In talking to healthcare leaders about drug utilization, I’ve fielded many questions concerning the application of clinical evidence to specific drugs and drug categories. I address one popular topic below.
DEAR LUMERE: While my hospital currently limits sugammadex usage, our anesthesiologists have been impressed by the clinical results and want to use it more broadly for reversal of neuromuscular blockade (NMB) after surgery. However, sugammadex is priced two to three times higher than neostigmine. Should we reconsider our restrictions? – SORTING OUT SUGAMMADEX
DEAR SORTING OUT SUGAMMADEX: The short answer is that your sugammadex use restrictions are probably warranted. Let’s look at the financial and clinical big picture to understand why.
First, note that the costs of sugammadex may not be as comparatively high as they seem. Neostigmine is typically administered with the more costly glycopyrrolate, and some hospitals have found that for moderate block, the combined cost of neostigmine + glycopyrrolate nearly rivals that of sugammadex. In those cases, the clinical effects help determine if the marginal cost difference is worth it.
While sugammadex has shown superior outcomes, questions remain about whether these effects are significant enough to make an impact:
- While sugammadex is associated with lower incidence of postoperative residual curarization (PORC)1, pulmonary complication rates have not specifically been studied as outcomes of either sugammadex or neostigmine.
- Sugammadex is associated with lower rates of postoperative nausea and vomiting (PONV), but the risk is not eliminated.2
- Time to recovery is definitely faster for sugammadex compared to neostigmine, but the biggest impact is on deep block, where it can save about 45 minutes.3 In moderate block, the time saved is closer to 10 or 15 minutes.3,4
The actual benefit of each of these findings is likely to vary by surgery type. This may explain why cost-effectiveness analyses typically focus on throughput over clinical advantage, highlighting the drug’s ability to save time and, as a result, reduce staff costs and expand the number of performed procedures. This seems clear: when case volume can be increased, sugammadex is more cost-effective than neostigmine. However, it’s hard to generalize that NMB reversal is what’s limiting OR caseload.
The million-dollar question is specifically when and where the clinical or financial payoff justifies sugammadex’s added expense. To answer this, you’ll need to assess patient outcomes by surgery type as well as by OR and PACU turnaround times to determine whether faster, more complete recovery would actually translate to reduced costs of care and higher throughput.
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1 “Effects of Sugammadex on Incidence of Postoperative Residual Neuromuscular Blockade: A Randomized, Controlled Study.” Brueckmann B, Sasaki N, Grobara P, Li MK, Woo T, de Bie J, et al. British Journal of Anaesthesia, (11/2015)
2 “Retrospective Investigation of Postoperative Outcome After Reversal of Residual Neuromuscular Blockade: Sugammadex, Neostigmine or No Reversal.” Ledowski T, Falke L, Johnston F, Gillies E, Greenaway, et al. European Journal of Anaesthesiology, (8/2014)
3 “Efficacy and Safety of Sugammadex Versus Neostigmine in Reversing Neuromuscular Blockade in Adults.” Hristovska AM, Duch P, Allingstrup M, Afshari A. The Cochrane Database of Systematic Reviews, (8/2017)
4“Sugammadex Efficacy for Reversal of Rocuronium- and Vecuronium-Induced Neuromuscular Blockade: A Pooled Analysis of 26 Studies.” Herring WJ, Woo T, Assaid CA, Lupinacci RJ, et al. Journal of Clinical Anesthesia, (9/2017)