IV acetaminophen: Is it worth the cost?

In the midst of the opioid epidemic, hospitals and health systems are constantly looking for ways to alleviate pain that minimize opioid use. Acetaminophen remains a viable alternative, though organizations are making a concerted effort to restrict its intravenous use and promote oral administration.

All of this started when IV acetaminophen was approved by the FDA in 2010 under its brand name Ofirmev and a review in 2011 found that the IV drug is particularly efficacious in postoperative pain management, lowering opioid use and length of stay, particularly in conjunction with NSAIDs. With no downsides in sight, Ofirmev soon became an important component of multimodal pain management therapy in hospitals across the country, leading to an overflow of prescriptions.

This overflow came to a halt when the manufacturer of Ofirmev was purchased by Mallinckrodt Pharmaceuticals in 2014 and, upon acquisition, the price of the drug increased by 140% from $14.60 to $35.05 for each one gram vial. This hike in price soon unveiled how the drug was being overprescribed in hospitals, as with the new price tag, every unnecessary prescription of the drug meant paying over 35 times the less than $1 cost of oral acetaminophen.

This cost increase—combined with the fact that the IV and oral forms of acetaminophen were found to be equally effective—began the trend of restricting its IV use in favor of oral. That is, except for NPO patients and postoperative patients for 24 hours after surgery, due to the slightly faster effects of acetaminophen’s IV version. Many organizations modified their formularies accordingly, as showcased by Stanford Healthcare’s pharmacy & therapeutics committee update. Chandler Regional Medical Center implemented similar changes, which helped it bring down its IV acetaminophen spending by $10,500 in three months.

While there have been newer studies attempting to illustrate the potential cost effectiveness of IV acetaminophen, they are funded by Mallinckrodt Pharmaceuticals, Ofirmev’s manufacturer, and the consensus remains that oral and IV acetaminophen have equal abilities to manage pain. So, to answer our title question, IV acetaminophen is not worth the cost, not unless patients are in the immediate postoperative period or are NPO.

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