Alternative of flumazenil

 Q: If flumazenil is not available midazolam can be reversed with (select one) 

A) Aminophylline 

B) Remimazolam

Answer: A

Aminophylline has the ability to reverse both sedatives as well as the respiratory depressive effects of midazolam. The dose is 1-2 mg/kg intravenous over five minutes. It is not used as a first-line reversal agent as the effect can be partial and the drug has not been extensively studied. Also, it requires caution in patients with seizures, older age, heart and liver insufficiencies. Aminophylline has been used as a reversal agent for midazolam three decades ago and has seen some come back in newer literature.

Remimazolam is itself a new generation of short-acting benzodiazepine, and may worsen the effect of midazolam.

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References:

1. Aghabiklooei A, Sangsefidi J. The effects of intravenous aminophylline on level of consciousness in acute intentional benzodiazepines poisoning in comparison to flumazenil. Hum Exp Toxicol 2017; 36:311. 

2. Bonfiglio MF, Fisher-Katz LE, Saltis LM, et al. A pilot pharmacokinetic-pharmacodynamic study of benzodiazepine antagonism by flumazenil and aminophylline. Pharmacotherapy 1996; 16:1166. 

3. Sibai AN, Sibai AM, Baraka A. Comparison of flumazenil with aminophylline to antagonize midazolam in elderly patients. Br J Anaesth 1991; 66:591. Gallen JS. Aminophylline reversal of midazolam sedation. Anesth Analg 1989; 69:268.