Background: Fomepizole (F), alone or in combination with hemodialysis (HD), may be used in the treatment of toxic alcohol exposures such as methanol (M) and ethylene glycol (EG). There is a paucity of data regarding the financial cost of each treatment approach. Using patient charge estimates specific to our institution, we present the Results of an analysis comparing F and HD for treatment of M and EG levels of 50 mg/dL.
Methods: Patient charges associated with treatment of toxic alcohol exposures in 2010 at our institution were reviewed and averaged with respect to the cost of the following: F dose, HD session, daily rate of a general care (GC) bed, and daily rate of an intensive care unit (ICU) bed. All other costs were assumed comparable irrespective of treatment received. Based on available pharmacokinetic (PK) data for M and EG in the presence of F, the duration of treatment was projected.
Results: The average patient charge for a dose of F was $ 1,267, HD session $765, GC bed (daily rate) $915, and ICU bed (daily rate) $1,524. For an EG or M level of 50 mg/dL treated with HD, patient charge would approximate $4,823; this cost was based on the administration of 2 doses of F, 1 HD session, and 1 day of hospitalization in the ICU. In contrast, the estimated cost associated with treatment of an EG level of 50 mg/dL with F only, based on a t 1/2of 12.9 h, to an endpoint of 20 mg/dL was $5,631. This was based on a treatment duration of 25.8 h and charges for 3 doses of F and 2 days of hospitalization in a GC bed. Similarly, for a M level of 50 mg/dL treated with F only, with an estimated t 1/2 of 54 h, the estimated cost was $17,245 based on administration of 10 doses of F and 5 days of hospitalization in a GC bed.
Discussion: Based solely on financial considerations, HD is a more favorable treatment approach for levels of M and EG 50 mg/dL than F alone. This is especially true for M, which has a significantly longer t 1/2 than EG. Limitations include not accounting for the cost of clinically significant complications related to HD such as vascular injury, infection, and thrombosis. However, data suggest these complications are rare. Another limitation is the failure to account for individual variability with respect to PK as well as patient weight, which may influence the number and volume of F doses required. Accounting for these parameters could make the cost difference between F and HD more favorable for HD, considering reports of extremely long EG and M t 1/2's treated with F alone and patients with weights that necessitate larger doses.
Conclusion: Hemodialysis is a more cost effective approach to the management of methanol and ethylene glycol toxicity than fomepizole alone if levels exceed 50 mg/dL.