Activated protein C: cost matters!

Introduction

Activated protein C (APC) is an effective treatment in multiorgan failure (MOF) due to severe sepsis. Recommended duration of treatment of APC is 96 hours infusion. The cost of APC infusion for 96 hours in a 60 kg person is an average INR 490,000 in India (€7,000) (€1 ~ INR 70 in November 2009, average value) whereas the average cost of 10 days of ICU treatment for a patient with sepsis with MOF, all inclusive, is approximately INR 140,000 in our hospital (€2,000). It is unclear whether stopping APC before 96 hours, in patients in whom MOF resolves before 96 hours, ultimately affects the final outcome in terms of survival. This is more relevant in developing countries like India where the cost of 96 hours of infusion of APC is beyond the reach of the majority of patients eligible for it. We retrospectively analysed the cost savings achieved by early stoppage of APC ensuring MOF reversal, before completion of the recommended 96 hours infusion.

Methods

During a period of 3 years, patients with severe sepsis having ≥3 organ failures were offered the option of APC. For those who opted for it, infusion was initiated within 24 hours of onset of MOF. APC infusion was stopped before completion of 96 hours only if septic shock, ARDS and coagulopathy was completely resolved, otherwise it was continued for 96 hours.

Results

Two hundred and thirteen patients with severe sepsis having MOF were offered the option of APC infusion. Twenty patients opted for it. In seven patients APC was infused for 96 hours as per the standard recommendation. In 13 patients APC infusion could be stopped before 96 hours assuring complete reversal of MOF. They were enrolled in our study. Eleven out of 13 patients were discharged home after complete recovery. MOF did not reappear in any of these 13 patients. Two patients developed a new episode of ventilatory-associated pneumonia on day 4 and day 10, respectively, after stopping the infusion of APC and could not be salvaged. Average duration of APC infusion was 70.33 ± 20.76 hours. Cost of APC infusion per patient for average 70 hours was INR 347,692 ± 38,330 (€4,967). Duration of ICU stay (average) was 11.61 ± 5.18 days. Average cost of ICU care for 11 days (excluding cost of APC) per patient was INR 144,272 ± 86,754 (€2,061). The cost saving achieved due to early stoppage of APC (per patient) was INR 132,708 ± 42,330 (€1,895).

Conclusions

Stopping APC infusion before 96 hours in patients who show rapid reversal of MOF is associated with significant cost saving without compromising the survival outcome. With this judicious early stoppage strategy, a greater number of patients can afford this effective drug.