Intended for healthcare professionals


Cost of nitric oxide is exorbitant

BMJ 2002; 325 doi: (Published 10 August 2002) Cite this as: BMJ 2002;325:336
  1. C M Pierce, consultant paediatric intensivist.,
  2. M J Peters, consultant paediatric intensivist,
  3. G Cohen, senior lecturer in paediatric cardiothoracic surgery,
  4. A P Goldman, consultant paediatric intensivist.,
  5. A J Petros, consultant paediatric intensivist. (PETROA.CAR1.GOSH{at}
  1. Intensive Care Units, Great Ormond Street Hospital for Children NHS Trust, London WC1NH 3JH

    EDITOR—Evidence based medicine is the gold standard for practice, and pharmaceutical companies appreciate the power of evidence based medicine. A positive result in a randomised controlled study produces pressure to use a specific agent regardless of cost.

    High costs seem to predominate in intensive care. Over the past 10 years several expensive treatments have been launched and subsequently failed. Inhaled nitric oxide (iNO) was the reverse, being initially inexpensive, and is of proved efficacy in reducing morbidity.

    Recently, two randomised controlled studies have shown improved oxygenation1 and a reduction in the need for extracorporeal membrane oxygenation with the use of inhaled nitric oxide in neonates with persistent pulmonary hypertension and hypoxic respiratory failure. 2 3 As a result, the use of inhaled nitric oxide was approved by the US Food and Drug Administration in 1999 and the European Medical Equipment Agency in 2001. As a consequence of these reports and the need to practise evidence based medicine the use of inhaled nitric oxide in persistent pulmonary hypertension is now almost mandatory.4

    In the early 1990s a patent was granted in the United States for the use of inhaled nitric oxide in persistent pulmonary hypertension. This was then sold to industry. Currently INOTherapeutics has the franchise and marketing authorisation for Europe and the United States.

    When medical grade inhaled nitric oxide first became available in the United Kingdom the cost was minimal ($1.99/h (£1.28/h)).5 Currently, British Oxygen Company supplies us with inhaled nitric oxide. Once the brand is established, however, BOC will have to stop providing us with inhaled nitric oxide. The licensed pharmaceutical grade product will be available only from INOTherapeutics. Each cylinder will have a gas meter attached, and we will be charged the American predicted rate of $125/h (£80/h). This could equate to a cost of up to £102/h (including value added tax) per patient, with a ceiling of 96 h per patient (£10 000 per patient maximally). INOTherapeutics have now quoted a sliding scale of costs depending upon national usage and indicated that above a certain threshold of usage the cost could come down to about £26/h. This is still a 20 fold increase.

    Our use of inhaled nitric oxide during 2001-02 amounted to 7200 h in 164 children, at a cost of £31 000. Should the proposed changes in price be implemented we would be looking at a possible projected cost of around £600 000/year for inhaled nitric oxide. As a result of evidence based studies we are obliged to prescribe inhaled nitric oxide. Is this enormous change in cost an unforeseen consequence of level 1 evidence?