Cost of inappropriate use of intravenous N-acetylcysteine for acetaminophen toxicity

study Background: Intravenous (IV) N-acetylcysteine (NAC) is the treatment of choice for acetaminophen (APAP) toxicity. The initiation of NAC should be based on specific criteria depicted by the Rumack-Matthew Nomogram. The treatment requires hospital admission and frequent laboratory tests, making it a costly treatment. The purpose of this analysis is to determine the financial impact of inappropriate IV NAC use for APAP toxicity. Methods: This single-center, retrospective chart review included adult and pediatric subjects who received at least one dose of IV NAC at a tertiary academic medical center for acute and chronic APAP toxicity. Primary objective; determine the financial impact of inappropriate use of IV-NAC concerning compliance with the nomogram when initiating the treatment. Secondary objectives; missed cost-saving opportunities resulting from non-compliance with treatment regimen recommendations for maximum doses, and the number of dosing cycles. Cost analysis was completed by the hospital billing department and utilized true cost charges. Total cost of hospitalization was calculated, and total medication charges were evaluated separately using the hospital’s group purchasing organization (GPO) pricing. Results: Ninety-six subjects were included in the final analysis. A potential savings of $253,891.85 United States Dollars (USD) could have been realized if the administration guidelines were followed. NAC was inappropriately initiated in 20 of the 56 subjects (35.7%) with an acute, known time of APAP ingestion. Of the 346 total doses of IV NAC administered throughout the study (n=47, 13.6%) exceeded manufacturer maximum suggested recommendations. The higher doses were all related to subjects with body weight higher than 100 kg. Conclusions: The results from this study show a high financial cost on the healthcare system when providers inappropriately initiate IV NAC for acute APAP toxicity. Healthcare systems should follow the administration guidelines of IV NAC to decrease overall expenses and potential adverse effects. Utilizing order sets to guide appropriate therapy initiation and/or discontinuation is advisable. A careful review of pertinent laboratory values and collaboration with regional Poison Control Centers to determine treatment duration may also be warranted.