My opinion

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American Society of Anesthesiologists (ASA) has apparently recommended sugammadex use over neostigmine use by anesthesia providers to antagonize maybe most of their patients' neuromuscular blockade [1]. This may make sugammadex use the norm rather than the exception because although dosing and redosing of sugammadex may warrant quantitative neuromuscular blockade monitoring, sugammadex may still be better than neostigmine even in the absence of quantitative neuromuscular blockade monitoring. Therefore, besides patient awareness about unintended pregnancy risk among reproductive age patients on hormonal contraception (low doses of estrogen and progesterone) [2], perioperative patient education may have to futuristically investigate to potentially inculcate patient awareness about maybe exorbitant copay among patients with inadequate insurance coverage and maybe withdrawal symptoms among patients on gender affirming hormone therapy (very high doses of estrogen with or without progesterone) and hormone replacement therapy (high doses of estrogen with or without progesterone) [3-7]. Although it may appear that sugammadex use may not be unsafe for pregnant patients presenting for non-obstetric surgeries [8] and lactating mothers presenting for postpartum surgeries, it may still be worth investigating systemically in postpartum clinics during first postpartum visits whether postpartum mind spectrum [9-10] transiently changes/fluctuates over blues-depression-psychosis scale when patients had received sugammadex during their cesarean sections because during basic research among pregnant rats [11], postpartum behavioral changes among rats could not rule out sugammadex effect on steroidal hormones as changed behaviors’ cause. Moreover, until sugammadex has a generic version approved for use in the United States (US) [12], ASA may have essentially recommended Bridion® (Merck & Co., Inc., Rahway, New Jersey, US) [13] use over neostigmine use. Anesthesia providers in Europe may not have to weigh in their conflicts of interest while following ASA recommendations because they may have an approved generic version of sugammadex available at hand as an alternative [14]. However, in good conscience for patient safety, ASA couldn't delay their recommendations anymore by waiting for US Food and Drug Administration (FDA) to approve a generic version of sugammadex in US [15]. Henceforth, after getting information from their pharmacies about the current billable patient charges for sugammadex, it may seem prudent for anesthesia providers to preoperatively educate their patients who are going to receive neuromuscular blockade with rocuronium or vecuronium that they are very likely to receive sugammadex perioperatively and thus may potentially owe hundreds of dollars as their copay for sugammadex which may be somewhat buffered by discount coupons and patient assistance programs if any available [16] unless Bridion® soon emulates the path of already transparently reimbursable Exparel® (Pacira Pharmaceuticals, Inc., Parsippany, New Jersey, US) [17-18]. Additionally, as ASA recommendations to anesthesia providers clearly support sugammadex use over neostigmine use, they may have an option to provide a copy of ASA recommendations [19] as patient education template to prepare them for sugammadex non-coverage by their healthcare insurance providers who can then potentially re-negotiate their copay for sugammadex. Cost concerns with sugammadex use may be raised by healthcare facilities as well [20]. However, by their sheer size and number, they may be way better-equipped to negotiate with their pharmaceutical vendors about costs of procuring sugammadex and with their patients' third-party payers about charges billed for sugammadex as compared to individual non-Veteran patients pleading with their healthcare insurance providers about copay for sugammadex. Summarily, although ASA practice guidelines may have overlooked patient education about sugammadex, it may become necessary with almost universal use of sugammadex in patients especially when healthcare facilities' investment into and anesthesia providers' acceptance for quantitative neuromuscular monitoring may lag behind easier administration of sugammadex to antagonize neuromuscular blockade among patients.

Reference(s)

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1. 2023 American Society of Anesthesiologists Practice Guidelines for Monitoring and Antagonism of Neuromuscular Blockade: A Report by the American Society of Anesthesiologists Task Force on Neuromuscular Blockade https://pubs.asahq.org/anesthesiology/article/138/1/13/137379/2023-American-Society-of-Anesthesiolog ists
2. Scopolamine and Sugammadex: Gateway To Litigation In Absence of Patient Education https://www.webmedcentral.com/article_view/5442
3. Perioperative considerations for transgender women undergoing routine surgery: a narrative review https://www.bjanaesthesia.org/article/S0007-0912(20)30087-8/fulltext
4. Intraoperative Considerations for Transgender Patients https://journals.lww.com/anesthesia-analgesia/Fulltext/2018/12000/Intraoperative_Considerations_for_ Transgender.42.aspx
5. Endocrine Withdrawal Syndromes https://academic.oup.com/edrv/article/24/4/523/2424552
6. Serious Progesterone Side Effects and Brittle Adrenals https://www.drlamcoaching.com/nem-therapy/hormonal/serious-progesterone-side-effects-and-brittle-adr enals/
7. Treatment of menopausal symptoms with hormone therapy https://www.uptodate.com/contents/treatment-of-menopausal-symptoms-with-hormone-therapy
8. Sugammadex administration in pregnant patients undergoing non-obstetric surgery: a case series https://www.sciencedirect.com/science/article/pii/S0104001421003237
9. Parental postpartum depression: More than “baby blues” https://www.contemporarypediatrics.com/view/parental-postpartum-depression-more-baby-blues
10. Screening for Perinatal Depression https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2018/11/screening-for-per inatal-depression
11. HIGHLIGHTS OF PRESCRIBING INFORMATION www.merck.com/product/usa/pi_circulars/b/bridion/bridion_pi.pdf
12. Generic Bridion Availability https://www.drugs.com/availability/generic-bridion.html
13. Bridion 100 mg/ml solution for injection https://www.medicines.org.uk/emc/product/6409
14. Sugammadex Mylan https://www.ema.europa.eu/en/medicines/human/EPAR/sugammadex-mylan
15. Gland Pharma obtains FDA tentative nod for generic Bridion https://drugstorenews.com/gland-pharma-obtains-fda-tentative-nod-generic-bridion
16. Bridion Prices, Coupons and Patient Assistance Programs https://www.drugs.com/price-guide/bridion
17. EXPAREL is a cost-effective option for postsurgical pain management in the hospital and ambulatory (outpatient) settings: Cost and Value https://www.exparel.com/hcp/value/total-hip-arthroplasty
18. Reimbursement: EXPAREL is reimbursed for procedures performed in ASCs using the code C9290 and for dental procedures using code D9613. https://www.exparel.com/reimbursement
19. Recommendations https://pubs.asahq.org/view-large/figure/2130608/11TT10.jpg
20. Sugammadex: Appropriate Use in the Context of Budgetary Constraints https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5988778/

Source(s) of Funding

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NOT APPLICABLE

Competing Interests

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NOT APPLICABLE