Creating A High-Cost Drug Use Policy That Puts Pediatric Patients First

Creating A High-Cost Drug Use Policy That Puts Pediatric Patients First

Children's hospitals are sharing their policies for managing IV acetaminophen use in children.
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Intravenous (IV) acetaminophen has been identified as a potential risk for children and it's higher cost than oral tablets. Children’s hospitals are openly sharing policies to control usage and costs.

Intravenous (IV) acetaminophen may be presented as a safer option than opioids for pediatric patients, which resonates with providers focused on safe care. 

However, it’s been identified as a potential risk for children and comes at a cost that’s more than 676 times greater than oral tablets. Now children’s hospitals are openly sharing policies to control usage. 

Risks to pediatric patients and hospitals

Vial size. Pediatric nurses are trained on smaller dose protocols for children, yet IV acetaminophen only comes in an adult-oriented 1000mg/100ml presentation.  Vial size is an issue for other high-cost drugs as well, and remaining medication is typically wasted after a small dose has been given.

Overdose potential.  A large vial increases the chances of overdosing a child or infant each time it is sent to the floor for administration.

Unknown toxicity. IV acetaminophen has different pharmacokinetic properties than the oral product. This includes a shorter time to peak concentration and a bypass of the first-pass effect.  Studies on adult patients have shown IV acetaminophen works slightly faster compared with other routes, but no research has been done on children. A nomogram doesn’t exist for IV acetaminophen, as it does for its oral counterpart, which leaves clinicians without clear guidance on how to treat a potential overdose. 

High cost and waste. Children’s hospitals currently spend more than $25 million annually on IV acetaminophen. Because most pediatric doses are much smaller than the commercially available 1000mg single-dose vial, children’s hospitals only use approximately $7 million—about 25%—of the product they purchase.

Perspectives from a pediatric pharmacy director

Children’s of Alabama is one of the lowest users of IV-administered acetaminophen among CHA’s Pediatric Health Information System (PHIS) hospitals. That’s attributed to an intense focus on patient safety, said Julie Lasseigne, PharmD, pharmacy director. Reviewing the risks of using IV acetaminophen and implementing steps to protect patients from potential harm have contributed to Children’s of Alabama’s successful drug use policy. 

IV acetaminophen lacks sufficient clinical data and research to demonstrate a reduction in opioid usage when compared with other methods of acetaminophen administration. Taking a safety-first approach allows Children’s of Alabama to limit IV acetaminophen use only to patients who meet specific criteria.

3 steps to manage usage of high-cost drugs

  1. Consider using analgesic alternatives for the pediatric patient population. Oral acetaminophen is comparable and as effective in pediatric pain management.
  2. Consider strategies and implement protocols to restrict usage. The Children’s of Alabama team maintained management through the pharmacy and eliminated availability in automated dispensing cabinets. Pharmacy management prevents it from being a convenient PRN product, as an oral or rectal form would produce pain relief by the time IV acetaminophen was received on the floor for administration.
  3. Advocate for the development of pediatric-sized vials to reduce patient safety risks and product waste.
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