Human albumin : cost – benefits
Pharmacoeconomic perspectives on fluid therapy
In the era when other colloids have been shown to be unsafe , albumin has come into its own as a safe , effective therapy with demonstrable cost effectiveness
Albert Farrugia BSc PhD ( Edin ) Adjunct Professor , School of Surgery , Faculty of Medicine and Surgery , The University of Western Australia , Perth , Australia albert . farrugia @ uwa . edu . au
The development of albumin ’ s role as a blood substitute and plasma-expanding agent has been reviewed . 1 This role appeared unquestioned until the publication of a rapidly discredited Cochrane review in 1998 , 2 which threw doubts on the safety of albumin . It is probable that this contributed to the consideration of other fluids and to the rapid ascendancy of hydroxyethyl starch solutions ( HES ) as the predominant colloid fluid therapy in the 2000s , despite the already established adverse events associated with these compounds . The obviation of much of the evidence base for HES through the Boldt scandal , 3 coupled with the increasing body of evidence that all types of HES were associated with serious adverse effects , 4 has led the regulatory agencies of the US and Europe to severely restrict or disallow totally the use of these products in critical illness . At the time of writing ( September 2013 ), the European Medicines Agency , at the behest of the HES manufacturers , is undertaking a review of its decision , and the use of HES , which has been sharply affected by the events outlined , may be further affected by this process . It seems unlikely that HES will regain a significant position in fluid replacement therapy and the position of albumin as the colloid least associated with adverse events 5 has undergone a remarkable evolution since the questions raised by the Cochrane
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Figure 1 : Relative ranking of survival with different fluid therapies in sepsis 6
Albumin Crystalloid
" The body of evidence demonstrating the efficacy of albumin in areas of critical care and hepatology is impressive "
review . The body of evidence demonstrating the efficacy of albumin in areas of critical care and hepatology is impressive , and a recently published meta-analysis 6 demonstrates its superiority relative to other treatments in conferring a survival benefit to patients with sepsis ( Figure 1 ).
Pharmacoeconomic perspectives on fluid therapy Despite these developments , it is likely
HES
that the controversy around the choice of fluid therapy in clinical care will continue , as it is essentially reflective of economic concerns which , if anything , are increasingly acute in the current healthcare landscape worldwide . It is intriguing that even supposedly objective and clinical evidence-based processes like the Cochrane Collaboration cannot help including comments on costs in their reports , irrespective of the relevance of such comments to the issue of best
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