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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

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

60 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


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 events5


undergone a remarkable evolution since the questions raised by the Cochrane

Figure 1: Relative ranking of survival with different fluid therapies in sepsis6

"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-analysis6

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

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 40 20 0 120 100 80

Albumin Crystalloid HES


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