Perceptions regarding vasopressin use and practices in septic shock, and cost containment strategies

Abstract

Background Clinician preferences and practices regarding appropriate vasopressin use in light of its increased acquisition cost secondary to rebranding has not been evaluated or described since the most recent iteration of the Surviving Sepsis Campaign Guideline was published. Objective To assess vasopressin cost containment initiatives and pharmacists' opinions regarding appropriate vasopressin use. Methods A scenario‐based survey was distributed to critical care and emergency medicine pharmacists. Responses were characterized using frequency and descriptive statistics. Categorical variables between those who implemented changes (Vasopressin Cost Consideration) and those who did not (Usual Care) were compared using chi‐square or Fisher's exact tests. McNemar's test was used to compare responses in clinical scenarios between Vasopressin Cost Consideration and Usual Care groups. Results Among 1757 pharmacists surveyed, 200 (11.3%) responded. When respondents considered vasopressin cost and evidence (vs evidence alone), fewer respondents would use vasopressin adjunctively with norepinephrine (21% vs 26.6%, P = 0.031), to raise mean arterial pressure compared with epinephrine (65.2% vs 72.3%, P = 0.012), or to reduce norepinephrine infusion rates (71.4% vs 81.4%, P < 0.001), but would use with steroids (62.4% vs 28.3%, P < 0.001). Most (72%) respondents had implemented vasopressin cost containment and/or education initiatives. The Vasopressin Cost Consideration group respondents were more likely to initiate vasopressin at 0.03 units/minute without titrating (47.9% vs 33.9%, P = 0.045). Conclusion Since vasopressin was generically rebranded, most institutions have implemented at least one initiative to reduce vasopressin use and/or educate clinicians about its appropriate use. When vasopressin acquisition costs were considered, pharmacists recommended its use less frequently, particularly in clinical scenarios where its use is controversial.

Norepinephrine and Vasopressin Compared With Norepinephrine and Epinephrine in Adults With Septic Shock

“…31 In addition to uncertain outcomes from vasopressor initiation and weaning strategies, 5,6,9,10,[33][34][35][36][37][38][39][40][41][42] medication costs may have important implications for the choice of adjuvant vasopressors in septic shock. 43,44 Vasopressor duration, a primary factor in medication cost, was similar between groups. Because vasopressin remains the highest-cost vasopressor in the United States, 45 preferential use of adjunctive epinephrine may offer a cost-effective alternative, with minimal or no meaningful effects on patient outcomes, based on this study's results.…”

Narrative Review of Controversies Involving Vasopressin Use in Septic Shock and Practical Considerations

“…67 In subsequent years, perceptions of vasopressin use in specific subpopulations and in general for hemodynamic support in septic shock have been altered to favor less frequent use. 16 Although vasopressin has a greater financial cost than catecholamine vasopressors, it appears to be cost-effective as a second-line vasopressor in septic shock, with an incremental cost-effectiveness ratio of US$19 762 per quality-adjusted life year. 68 This is well below the established willing-to-pay thresholds of US$50 000 to US$100 000.…”

“…Strategies for reducing medication waste may be implemented to improve cost-effectiveness further and include reducing the amount of vasopressin in each infusion bag, using a guideline-recommended standard starting dosage (eg, 0.03 U/min as opposed to 0.04 U/min), and penultimate discontinuation of vasopressin rather than norepinephrine. 16…”

“…5,9,10,70 Given the uncertain benefits of vasopressin on renal function and mortality and questionable interaction with corticosteroids, clinicians are encouraged to implement cost-effective use of the medication and use it in the care of patients for whom there appears to be a reasonable indication. 16 It is recommended to discontinue vasopressin if patients appear not to be benefiting from its use based on reduction in norepinephrine requirements and improvements in hemodynamic parameters, such as MAP and cardiac output. Further studies are needed to identify the patient populations that would benefit most from vasopressin use.…”

“…5,13 However, additional landmark trials, observational studies, and meta-analyses have been published, since this pivotal trial, that have created clinical controversies and a variety of practice variations. 14-27 We, therefore, sought to focus on the literature after the publication of VASST to address controversies surrounding vasopressin use in septic shock.…”