Cost Analysis of Clinical Compounding in Saudi Arabia : Anti-tuberculosis Pediatrics Formulations

Yousef Ahmed Alomi* , General Administration of Pharmaceutical Care, Ministry of Health, Riyadh, Saudi Arabia. Faiz A. Bahadig, Informatics Pharmacist, Pharmaceutical Care Department, King Abdul-Aziz Medical, City-WRJeddah, Ministry of National Guard, Saudi Arabia. Malika Alhadab, Head, Pharmacy Services, Alyamma Hopsital, Ministry of Health, Riyadh, Saudi Arabia. Mona Lubbad, Former Head, Extemporaneous Preparation Unit, Pharmacy services, Alyamma Hopsital, Ministry of Health, Riyadh, Saudi Arabia. Ebtesam Nazal, Head, Extemporaneous Preparation Unit, Pharmacy Services, Alyamma Hopsital, Ministry of Health, Riyadh, Saudi Arabia. Mayssa Ahmed Assiri, Clinical Pharmacy Staff, General Manager of General Administration of Pharmaceutical Care, Ministry of Health, Riyadh, Saudi Arabia.


INTRODUCTION
The pediatrics or neonates Nephrology one of the well-known specialists in the medical and pharmacy field. [1,2] The pediatrics or neonates suffer from several diseases of Nephrology including but not limited to the nephrology system, acute glomerulonephritis and nephrotic syndrome, while the most common diseases in Saudi Arabia were the following, congenital renal diseases, urinary tract infection and congenital and infantile nephrotic syndrome were. [3,4] Several medications used for the management of the kidney disease, for instance immunosuppressant agent (Hydrocortisone, Prednisolone) or diuretics (Hydrochlorothiazide, Spironolactone) for cardiovascular diseases. [5,6] Most of the medications came as a tablet's dosage form, while oral syrup or suspension not marketed in most places. Several pediatric formulations of those medications can be done. [7] As results, most of those medications not registered and subsequent there is not registered prices. It badly demands to calculate the cost of those pediatrics formulations as part of a pharmacoeconomic project of the updated Pharmacy strategic with new Saudi vision 2030. [8] It seldom to find cost analysis of pediatric formulations of immunosuppressant agent and diuretics or other renal products. The authors based on the best of their knowledge they are not familiar with any publications about cost analysis of pediatric formulations of kidney diseases. The aim of the current study is to explore the cost analysis of nephrology pediatrics populations in the Kingdom of Saudi Arabia.

METHODS
It is a retrospective cost analysis of renal pediatrics formulation services past one year at 300-beds pediatrics and maternity hospital in Riyadh city, Saudi Arabia. It had inpatient admission and ambulatory care clinics and Emergency departments. The hospital had a different specialty for women, adults and pediatrics. The hospital treats the common neonatal, pediatric and women's health disease. The hospital had pharmacy serve the patient, including inpatient pharmacy with unit dose drug distribution system, outpatient

Cost Analysis of Clinical Compounding in Saudi Arabia: Nephrology Pediatrics Formulations
S29 pharmacy and extensive extemporaneous pediatrics section and drug information center. The pharmacy computerized physician order entry with an electronic prescription in addition to the pharmacy had a medication safety program. The pharmacy trained clinical and pharmacy student training programs. The extemporaneous section had very comprehensive pediatric formulations for neonates and pediatrics in the central region of the Ministry of Health hospitals. The section received the specific formulation from physician then the expert pharmacist applied the international standard of clinical compounding through by providing to healthcare staff over eight hours per days for five days per a week. The pediatric formulations consisted of antibiotics, antituberculosis (TB) medications, anticonvulsant medications and Gastrointestinal (GI) drugs, anti-hypertension medications, electrolyte supplements, renal preparations, diuretics formulation, steroid perorations and other supportive substances formulation. The analysis of the cost included the variable expenses included personal cost, material and supply cost. Fixed costs, including direct costs, nonsalary cost and overhead cost. [9,10] In addition to the cost of compounding substances, a number of preparations and time of preparations. The price was derived from the Ministry of Health information database. All cost was used US dollar currency. The study analyzed antibiotics pediatric formulations through the Microsoft Excel sheet version 10 th .

RESULTS
The estimated average total standard cost of pediatrics formulations per hour was (53.82 USD) and consisted of 58.58% (31.53 USD) for personal cost, 25.14% (13.53 USD) for overhead cost, 3.34% (1.8 USD) for material and supply cost, 12.93% (6.96 USD) for non-salary cost ( Table 1). The average estimated cost of hydrochlorothiazide per each preparation was (5.204 USD) with consisted of standard cost (0.034 USD) and the direct cost was (5.17 USD). The total annual cost of hydrochlorothiazide was (2,071.2 USD) ( Table 2). The average estimated cost of acetazolamide per each preparation was (5.72 USD) with consisted of standard cost (0.63 USD) and the direct cost was (5.09 USD). The total annual cost of acetazolamide was (366.1 USD) ( Table 3). The average estimated cost of spironolactone per each preparation was (2.513 USD) with consisted of standard cost (0.033 USD) and the direct cost was (2.48 USD). The total annual cost of spironolactone was (1,507.8 USD) ( Table 4). The average estimated cost of sodium citrate per each preparation was (1.23 USD) with consisted of standard cost (0.083 USD) and the direct cost was (1.147 USD). The total annual cost of sodium citrate was (599.01 USD) ( Table 5). The average estimated cost of citric acid per each preparation was (1.136 USD) with consisted of standard cost (0.187 USD) and the direct cost was (0.949 USD). The total annual cost of citric acid was (81.782 USD) ( Table 6).

DISCUSSION
Several medications had been used for kidney diseases in pediatrics. The diuretic and some pediatrics formulations used for that is an indication. Most of Diuretic and renal medications came as tablets or capsules and Parenteral dosage form (Table 7). [11][12][13][14] As a result, the extemporaneous preparation section at the current site Pharmacy prepares those formulations to meet the demand of the patients. [7] As a result, the pharmacy wishes to calculate the cost foundations of all pediatrics formulations, including the renal products. In all renal pediatrics formulations, the most indirect cost came from personal cost and overhead cost. Because of the preparation need more of pharmacy staff without much demand for equipment. In the current study three pediatrics formulations including the cost analysis of Hydrochlorothiazide, Acetazolamide and Spironolactone. The most expensive medications were Hydrochlorothiazide, followed by Acetazolamide and Spironolactone. The most consumed from Diuretic budget was Hydrochlorothiazide and Spironolactone. All the Diuretic pediatric formulations the direct cost more than indirect cost because the number of preparations were high lead to the reduction in the indirect cost. All of the medications not registered in Saudi or the UK and USA and the pharmacist should continue to prepare all diuretic pediatrics formulations (Table 7). [11][12][13][14] Two medications used for acidification of the urine for renal stone Sodium citrate and Citric Acid. One of them Sodium citrate 0.3 Molar solution more expensive than registered in UK (Table 7), [13,14] while Citric Acid 25% Solution similar cost to the UK. Both of product not registered in KSA or USA (Table 7). [11,12] That is maybe not high utilization in the country or pediatrician not used for their patients. If the pharmaceutical company can sell the medication with lower prices may the pharmacist can get them, if the prices don't change the pharmacist may continue prepare both medications if the medications were seldom found in the market. Renal pediatrics formulation, cost analysis is essential for the financial budget and explores the income and expenses in a particular hospital.

CONCLUSION
Although several products ready-made though pharmaceutical companies, still the pediatric     renal formulation not available in the local or international market with product prices. The cost analysis of extemporaneous preparation of renal product is the primary tools of Pharmacoeconomics goal of new pharmacy strategic with Saudi vision 2030. Regular measures of a cost analysis of the renal extemporaneous product are highly recommended of pediatric pharmacy services in the kingdom of Saudi Arabia.