Cost-Consequences of Fondaparinux Use for Treatment of Heparin-Induced Thrombocytopenia.

Heparin-induced thrombocytopenia (HIT) is a severe complication of therapy with heparin and low molecular-weight heparins and is associated with increased morbidity and mortality. Furthermore, HIT constitutes an economic burden on health care systems. Direct thrombin inhibitors (DTIs) lepirudin and argatroban; the approved agents for HIT treatment; are expensive and require intravenous administration with substantial use of resources and increased duration of hospital stay. Indeed, the cost of management of HIT utilizing DTIs in heart surgery has been estimated to range from over $100 to $300 million dollars nationwide. Published case reports, abstracts, and our own data support the use of fondaparinux, a pentasaccharide, in the management of HIT as an effective and safe alternative to DTIs. We evaluated the cost associated with fondaparinux use in a series of patients with HIT treated at our tertiary care teaching institution. We performed a retrospective review of 18 patients with HIT receiving fondaparinux during study period from January 2002 through June 2006. HIT diagnosis was found in 77.7% of patients during their hospital stay and in 22.2% at admission. Ten patients were initially treated with argatroban (9) or lepirudin (1) before switching to fondaparinux due to concerns of increased risk of bleeding mandating the use of an anticoagulant with short half-life or to renal failure prohibiting the use of fondaparinux. The total cost for the group including actual direct variable (room, pharmacy, lab, and supplies), actual direct fixed, and indirect costs was $1,484,297 and the mean was $82,462±70,153. The actual direct variable cost was $888,461 with a mean of $49,359±43,047 per patient. The actual direct fixed cost was $344,563 with a mean of $19,142±15,257. The indirect cost was $251,273 with a mean of $13,960±12,094. In this series, the daily cost of anticoagulant per patient based on average wholesale price (AWP) $407. This compared favorably to a daily cost per patient of $1093.76 for argatroban and $1732.8 for lepirudin. The total cost of drug for all patients was $70,414 as opposed to an estimated cost of $189,220 or $299,774 should argatroban or lepirudin have been used, respectively. This translated into an estimated savings from $129,000 to $229,000. In summary, the utilization of fondaparinux in HIT treatment at our institution resulted in a dramatic drug cost reduction. Coupled with its subcutaneous route of administration and the absence of need for laboratory monitoring, allowing reduction in hospital stay and spared resources, fondaparinux would represent an attractive alternative to DTIs in the management of HIT pending further clinical studies to confirm its safety and efficacy.