Comparative Efficacy and Safety of Remimazolam Versus Propofol for Sedation in Gastrointestinal Endoscopy: A Systematic Review and Meta-Analysis

Propofol is the cornerstone sedative for gastrointestinal (GI) endoscopy but is associated with dose-dependent cardiorespiratory depression. Remimazolam, a novel ultrashort-acting benzodiazepine with a specific antagonist (flumazenil), may offer a safer profile. This meta-analysis aimed to compare the efficacy and safety of remimazolam versus propofol for sedation in adult patients undergoing GI endoscopic procedures. We systematically searched PubMed, Web of Science, EMBASE, and the Cochrane Library from inception to January 5, 2026. Randomized controlled trials (RCTs) comparing intravenous remimazolam with propofol for sedation during GI endoscopy were included. The primary outcome was the incidence of a composite of cardiorespiratory adverse events (hypotension, respiratory depression/hypoxemia, bradycardia). Secondary outcomes included sedation success rate, recovery times, and patient/physician satisfaction. Risk of bias (RoB) was assessed using the Cochrane RoB 2 tool. Data were pooled using a random-effects model. Heterogeneity was quantified by I². 14 RCTs (n=2,883 patients) were included. Remimazolam significantly reduced the risk of the composite cardiorespiratory adverse event compared to propofol (risk ratio (RR) = 0.34, 95% confidence interval (CI): 0.27-0.44; I² = 56%). Sedation success rates were comparable between groups. Recovery profiles were similar or favorable for remimazolam in several studies, and it was associated with significantly less injection pain and higher patient satisfaction in some trials. Remimazolam offers a superior safety profile regarding cardiorespiratory stability compared to propofol for sedation in GI endoscopy, while maintaining non-inferior efficacy. These findings support remimazolam as a valuable alternative, especially for patients at higher risk of sedation-related complications.