• Practice your interview with the new SDN AI Interview Coach. Choose a school, answer by voice or typing, and receive a personalized feedback report. Available now to all SDN members. Try the AI Interview Coach.

Sugammadex Usage / Cost versus Benefit

Started by YadaYadaNext
This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.
Y

YadaYadaNext

Full Member
Verified Member
15+ Year Member
Advertisement - Members don't see this ad
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
 
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.
 
Advertisement - Members don't see this ad
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
 
Newtwo said:
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
Click to expand...

What's the cost analysis of remifentanil vs sugammadex?
It isn't cheap either.
 
YadaYadaNext said:
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
Click to expand...
 
coffeebythelake said:
What's the cost analysis of remifentanil vs sugammadex?
It isn't cheap either.
Click to expand...
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
 
Newtwo said:
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
Click to expand...

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)
 
okayplayer said:
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?
Click to expand...
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.
 
abolt18 said:
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.
Click to expand...

And that is a guessing game I no longer have to play.
 
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.
 
okayplayer said:
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?
Click to expand...
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.
 
Advertisement - Members don't see this ad
okayplayer said:
All of the above, every time.

Would be like going back to a 1970 Ford Pinto after driving a brand new Tesla.
Click to expand...
That's funny, pretty sure you hated Tesla?

DrOwnage said:
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.
Click to expand...

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)
 
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 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.
 
How sure are you off the cost difference?

dchz said:
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)
Click to expand...
 
YadaYadaNext said:
How sure are you off the cost difference?
Click to expand...

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

dchz said:
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
Click to expand...
 
DrOwnage said:
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 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.
Click to expand...

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.

en.wikipedia.org

Pholcodine - Wikipedia

en.wikipedia.org en.wikipedia.org
.
 
DrOwnage said:
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.
Click to expand...
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.
 
Last edited:
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.
 
Last edited by a moderator:
Newtwo said:
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
Click to expand...

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

dchz said:
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
Click to expand...

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).
 
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.
 
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]
 
Advertisement - Members don't see this ad
caligas said:
Anyone seen or know of an episode of allergic reaction to sugamadex?
Click to expand...
Justice4all said:
I have seen 3. From mild to true anaphylaxis. Likely due to the cyclodextrin.
Epinephrine to the rescue
Click to expand...

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.
 
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.
 
PainDrain said:
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.
Click to expand...

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.
 
  • Like
Reactions: dhb
epidural man said:
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.
Click to expand...

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.
 
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.
 
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??
 
2Fast2Des said:
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??
Click to expand...
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.
 
Merck patent extension expired in January (and June for peds) 😀. Initial patent was issued at the end of 2003. Patent was extended because the FDA took 12 years to approve it. Europe has had generic sugammadex for a while.

“Sugammadex was discovered by the pharmaceutical company Organon at the Newhouse Research Site in Scotland. Organon was acquired by Schering-Plough in 2007; Schering-Plough merged with Merck in 2009. Sugammadex is now owned and sold by Merck.

The US Food and Drug Administration(FDA) initially rejected Schering-Plough's New Drug Application for sugammadex in 2008, but finally approved the medication for use in the United States in December 2015. Sugammadex was approved for use in the European Union in July 2008.”

en.wikipedia.org

Sugammadex - Wikipedia

en.wikipedia.org en.wikipedia.org


B Braun, Glenmark, Hikma, Lupin, and Dr. Reddy’s just launched generic sugammadex in the US. Will be interesting to see where the price settles. Generics in Europe are around $5-10/vial.
 
Last edited:
Advertisement - Members don't see this ad
cittykat said:
Merck patent extension expired in January (and June for peds) 😀. Initial patent was issued at the end of 2003. Patent was extended because the FDA took 12 years to approve it. Europe has had generic sugammadex for a while.

“Sugammadex was discovered by the pharmaceutical company Organon at the Newhouse Research Site in Scotland. Organon was acquired by Schering-Plough in 2007; Schering-Plough merged with Merck in 2009. Sugammadex is now owned and sold by Merck.

The US Food and Drug Administration(FDA) initially rejected Schering-Plough's New Drug Application for sugammadex in 2008, but finally approved the medication for use in the United States in December 2015. Sugammadex was approved for use in the European Union in July 2008.”

en.wikipedia.org

Sugammadex - Wikipedia

en.wikipedia.org en.wikipedia.org


B Braun, Glenmark, Hikma, Lupin, and Dr. Reddy’s just launched generic sugammadex in the US. Will be interesting to see where the price settles. Generics in Europe are around $5-10/vial.
Click to expand...

The generic stuff has arrived and is stocked in our ORs.

I've heard a couple of anecdotal musings that maybe it's not as good as Bridion. I've only used it a few times and it seems to be just fine.

No idea what the cost difference is.

Pharmacy has whined piteously for years that sugammadex is their single highest line item expenditure. Hopefully this stuff is cheaper and just as good.
 
pgg said:
The generic stuff has arrived and is stocked in our ORs.

I've heard a couple of anecdotal musings that maybe it's not as good as Bridion. I've only used it a few times and it seems to be just fine.

No idea what the cost difference is.

Pharmacy has whined piteously for years that sugammadex is their single highest line item expenditure. Hopefully this stuff is cheaper and just as good.
Click to expand...
This is where it’s interesting that we’re required to train residents in “systems based care” yet hospital cost centers are silo’d into pharmacy vs everybody else. If OR time costs about $100 per minute, and you’re able to get return of 4/4 twitches with no fade faster, -and- you have fewer people under reversed who require emergent reintubation (and a surprise night in the ICU). I know I’m hyperbolizing a bit here, but dinosaurs like me who grew up pushing thiopental and pancuronium would have gotten a few hours of our lives back if this wonderdrug had surfaced 20 years earlier.
 
pgg said:
The generic stuff has arrived and is stocked in our ORs.

I've heard a couple of anecdotal musings that maybe it's not as good as Bridion. I've only used it a few times and it seems to be just fine.

No idea what the cost difference is.

Pharmacy has whined piteously for years that sugammadex is their single highest line item expenditure. Hopefully this stuff is cheaper and just as good.
Click to expand...
Down to $9/200mcg I believe (generic).
 
You must log in or register to reply here.

Similar threads

urge
MOCA cost
2
Replies
59
Views
6K
Gern Blansten
Gern Blansten
G
How to Reduce Group's BLOATING Overhead Cost
Replies
3
Views
1K
deleted1130227
D
linkin06
Sugammadex now recommended per ASA
2 3
Replies
107
Views
10K
narcusprince
narcusprince
P
Pain versus cardiac fellowship?
2 3 4 5
Replies
228
Views
26K
AKMD_1984
A
DocVapor
  • Poll Poll
If using sugammadex, do you check twitches?
2 3
Replies
104
Views
9K
UscGhost
U