Sugammadex Vial Wastage: Implications for the Cost of Anesthesia Care in Children: Research Letter.

Abstract

Although pharmaceutical costs account for approximately 15% of the overall cost of anesthetic care, these expenses are frequently assumed to be due to the choice of anesthetic technique (general vs. regional) or the choice of medications used for anesthetic care.1 Seldom addressed in measures to control care-related expenditures is the issue of medication wastage that occurs when a medication vial is opened but not used.1 This waste represents a potential cost saving if the drug was not discarded, because unadministered drugs account for more than 25% of the anesthesia medication budget.1One of the more expensive medications used in anesthetic care is sugammadex, which is currently supplied in 200 mg/2 ml or 500 mg/5 ml vials. Because sugammadex vials are labeled single-dose or single-use only, the standard of care is that partially used or unadministered opened vials are discarded.2 Medication vial wastage is particularly common in pediatric anesthesia because of the variability in patient weights and the fact that medications are administered on a milligram per kilogram body weight basis.1The present study had two objectives. First, we examined the longitudinal trends in sugammadex administration in a national pediatric surgical population, and second, we estimated the proportion of drug wastage and its economic implications based on the minimum sugammadex vial size of 200 mg/2 ml. After institutional review board approval from the Nationwide Children’s Hospital (Columbus, Ohio), we identified 1,550,894 administrations of either rocuronium or vecuronium during induction of anesthesia among children 18 yr or younger across 49 children’s hospitals reporting to the Pediatric Health Information System between January 1, 2017, and September 31, 2022. We then examined the longitudinal trends in sugammadex administration for reversal of neuromuscular blockade across all study centers. We finally performed a budget impact analysis of the amount of wasted drug based on the minimum sugammadex vial size of 200 mg/2 ml. We defined drug wastage as documented less than 100 mg administration because such instances signify partial vial use, consistent with the Centers for Disease Control and Prevention (Atlanta, Georgia) recommendation.2 We calculated the 2022 inflation-adjusted cost saving, if a sugammadex vial size of 100 mg/1 ml were available, by multiplying the frequency of 100 mg or less administered to $49.87 (half of the acquisition cost of 200 mg/2 ml sugammadex).We identified 400,838 sugammadex administrations during the study period between January 1, 2017, through the third quarter of 2022. Sugammadex administration increased by 43% by the end of the study period. Drug wastage occurred in almost 3 of 5 administered doses (59.2%, n = 237,092). If sugammadex vial size of 100 mg/ml were available and it cost roughly half that of a 200-mg vial, or if vials were split, then an estimated $14,000,000 worth of drug would not have been discarded during the study period. By the third quarter of 2022, the quarterly average cost saving in the absence of medication wastage was $40,235 (fig. 1).Sugammadex is one of many expensive medications where the minimum vial contains quantities larger than the amount needed for pediatric patients. Two other commonly used medications with similar concerns are acetaminophen (1,000 mg/100 ml) and dexmedetomidine (100 mcg/2 ml). Previous research has proposed cost-saving solutions to reduce or eliminate the cost associated with drug wastage.3 These solutions include regulations to require manufacturers to identify vials that match doses commonly used in the pediatric population (e.g., 50-mg or 100-mg vials). Another solution would be the adoption of certified disposal and a virtual return system that would require manufacturers to refund the cost of leftover drugs. Finally, there is the option of not using sugammadex for neuromuscular blockade reversal given the recent findings that its use is not associated with reduced incidence of perioperative respiratory adverse events.4 Studies in adults have shown mixed results about the cost-effectiveness of neostigmine in comparison with sugammadex.5 Given the unique dosage requirements in children, further research is needed to determine whether using neostigmine is associated with cost reductions compared with sugammadex, given currently available vial sizes.The Centers for Disease Control and Prevention has published formal guidelines regarding vial repackaging that should be performed under USP Pharmaceutical Compounding Compendium, as well as the manufacturer’s recommendations about the safe storage of medications outside their original containers. Vial repackaging should be performed by a trained pharmacist or pharmacy technician under a sterile hood. The new vial or syringe must be labeled with pertinent information regarding the medication, including its name, medication concentration, total volume, and expiration date.2 Research is needed to describe current vial-splitting practices and explore any missed opportunity to maximize their safety (e.g., medication contamination).Certain limitations of this report must be acknowledged. Some pharmacies may report the total cost of vials instead of the administered dose. However, if this were to happen, it would only underestimate the magnitude of the total potential cost saving. In conclusion, we observed increasing trends of sugammadex administration, most of which were associated with drug wastage. The financial implications of such drug wastage underline an urgent need for pharmaceutical companies to produce vials appropriate for pediatric anesthesia and for hospitals to consider repackaging strategies in the short term.The authors declare no competing interests.