NEUROMUSCULAR BLOCKADE (GS MURPHY, SECTION EDITOR)
Mivacurium: a Review
Lisa S. Molloy
Published online: 22 March 2018
Springer Science+Business Media, LLC, part of Springer Nature 2018
Purpose of Review Mivacurium is a short-acting non-depolarizing neuromuscular-blocking agent (NMBA) which has recently
been re-released onto the US market. This review provides a brief overview about the pharmacology of mivacurium and
discusses its use in recent clinical practice.
Recent Findings Mivacurium has been reported to be especially useful in the pediatric population, especially for shorter cases,
and infusions can be used for longer cases without inducing tachyphylaxis. As it is rapidly metabolized by pseudocholinesterase
(PChE), mivacurium does usually not require a specific reversal agent to offset its actions at the end of surgery. Especially for use
in short cases, this makes it a potentially advantageous alternative to the use of other NMBA. However, deficiencies in PChE as
well as old age and some drug interactions can be associated with prolonged neuromuscular blockade. The rapid administration
of higher doses may provoke significant histamine release leading to hemodynamic compromise.
Summary Despite other NMBA being available on the market and its side effects, mivacurium may still be a useful agent in short
cases, particularly in the pediatric population.
Mivacurium chloride is a short-acting, non-depolarizing neu-
romuscular-blocking agent (NMBA) which was first synthe-
sized in 1981. It belongs to the benzylisoquinolinium group.
Although muscle relaxation with mivacurium can principally
be extended to any duration of surgery, it may be best suited to
short surgical procedures, where rapid recovery without the
need for reversal may be advantageous. Interestingly, and pos-
sibly related to either the non-availability or the high costs of
the reversal agent sugammadex, mivacurium has recently
been re-released in the USA after previous discontinuation
of sales in 2007.
The aim of this article is to briefly review the pharmacology
of mivacurium, with particular emphasis on its side effects and
its current use in clinical practice. We also discuss the need for
such NMBAs in an era where alternative agent-reversal strate-
gies (i.e., rocuronium-sugammadex) are readily available.
Mivacurium is a short-acting, highly selective
benzylisoquinolinium consisting of three isomers in an acidic
solution with a pH of 4.5. As with all NMBA, mivacurium is a
competitive antagonist of acetylcholine at the postsynaptic
nicotinic receptors. An additional phenolic group sets its struc-
ture apart from atracurium. Mivacurium does not undergo
Hoffman degradation—it relies predominantly on plasma
pseudocholinesterase (PChE) for metabolism, and, although
only infrequently found, any deficiency will result in a pro-
longation of the neuromuscular block.
This article is part of the Topical Collection on Neuromuscular Blockade
* Thomas Ledowski
Lisa S. Molloy
Medical School University of Western Australia, 35 Stirling Hwy,
Crawley, WA 6009, Australia
Department of Anaesthesia and Pain Medicine, Royal Perth Hospital,
Wellington Street, Perth, WA 6000, Australia
Current Anesthesiology Reports (2018) 8:125–129