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Ann Thorac Surg 2001;72:1798
© 2001 The Society of Thoracic Surgeons
a School of Pharmacy, University of Connecticut, Storrs, CT 06269, USA
b Drug Information Center, Hartford Hospital, Hartford, CT 06102, USA
To the Editor
We read with interest the recently published study by Dr Shapira and associates [1] in which nitroglycerin was found to be as effective but safer and less expensive than diltiazem in preventing coronary artery bypass conduit spasm. Of particular note were the reported doses and cost analysis.
In their study, Dr Shapira and associates [1] gave a loading dose of diltiazem 0.1 mg/kg followed by a continuous infusion of 0.1 mg/kg/min, or gave 0.1 µg/kg/min of nitroglycerin for 24 hours. Oral diltiazem and nitroglycerin were then commenced on the first postoperative day and continued for 6 months; the actual doses used in the study were not reported [1]. The authors then compared the cost of diltiazem to nitroglycerin using actual hospital pharmacy costs.
The maximum infusion rate recommended by Baxter Healthcare Corporation [2] (the manufacturers of the brand of intravenous diltiazem used in the study) is 15 mg/h or 
0.004 mg/kg/min for a 70-kg patient, less than 25 times the dose used in the study [1]. In addition, their dose is 100-fold greater than the 0.001 mg/kg/min employed in a prior evaluation of the use of radial arteries in coronary artery bypass graft surgery, which was followed by oral diltiazem up to a maximum dose of 240 mg per day [3]. Moreover, the intravenous dose in this latter study was later reduced by 50% to 75% due to a 32% incidence of adverse events.
We estimated costs utilizing the 2000 Advertised Wholesale Price (AWP) [4], which is typically higher than the cost negotiated by hospital pharmacies. The cost of the 24-hour intravenous regimen of diltiazem, according to our estimates and using the maximum recommended loading dose of 25 mg plus 15 mg/h for 24 hours [2], was $77 compared with the $3,312 reported by Shapira and colleagues [1]. Similarly, we found that a 24-hour infusion at 0.1 µg/kg/min of nitroglycerin, based on a 70-kg patient, cost $9 compared with $340 [1] recorded in their study. We estimated the 6-month cost of the oral medication using the maximum recommended doses in our calculations [5, 6]. A 6-month supply of Cardizem CD (Hoechst Marion Roussel, Inc, Strasbourg, France) 540 mg daily was calculated to be $787 versus the substantially higher reported cost of $13,340. We found that a 6-month supply of Imdur (Key Pharmaceuticals, Schering-Plough, Kenilworth, NJ) 240 mg daily [6] cost $724, which is similar to the observed cost of $756 [1]. Thus, Shapira and associates [1] found the total cost of the diltiazem regimen to be $16,652 compared with $1,096 for the nitroglycerin regimen, a difference of $15,556. In contrast, we found that the total cost of diltiazem was $864 versus $733 for nitroglycerin, a difference of only $131.
Based on our estimates, it appears that diltiazem is, indeed, more expensive than nitroglycerin, although the cost difference is considerably less than the 16-fold difference stated by the authors [1].
References
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