P006: CHANGES IN UTILIZATION AND COST FOR REVERSAL OF NEUROMUSCULAR BLOCKADE ASSOCIATED WITH THE ADOPTION OF SUGAMMADEX
Julio A Warren, MD, FASA; Amanda M McGehee, PharmD; Department of Veterans Affairs
Acetylcholinesterase inhibitors (ACHEI) have been a mainstay of use to increase the speed of recovery from neuromuscular blockade induced by nondepolarizing neuromuscular blocking drugs used for the purpose of facilitating intubation and surgical procedures. ACHEI’s however produce unwanted side effects related to their muscarinic activity and are incompletely effective in the absence of some spontaneous neuromuscular recovery. Sugammadex is the first-of-its-kind molecule to selectively encapsulate and inactivate rocuronium. The availability of this medication has affected anesthesia provider prescribing habits and utilization with respect to nondepolarizing neuromuscular blocking agents and neuromuscular blocking reversal agents.
Methods: The Bay Pines VA Healthcare System provides health care services to more than 110,000 Veterans across a 10-county area in southwest Florida. The department of anesthesia adopted the use of sugammadex to the formulary in 2018. Pharmacy purchasing and procurement data from both calendar years 2017 and 2019 for nondepolarizing neuromuscular blocking agents, neuromuscular blocking reversal agents (neostigmine, sugammadex) and glycopyrrolate were examined. 2018 data was intentionally excluded due to the intra-year adoption of sugammadex.
Results: From 2017 to 2019, with the interval introduction of sugammadex to the formulary in 2018, changes in prescribing habits and utilization in the healthcare system favored the increased use of rocuronium for neuromuscular blockade. Commensurate with a substantial pivot from cisatracurium to rocuronium use, there was a 91% decrease in purchasing costs for cisatracurium. Similarly, introduction of sugammadex coincided with decreased purchases of neostigmine amounting to 96%. Overall, there was a 217% annual cost increase for the pharmacologic agents examined in this analysis.
Conclusions: This analysis examined utilization of steroid class versus benzylisoquinolinium muscle relaxants after the introduction of sugammadex to the formulary at the Bay Pines VA Healthcare System. Further, it investigated the use of neuromuscular blocking drug reversal agents after the introduction of sugammadex, contrasting the frequency of its use versus that of neostigmine. Significant cost considerations also applied. Further analysis may determine whether changes in prescribing habits in this healthcare system were associated with changes in the occurrence of postoperative pulmonary complications in general, and also among different risk subsets of our Veteran patient population. Analysis of cost-effectiveness of this change in utilization favoring sugammadex usage is also warranted.