthcare professionals in the hospital or surgical facility. The following storage guidelines apply:
- Unopened vials: Store below 30°C. Do not freeze. Keep the vials in the outer carton to protect from light. Shelf life is 3 years from manufacture.
- After opening or dilution: Store at 2–8°C and use within 24 hours. Chemical and physical stability data show that sugammadex is stable for 48 hours at 2–25°C, but from a microbiological standpoint, the diluted product should be used immediately unless dilution was performed under controlled and validated aseptic conditions.
- Appearance: Bridion is a clear, colourless to slightly yellow solution. Do not use if the solution appears discoloured or contains particulate matter.
Bridion can be injected into an intravenous line concurrently running with: 0.9% sodium chloride, 5% glucose, 0.45% sodium chloride with 2.5% glucose, Ringer's lactate solution, or Ringer's solution. The intravenous line must be flushed thoroughly (e.g. with 0.9% sodium chloride) between the administration of Bridion and other drugs.
Any unused medicine should be disposed of in accordance with local requirements. Do not dispose of medicines via wastewater or household waste.
What Does Bridion Contain?
Active Ingredient
The active substance is sugammadex, supplied as sugammadex sodium. Each 1 ml of solution for injection contains sugammadex sodium equivalent to 100 mg sugammadex. Bridion is available in two vial sizes:
- 2 ml vial: 200 mg sugammadex
- 5 ml vial: 500 mg sugammadex
Inactive Ingredients (Excipients)
- Water for injections
- Hydrochloric acid 3.7% (for pH adjustment)
- Sodium hydroxide (for pH adjustment)
Packaging
Bridion is supplied in packs of 10 vials containing either 2 ml or 5 ml of solution for injection. Not all pack sizes may be marketed in all countries. The marketing authorisation holder is Merck Sharp & Dohme B.V., Waarderweg 39, 2031 BN Haarlem, The Netherlands.
Frequently Asked Questions About Bridion
Bridion (sugammadex) is used in hospitals to reverse the effects of neuromuscular blocking agents rocuronium and vecuronium. These muscle relaxants are given during general anaesthesia to paralyse muscles for surgery. After the operation, Bridion is administered intravenously by an anaesthesiologist to rapidly restore muscle function, allowing the patient to breathe on their own again. It is approved for adults (both rocuronium and vecuronium) and paediatric patients from birth to 17 years (rocuronium only).
Bridion works very quickly compared to traditional reversal agents. At a dose of 2 mg/kg (routine reversal at T2), the median time to full recovery is about 2 minutes. At 4 mg/kg (deep blockade reversal), it takes about 3 minutes. For immediate reversal using 16 mg/kg given 3 minutes after rocuronium 1.2 mg/kg, the median recovery time is approximately 1.5 minutes. This is substantially faster than neostigmine, which can take 15–30 minutes or longer.
Yes. Bridion can reduce the effectiveness of hormonal contraceptives by binding to progestogen and reducing its plasma concentration. The effect is equivalent to missing one contraceptive pill. If you take the pill on the same day as receiving Bridion, follow the missed pill instructions in your contraceptive leaflet. If you use a vaginal ring, implant, or hormonal IUD, use an additional non-hormonal method such as a condom for the following 7 days after receiving Bridion.
Bridion is not recommended for patients with severe renal impairment (creatinine clearance below 30 ml/min) or those on dialysis, because the drug is excreted by the kidneys. Patients with mild or moderate kidney impairment can receive Bridion at standard doses, but the waiting time before any re-administration of rocuronium or vecuronium should be extended to 24 hours. If sugammadex is given to a patient who later requires dialysis, a high-flux dialysis filter can remove up to 70% of the drug over 3–6 hours.
Bridion and neostigmine reverse neuromuscular blockade through fundamentally different mechanisms. Neostigmine is an acetylcholinesterase inhibitor that increases acetylcholine at the neuromuscular junction, competing with the blocking agent. It requires co-administration of an anticholinergic (such as glycopyrrolate) to counteract muscarinic side effects, works only when the blockade has already started to spontaneously recover, and takes 15–30 minutes. Bridion (sugammadex) directly encapsulates rocuronium or vecuronium, can reverse even deep or immediate post-dose blockade, works in 1.5–3 minutes, and does not require an anticholinergic. However, sugammadex only works against steroidal NMBAs (rocuronium and vecuronium), not benzylisoquinolinium agents like cisatracurium.
There are no adequate clinical data on the use of sugammadex in pregnant women. Animal studies have not shown harmful effects on pregnancy or foetal development. If surgery requiring neuromuscular blockade and reversal is needed during pregnancy, Bridion may be used after careful discussion between the patient and the anaesthesiologist, weighing the clinical benefit against potential risks. The decision should be made on a case-by-case basis.
References
- European Medicines Agency (EMA). Bridion (sugammadex) — Summary of Product Characteristics. Last updated 2025. Available at: www.ema.europa.eu/en/medicines/human/EPAR/bridion
- U.S. Food and Drug Administration (FDA). BRIDION (sugammadex) Prescribing Information. Merck Sharp & Dohme LLC. Available at: www.accessdata.fda.gov
- Hristovska AM, Duch P, Allingstrup M, Afshari A. Efficacy and safety of sugammadex versus neostigmine in reversing neuromuscular blockade in adults. Cochrane Database of Systematic Reviews. 2017;(8):CD012763. doi:10.1002/14651858.CD012763
- Carron M, Zarantonello F, Lazzarotto N, Tellaroli P, Ori C. Role of sugammadex in accelerating postoperative discharge: A meta-analysis. J Clin Anesth. 2017;39:38–44.
- Puhringer FK, Rex C, Sielenkamper AW, et al. Reversal of profound, high-dose rocuronium-induced neuromuscular blockade by sugammadex at two different time points: an international, multicenter, randomized, dose-finding, safety assessor-blinded, phase II trial. Anesthesiology. 2008;109(2):188–197.
- World Health Organization. WHO Model List of Essential Medicines — 23rd List (2023). Geneva: WHO; 2023.
- Fuchs-Buder T, Meistelman C, Raft J. Sugammadex: clinical development and practical use. Korean J Anesthesiol. 2013;65(6):495–500.
- Naguib M. Sugammadex: another milestone in clinical neuromuscular pharmacology. Anesth Analg. 2007;104(3):575–581.
Editorial Team
iMedic Medical Editorial Team — specialists in anaesthesiology and clinical pharmacology with extensive experience in perioperative medicine and drug safety.
iMedic Medical Review Board — independent panel of physicians who review all content according to EMA, FDA, and WHO guidelines using the GRADE evidence framework.
Evidence standard: All medical claims in this article are supported by Level 1A evidence from systematic reviews, randomised controlled trials, and official regulatory documents (EMA SmPC, FDA prescribing information). This content is updated regularly to reflect the latest approved prescribing information.
Conflict of interest statement: iMedic receives no funding from pharmaceutical companies. All editorial content is independent and free from commercial influence.