Cost-Effective Use of Sugammadex

Neostigmine and sugammadex (Bridion) are the currently available neuromuscular blockade reversal agents.  Both have a place in therapy, but sugammadex is much more expensive than neostigmine.  Use this checklist to improve the cost-effective use of sugammadex.

Goal

Suggested Approach

Use sugammadex in appropriate patients.

 

  • Generally, use neostigmine plus glycopyrrolate (reduces adverse effects of neostigmine [e.g., bradycardia, secretions]6) to reverse neuromuscular blockade.11
    • Exception:  neostigmine does NOT effectively reverse deep blockade.9,13
    • Neostigmine has a long history of safe use and is less expensive (i.e., ~$110 or $200 depending on the dose [sugammadex] versus ~$25 [neostigmine plus glycopyrrolate]).11,a
    • Sugammadex only reverses rocuronium or vecuronium.6
    • Routine use of sugammadex does NOT seem to lead to faster discharge from the PACU.4
    • Data are mixed on risk of pulmonary complications.  One study suggests that patients receiving sugammadex may have fewer major pulmonary complications (e.g., pneumonia, respiratory failure) compared to those receiving neostigmine for noncardiac surgery [Evidence Level B-3].16  More data are needed to confirm this.16
  • Save sugammadex to reverse rocuronium- or vecuronium-induced blockade in certain situations, such as:
    • to reverse moderate blockade in patients at high risk for pulmonary complications from incomplete reversal (e.g., unplanned postoperative mechanical ventilation in patients with COPD or OSA).10,12
    • when it is necessary to reverse deep blockade such as with neurosurgery or thoracic surgery.12  In these situations, there is inadequate time to allow blockade to lessen to a moderate level when neostigmine could then be used for reversal.
  • Generally, avoid sugammadex use in patients with a GFR <30 mL/min/1.73 m2, as it is eliminated by the kidneys and safety data are lacking.5,6
  • If possible, avoid sugammadex use in females of childbearing age who take oral contraceptives.  Sugammadex can lower progesterone levels and may reduce oral contraceptive effectiveness.1,5,6
    • If sugammadex is used in a patient who took an oral contraceptive that day, counsel the patient to use an alternate, nonhormonal method of contraception for seven days after receiving sugammadex.1,5,6

Use objective monitoring techniques to determine depth of neuromuscular blockade.

  • Ensure your facility has protocols to monitor depth of neuromuscular blockade to help guide/monitor sugammadex dosing.
  • Experts recommend objective train-of-four ratio (TOFR) monitoring whenever nondepolarizing neuromuscular blockers are used with a goal of ≥0.9 (90%) defining complete reversal.5,9,15
    • Subjective assessments (e.g., visual or tactile assessments) are prone to error and results can vary among practitioners conducting them.15

Use appropriate doses of sugammadex.

  • To reverse MODERATE neuromuscular blockade:  sugammadex 2 mg/kg
    • AVOID using half-dose sugammadex (e.g., 1 mg/kg) plus neostigmine as this may lead to unwanted adverse effects (e.g., weakness).14
  • To reverse DEEP neuromuscular blockade:  sugammadex 4 mg/kg.
  • Rarely you may see sugammadex 16 mg/kg used for emergent reversal (within ~3 minutes) if rocuronium was used, for rapid sequence intubation or in the operating room, and intubation fails.1

Use an appropriate dosing weight for sugammadex

  • For most patients, use total body weight to dose sugammadex.1
  • In patients with a BMI ≥40 kg/m2, consider using adjusted body weight to dose sugammadex.3,9
    • Use of adjusted body weight to dose sugammadex 4 mg/kg was non-inferior to use of total body weight to reverse deep neuromuscular blockade with rocuronium in morbidly obese patients [Evidence Level B-1].2
    • Avoid using ideal body weight to dose sugammadex in patients who are obese.  Dosing based on ideal body weight leads to slower neuromuscular blockade reversal and increases the risk for recurarization (an increase in neuromuscular blockade after a period of recovery).8,9

Use the most cost-effective vial size.

  • Sugammadex prices are ~$110 (200 mg/2 mL) and ~$200 (500 mg/5 mL).a
  • Follow hospital protocols for rounding down doses to limit waste (sugammadex is available in single-dose vials).  For example, the facility P&T committee may approve rounding down ≤10% in certain situations.  For example, for a 110 kg patient receiving sugammadex 2 mg/kg (220 mg), using 10% less or one 200 mg vial instead is often considered an acceptable difference in dose.7
  • Reserve use of sugammadex 500 mg/5 mL vials for doses >200 mg.11

Securely store sugammadex.

  • Follow your facility policy for storing sugammadex.  Consider the following strategies to minimize inappropriate use and allow for data collection to monitor use:11
    • Store sugammadex in locked, lidded pockets within ADCs.
    • Use pop-ups within the ADC to remind staff of appropriate indications for use.
    • Require documentation (e.g., indication, requesting prescriber) to remove sugammadex from the ADC.
    • Consider using a blind count to identify discrepancies in a timely manner.

Monitor use of sugammadex.

  • Conduct reviews (e.g., medication use evaluations) to monitor for appropriate use of sugammadex or areas where additional education may be needed.  Examples of inappropriate use could include:
    • Reversal of rocuronium after successful rapid sequence intubation:  It is NOT necessary to reverse rocuronium after successful intubation.  Instead, follow post-intubation sedation protocols to ensure patients receive adequate sedation and analgesia until rocuronium wears off.6
  1. Pricing is based on wholesale acquisition cost (WAC). Medication pricing by Elsevier, accessed December 2021.

Abbreviations:  ADC = automated dispensing cabinet; BMI = body mass index; COPD = chronic obstructive pulmonary disease; GFR = glomerular filtration rate; OSA = obstructive sleep apnea; P & T = Pharmacy and Therapeutics; PACU = postanesthesia care unit.

 

Levels of Evidence

In accordance with our goal of providing Evidence-Based information, we are citing the LEVEL OF EVIDENCE for the clinical recommendations we publish.

Level

Definition

Study Quality

A

Good-quality patient-oriented evidence.*

  1. High-quality randomized controlled trial (RCT)
  2. Systematic review (SR)/Meta-analysis of RCTs with consistent findings
  3. All-or-none study

B

Inconsistent or limited-quality patient-oriented evidence.*

  1. Lower-quality RCT
  2. SR/Meta-analysis with low-quality clinical trials or of studies with inconsistent findings
  3. Cohort study
  4. Case control study

C

Consensus; usual practice; expert opinion; disease-oriented evidence (e.g., physiologic or surrogate endpoints); case series for studies of diagnosis, treatment, prevention, or screening.

*Outcomes that matter to patients (e.g., morbidity, mortality, symptom improvement, quality of life).

[Adapted from Ebell MH, Siwek J, Weiss BD, et al. Strength of Recommendation Taxonomy (SORT): a patient-centered approach to grading evidence in the medical literature. Am Fam Physician 2004;69:548-56. https://www.aafp.org/afp/2004/0201/p548.pdf.]

References

  1. Product information for Bridion. Merck & Co.  Whitehouse Station, NJ 08889.  June 2021.
  2. Li D, Wang Y, Zhou Y, Yin C. Efficacy and safety of sugammadex doses calculated on the basis of corrected body weight and total body weight for the reversal of deep neuromuscular blockage in morbidly obese patients.  J Int Med Res 2021;49:300060520985679.
  3. Carron M, Ieppariello G, De Cassai A, et al. Corrected versus total body weight for dosage of sugammadex in morbidly obese patients.  A randomized, double-blind, controlled trial.  Minerva Anestesiol 2021;87:371-3.
  4. Echeverry G, Polskin L, Tollinche LE, et al. Routine use of sugammadex does not shorten pacu length of stay:  a prospective double-blinded randomized controlled trial.  Perioper Care Oper Room Manag 2021;24:100199.
  5. Harvard Medical Center. Guidelines for the use of sugammadex and neostigmine/glycopyrrolate.   https://anesthesia.bidmc.harvard.edu/Clinical_Pathways/documents/Sugam_Use.PDF.  (Accessed December 15, 2021).
  6. Clinical Pharmacology powered by ClinicalKey. Tampa (FL):    2021.  http://www.clinicalkey.com.  (Accessed December 15, 2021).
  7. Wagner D. Revising thoughts on neuromuscular blocking reversal agents.  February 8, 2021.  https://ashpadvantage.com/expert-insight/revising-thoughts-on-neuromuscular-blocking-reversal-agents/.  (Accessed December 15, 2021).
  8. Elfawy DM, Saleh M, Nofal WH. Sugammadex based on ideal, actual, or adjusted body weights for the reversal of neuromuscular blockade in patients undergoing laparoscopic bariatric surgery.  Res Opin Anesth Intensive Care 2019;6:20-6.
  9. Wolf RC, Renew JR. Reverse to go forward?  Safe neuromuscular blockade and reversal in the perioperative setting.  Virtual symposium.  ASHP Midyear Clinical Meeting and Exhibition.  December 8, 2021.  https://ashpadvantagemedia.com/nmbr/webinar1/.  (Accessed December 15, 2021).
  10. Ledowski T, Szabo-Maak Z, Loh PS, et al. Reversal of residual neuromuscular block with neostigmine or sugammadex and postoperative pulmonary complications:  a prospective randomised, double-blind trial in high-risk older patients.  Br J Anaesth 2021;127:316-23.
  11. Pimentel MP, Billings F, Sivashanker K, et al. Reducing medication waste while improving access to sugammadex:  a quality improvement project in medication stewardship.  A A Pract 2020;14:e01223.
  12. Hurford WE, Welge JA, Eckman MH. Sugammadex versus neostigmine for routine reversal of rocuronium block in adult patients:  a cost analysis.  J Clin Anesth 2020;67:110027.
  13. Raval AD, Uyei J, Karabis A, et al. Incidence of residual neuromuscular blockade and use of neuromuscular blocking agents with or without antagonists:  a systematic review and meta-analysis of randomized controlled trials.  J Clin Anesth 2020;64:109818.
  14. Cammu G. Sugammadex:  appropriate use in the context of budgetary constraints.  Curr Anesthesiol Rep 2018;8:178-85.
  15. Naguib M, Brull SJ, Kopman AF, et al. Consensus statement on perioperative use of neuromuscular monitoring.  Anesth Analg 2018;127:71-80.
  16. Kheterpal S, Vaughn MT, Dubovoy TZ, et al. Sugammadex versus neostigmine for reversal of neuromuscular blockade and postoperative pulmonary complications (STRONGER):  a multicenter matched cohort analysis.  Anesthesiology 2020;132:1371-81.

 

 





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