Buccal Midazolam Solution for the Management of Prolonged Acute Convulsive Seizures: A Cost Analysis

There is little published evidence on how pack size impacts on health system costs. In the UK, children and adolescents aged 10 to < 18 years with prolonged acute convulsive seizures (PACS) occurring in the community setting are usually managed by the administration of buccal midazolam: Epistatus^® or Buccolam^®. These two preparations have markedly differing cost structures, being sold at different prices and presented as single units versus 4-packs, respectively. Consequently, the cost-per-PACS and overall budget impact of the two products cannot be simply inferred but is instead dependent on the likelihood of use. Also relevant to its likelihood of use is midazolam's status as a controlled substance under the Misuse of Drugs Act.

The purpose of this economic analysis was to present the cost implications of single-unit versus multi-pack prescribing of a rescue medication based on likelihood of use. There is little published evidence to inform the likelihood of a midazolam dose being used once prescribed. A Delphi survey was conducted with physicians (n = 5), nurses (n = 11) and pharmacists (n = 24) from the community and hospital healthcare settings in the UK to explore the frequency distribution of prolonged seizures in the general epileptic population per 6-month period, along with common patterns of prescribing. This informed a model of the budgetary impact of single-unit (Epistatus^®) versus 4-pack (Buccolam^®) prescribing.

Respondents cited both 'wastage' and 'dispensing more than is likely to be used of a controlled drug' as poor clinical practice, which suggests that prescribing in multiples of four should be reserved for patients who are likely to experience PACS at a higher frequency. The Delphi survey and subsequent regression analysis found that PACS frequency distribution follows an exponential drop, with over half (55%) of patients experiencing zero to one prolonged seizure(s) per 6-month period. Despite this, the majority (70%) of low PACS frequency patients are prescribed buccal midazolam in multiples of four by their treating physician. When looking at overall budgetary impact, the strategy of prescribing single-unit Epistatus^® versus 4-pack Buccolam^® is cost saving in low PACS frequency patients who do not require multiple units (referred to as spare loading), at - £15.33 per patient per 6 months. If spare loading is universally applied to all patients irrespective of seizure frequency, the mean incremental cost of single unit Epistatus^® instead of 4-pack Buccolam^® equates to £51.23 per patient per 6 months. If spare loading is reserved for higher PACS frequency patients (two or more per 6 months), the universal prescribing of single-unit Epistatus^® versus 4-pack Buccolam^® would result in a mean incremental cost of £17.82 per patient per 6 months.

The availability of single-unit Epistatus^® allows for greater flexibility in prescribing. Physicians should attempt to categorise patients according to past PACS frequency with low PACS patients being prescribed single unit Epistatus^® (with/without spare loading) and 4-pack Buccolam^® reserved for patients in whom a high volume of usage is anticipated.