Sugammadex Usage / Cost versus Benefit

[YadaYadaNext]

Wondering what the thoughts/opinions/practices are regarding use of Sugammadex for :

routine reversal (does this warrant the cost?)

reversal in a limited patient population (what patient risk factors?)

based off of select procedures (what procedures?)

emergency reversal of a cannot intubate/cannot ventilate

no use at all based off of hospital formulary denial

Understood that the cost of sugammadex versus neostigmine plus glyco varies with hospital negotiations/pharma contacts.

Thanks

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[okayplayer]

All of the above, every time.

Would be like going back to a 1970 Ford Pinto after driving a brand new Tesla.

 

[okayplayer]

Things I don’t miss include:
-underdosing roc for short cases and having to intubate when inadequately relaxed
-making pts w/ hx of CAD tachycardic (nice mini stress test) at the end of the case by giving them glyco
-getting called for ? inadeq reversal by PACU RN (for either my or my partners’ patients)

This is by no means a complete list.

 

[abolt18]

Our hospital has transitioned recently to using sugammadex as the standard reversal agent for roc/vec unless you have a really good reason not to.

 

[deleted697535]

Give remi. Haven't thought about needing suggamadex in years. We had it in 2012 or earlier in Europe and gave it to every single case. I have to say I used to think it was great and would always use it. Now I could take it or leave it.

I don't even want to think about needing it for a cico situation

 

[coffeebythelake]

Give remi. Haven't thought about needing suggamadex in years. We had it in 2012 or earlier in Europe and gave it to every single case. I have to say I used to think it was great and would always use it. Now I could take it or leave it.

I don't even want to think about needing it for a cico situation

What's the cost analysis of remifentanil vs sugammadex?
It isn't cheap either.

 

[coffeebythelake]

Wondering what the thoughts/opinions/practices are regarding use of Sugammadex for :

routine reversal (does this warrant the cost?)
Arguable, I don't think there is much additional benefit in otherwise healthy patients where you are careful with NMBD use.

reversal in a limited patient population (what patient risk factors?)
Sure

based off of select procedures (what procedures?)
Procedures where you need muscle relaxant until basically the end of case, short procedures where you need muscle relaxant

emergency reversal of a cannot intubate/cannot ventilate
The alternative is what? Surgical airway?

no use at all based off of hospital formulary denial

Understood that the cost of sugammadex versus neostigmine plus glyco varies with hospital negotiations/pharma contacts.

Thanks

 

[deleted697535]

What's the cost analysis of remifentanil vs sugammadex?
It isn't cheap either.

Good question, I've no idea. It seems like no one really cares about remi anymore so it kind of sneaks under the radar I guess.

Outside of cardiac & suf, I basically only use remi these days. Our clip room can be very busy for example, 4 mitrals clips done, extubated, perky and me gone home by half 3, no suggamadex needed. And these clip ppl ain't exactly athletes

 

[coffeebythelake]

Good question, I've no idea. It seems like no one really cares about remi anymore so it kind of sneaks under the radar I guess.

Outside of cardiac & suf, I basically only use remi these days. Our clip room can be very busy for example, 4 mitrals clips done, extubated, perky and me gone home by half 3, no suggamadex needed. And these clip ppl ain't exactly athletes

I'm sure for the purposes here, there is an inflection point based on (primarily) the case duration where it might make more sense to use remifentanil (shorter case) vs. sugammadex (longer case)

 

[drmwvr]

Things I don’t miss include:
-making pts w/ hx of CAD tachycardic (nice mini stress test) at the end of the case by giving them glyco

then the patient is getting too much glyco

 

[okayplayer]

then the patient is getting too much glyco

And if they need a large dose of neostigmine due to still having a reasonable amount of roc on board, how much glyco do you give?

 

[abolt18]

And if they need a large dose of neostigmine due to still having a reasonable amount of roc on board, how much glyco do you give?

Just enough to prevent bradycardia and bronchospasm from neostigmine. Not so much that they get tachycardic. I know a lot of people give their glyco/neo in equal volumes, but I literally never do that. 3-4cc glyco with 5cc neostigmine is usually my dose. If tachycardic at baseline I may do 2cc glyco.

 

[okayplayer]

Just enough to prevent bradycardia and bronchospasm from neostigmine. Not so much that they get tachycardic. I know a lot of people give their glyco/neo in equal volumes, but I literally never do that. 3-4cc glyco with 5cc neostigmine is usually my dose. If tachycardic at baseline I may do 2cc glyco.

And that is a guessing game I no longer have to play.

 

[DrOwnage]

In my opinion, Sugammadex should be standard of care for NMBD reversal, albeit with a rate of anaphylaxis similar or higher than rocuronium being the only downside.

I've always felt that I can justify my sugammadex use in a stringent pharmacy based on a couple of patient parameters/comorbidities:
- Renal failure or severe renal insufficiency
- BMI > 35
- OSA/Respiratory comorbidities
- Quick cases requiring deep neuromuscular blockade
- Patients with risk factors for CAD
- Angle closure glaucoma

Cool fact: Sugammadex works in the same mechanism of action of Febreze, which contains a beta cyclodextrin ring that binds volatilized hydrocarbons within its structural ring, retaining malodorous molecules and reducing scent.

 

[drmwvr]

And if they need a large dose of neostigmine due to still having a reasonable amount of roc on board, how much glyco do you give?

Whatever dose of neostigmine I give, I'll give half that volume in glyco. I'll admit that I won't do that reversal if I don't think there's adequate recovery. Where I used to just wait, now of course it's suggamadex.

 

[dchz]

All of the above, every time.

Would be like going back to a 1970 Ford Pinto after driving a brand new Tesla.

That's funny, pretty sure you hated Tesla?

In my opinion, Sugammadex should be standard of care for NMBD reversal, albeit with a rate of anaphylaxis similar or higher than rocuronium being the only downside.

I would like your source on this please.



For OP:
Good reasons to use neo/glyco over sugammadex:
- You forgot to tell your female patient to use alternative birth control and you're too lazy to tell her after surgery.

Reasons to use neo/glyco over sugammadex:
- your resident used so much sugammadex you have to teach them a lesson so they know how to use neo/glyco
- you want to use neo to induce a code brown because you hate the circulator
- cost saving (although it'll be like $10-20)

 

[DrOwnage]

I'll have to do some more searching for the specific source, but I had this conversation with an attending who has done quite a bit of research on sugammadex and seen 2 anaphylactic reactions firsthand.

I've seen rocuronium anaphylaxis rates as high as 1:2500 such as in this paper:

Anesthesiology

pubs.asahq.org

In sugammadex's clinical studies it was 0.3%. There was a japanese study recently that found somewhere between 0.02-0.035%.

Orihara M, Takazawa T, Horiuchi T, Sakamoto S, Nagumo K, Tomita Y, Tomioka A, Yoshida N, Yokohama A, Saito S. Comparison of incidence of anaphylaxis between sugammadex and neostigmine: a retrospective multicentre observational study. Br J Anaesth. 2020 Feb;124(2):154-163. doi: 10.1016/j.bja.2019.10.016. Epub 2019 Nov 30. PMID: 31791621.

I do believe the rates of anaphylaxis are most likely to occur with larger doses for deep blockade we don't usually use. And the data is sparse. But foreign countries have much more data as they have been using the drug for almost 10 years longer than us in the U.S.

 

[YadaYadaNext]

How sure are you off the cost difference?

That's funny, pretty sure you hated Tesla?



I would like your source on this please.



For OP:
Good reasons to use neo/glyco over sugammadex:
- You forgot to tell your female patient to use alternative birth control and you're too lazy to tell her after surgery.

Reasons to use neo/glyco over sugammadex:
- your resident used so much sugammadex you have to teach them a lesson so they know how to use neo/glyco
- you want to use neo to induce a code brown because you hate the circulator
- cost saving (although it'll be like $10-20)

 

[dchz]

How sure are you off the cost difference?

as you've said, the real cost depends on the specific institution.

I have verified with the pharmacist on the cost at 4 different institutions. One of them sugammadex is actually less expensive. the other 3 i am 100% sure. But this is only N= 4

 

[YadaYadaNext]

what ballpark cost is a 200mg vial of sugammadex? How about a 10mg vial of neostigmine (Only use 5mg but single vial) plus glyco?

as you've said, the real cost depends on the specific institution.

I have verified with the pharmacist on the cost at 4 different institutions. One of them sugammadex is actually less expensive. the other 3 i am 100% sure. But this is only N= 4

 

[Drwine]

I'll have to do some more searching for the specific source, but I had this conversation with an attending who has done quite a bit of research on sugammadex and seen 2 anaphylactic reactions firsthand.

I've seen rocuronium anaphylaxis rates as high as 1:2500 such as in this paper:

Anesthesiology

pubs.asahq.org

In sugammadex's clinical studies it was 0.3%. There was a japanese study recently that found somewhere between 0.02-0.035%.

Orihara M, Takazawa T, Horiuchi T, Sakamoto S, Nagumo K, Tomita Y, Tomioka A, Yoshida N, Yokohama A, Saito S. Comparison of incidence of anaphylaxis between sugammadex and neostigmine: a retrospective multicentre observational study. Br J Anaesth. 2020 Feb;124(2):154-163. doi: 10.1016/j.bja.2019.10.016. Epub 2019 Nov 30. PMID: 31791621.

I do believe the rates of anaphylaxis are most likely to occur with larger doses for deep blockade we don't usually use. And the data is sparse. But foreign countries have much more data as they have been using the drug for almost 10 years longer than us in the U.S.

The reason rocuronium anaphylaxis is seen in Europe is because of the widespread use of pholcodine as a cough medicine. As far as the original question until the cost goes down I am selective with using it.

Pholcodine - Wikipedia

en.wikipedia.org

.

 

[dchz]

what ballpark cost is a 200mg vial of sugammadex? How about a 10mg vial of neostigmine (Only use 5mg but single vial) plus glyco?

ball park ~$80 for 200mg of sugammadex. neo has some variability and it's institutionally dependent.

 

[MirrorTodd]

The reason rocuronium anaphylaxis is seen in Europe is because of the widespread use of pholcodine as a cough medicine. As far as the original question until the cost goes down I am selective with using it.

Pholcodine - Wikipedia

en.wikipedia.org

.

OMFG that's super ****ing interesting! (not sarcasm)

 

[pjl]

Cool fact: Sugammadex works in the same mechanism of action of Febreze, which contains a beta cyclodextrin ring that binds volatilized hydrocarbons within its structural ring, retaining malodorous molecules and reducing scent.

You mean I can dump it on my hands after an Ancef issue to remove cat piss smell?

Here it is 80 bucks, neo/glyco was 72 until a year or two ago when they dropped to the 20s. We use it every case, happily. It is a better drug with lower complication rate.

 

[nimbus]

Benefits>>>cost

I was a resident shortly after propofol came out. The rep would come by from time to time but she said she didn’t have to do anything because it was just a better drug. I think that’s true for sugammadex too. It’s the NMB “off switch” that surgeons thought we had for the past 50 years.

 

[DrN2O]

Outside of cardiac & suf, I basically only use remi these days. Our clip room can be very busy for example, 4 mitrals clips done, extubated, perky and me gone home by half 3, no suggamadex needed. And these clip ppl ain't exactly athletes

So that's why there is a remi shortage where I am.

I have verified with the pharmacist on the cost at 4 different institutions. One of them sugammadex is actually less expensive. the other 3 i am 100% sure. But this is only N= 4

That won't last forever. Similar to IV acetaminophen, they give the hospital a sweet deal to get them hooked on the new drug. Then after a few years, the price goes up. Sugammadex was cheaper than neo/glyco for awhile here, now our pharmacy wants us go back to neo/glyco, but can't argue with a better drug. (unlike Ofirmev).

 

[epidural man]

We used to have quantitative neuromuscular blockade monitoring - but now all our twitch monitors are broken. They are so finicky.

But that was like driving a cyber truck TESLA. It's hard not having it.

I'm surprised hospitals don't buy them because with that monitor, you can justify not giving anything. That saves a ton of money.

 

[caligas]

Anyone seen or know of an episode of allergic reaction to sugamadex?

 

[deleted697127]

Anyone seen or know of an episode of allergic reaction to sugamadex?

yeup

 

[YadaYadaNext]

This is what I am experiencing. So, if Sugammadex is say $100 - $200 more per case versus neostigmine, multiplied by the number of cases at a high volume center..... where is the breaking point?


That won't last forever. Similar to IV acetaminophen, they give the hospital a sweet deal to get them hooked on the new drug. Then after a few years, the price goes up. Sugammadex was cheaper than neo/glyco for awhile here, now our pharmacy wants us go back to neo/glyco, but can't argue with a better drug. (unlike Ofirmev).
[/QUOTE]

 

[Justice4all]

Anyone seen or know of an episode of allergic reaction to sugamadex?

I have seen 3. From mild to true anaphylaxis. Likely due to the cyclodextrin.
Epinephrine to the rescue

 

[caligas]

I have seen 3. From mild to true anaphylaxis. Likely due to the cyclodextrin.
Epinephrine to the rescue

so isn’t this a reason to use only when neo/glyco is not going to do the trick?

 

[coffeebythelake]

so isn’t this a reason to use only when neo/glyco is not going to do the trick?

Would you avoid suxx or rocuronium because of their anaphylaxis risk? U can always use cistracurium for all your cases, the risk is much lower.

 

[PainDrain]

Anyone seen or know of an episode of allergic reaction to sugamadex?

I have seen 3. From mild to true anaphylaxis. Likely due to the cyclodextrin.
Epinephrine to the rescue

Had one two months ago. End of a long spine case and I gave suggamadex to reverse, extubated about two minutes later and as I was removing the monitors I noticed a single hive on his chest. I thought it was strange but then the nurse changes his gown out and they start appearing all over his chest, legs and neck. I gave Benadryl 50mg and just monitored him. The hives stopped erupting about 5-10 minutes after the dose. I ended up putting it as an allergy in the guys record.

 

[PainDrain]

As for cost-benefit of suggamadex vs neo/glyco it is very difficult to tell overall. I know it’s been studied to death but I think neostigmine still contributes to nausea/vomiting. More N/V means more time in the PACU and more medication to treat the patient; and costs go up.

 

[epidural man]

Had one two months ago. End of a long spine case and I gave suggamadex to reverse, extubated about two minutes later and as I was removing the monitors I noticed a single hive on his chest. I thought it was strange but then the nurse changes his gown out and they start appearing all over his chest, legs and neck. I gave Benadryl 50mg and just monitored him. The hives stopped erupting about 5-10 minutes after the dose. I ended up putting it as an allergy in the guys record.

Maybe.

I have seen people wake up with hive like rashes all over - with no idea where it came from (without using reversal).

People get weird rashes under anesthesia.

 

[PainDrain]

Maybe.

I have seen people wake up with hive like rashes all over - with no idea where it came from (without using reversal).

People get weird rashes under anesthesia.

This was temporally related to the dose of suggamadex so I think it was an actual reaction to the drug. And these were true hives and the guy kept saying how his body was very itchy.

 

[vector2]

This argument over neo/glyco vs sugammadex is absurd. I don't care if neo/glyco is $1 and sug is $100- sug is worth it. In the grand scheme of the cost of surgery and the anesthetic, spending $100 on sug avoid the small (and very expensive) risk of emergence and PACU airway complications is a no brainer.

Not to mention, we should be using the most specific drug when we have a specific purpose in mind. Advocating for neo/glyco for NMB reversal instead of sug is like having an opioid overdose come into the ER and then advocating for a non-narcan alternative that's less effective but which also makes the pt sht their pants.

 

[2Fast2Des]

Can anyone provide a cost analysis of desflurane vs sugammadex vs neo\glyco? Our pharmacy specifically does not stock our room pyxis of sugammadex so we don't use it liberally. It is only in the main pyxis where nurses get their stuff (only a handful usually). They claim cost, however our machines also have des vaporizer as well, and some of the docs use Des (and not at low flows either), one time relieved someone with flows of 4L... How can I show that if they are concerned about cost they should get rid of des and give us sugammadex and not lose money??

 

[deleted875186]

Can anyone provide a cost analysis of desflurane vs sugammadex vs neo\glyco? Our pharmacy specifically does not stock our room pyxis of sugammadex so we don't use it liberally. It is only in the main pyxis where nurses get their stuff (only a handful usually). They claim cost, however our machines also have des vaporizer as well, and some of the docs use Des (and not at low flows either), one time relieved someone with flows of 4L... How can I show that if they are concerned about cost they should get rid of des and give us sugammadex and not lose money??

Ask the department how much they pay for volatiles, pharmacy usually doesn’t order the volatiles so they probably won’t know.

Last hosptial I was at, 80$ for a bottle of sevo, 130$ for a bottle of des. If you factor in the % volatile needed for similar MAC levels, and the greater cost of DES, DES is about 50 times more expensive than sevo to maintain the same MAC level at the same FGF.

You can do some back if the envelope calculations with the formulas in the article I posted above.

 

[deleted875186]

Calculation of volatile anaesthetics consumption from agent concentration and fresh gas flow - PubMed

By application of the presented specific volatile agent constants and equations, it becomes easy to calculate volatile agent consumption if the fresh gas flows and the resulting inhaled concentration of the volatile agent are known. By this method, it is possible to extract data about volatile...

pubmed.ncbi.nlm.nih.gov