Size Matters:

March 31, 2016

Why Oversize Dosage Vials of Cancer Drugs Are a Huge Problem


by Yoram Unguru, MD, MS, MA


Drug pricing and waste matter.  The pharmaceutical industry practice of producing oversized, single-dose vials of cancer drugs results in tremendous and unnecessary cost absorbed by patients, insurance carriers, and other stakeholders – costs that are not associated with improved health outcomes.  Quite the opposite; the waste associated with this practice also creates downstream problems that negatively affect patients.  For example, when a given medication produced strictly in a single oversized vial experiences a disruption in the production process, the inevitable end result is a shortage of the drug.


Leftover drug cannot be stored for later use; medications, like many other products, have a “shelf life.”  Milk for example, has a “best used by date” and in this regard, drugs are no different.  As such, saving a drug for use beyond its expiration date is problematic, not to mention, illegal.  In some instances, a drug’s stability and sterility profile may allow for extending its use beyond accepted practice. Should such an approach be adopted, it is important that hospitals, pharmacists, and physicians be transparent about such a practice and fully inform patients.


Cost is an important consideration in many other aspects of life; drugs should be no different.  Patients and physicians should care about the cost of drugs.  If we continue to ignore drug prices, our fractured healthcare system will collapse and many more people will be negatively affected.


Preventing such a breakdown begins with strategies to minimize wasted medicine.  A common approach adopted by many physicians has been so-called “cohorting” of patients, wherein patients requiring the same therapy share vials packaged for use by a single patient.


Another strategy hospitals should adopt is to stop ordering more drug(s) than they require.  Such hoarding of drugs indirectly results in waste, especially when the medication in question is an oversized vial.


But perhaps most significantly, as appreciated by Bach and colleagues in their recently published analysis, the US healthcare system is constrained by its inability to directly negotiate with drug manufacturers.  The fact that smaller and alternative vial sizes exist outside the US is at least partially due to these governments’ ability to negotiate with pharmaceutical companies and the companies willingness to do so. These non-US governments also set national wholesale prices for drugs, keeping down cost, a practice that does not occur in the US.  US hospitals and other drug purchasers should be allowed to directly negotiate with drug companies.  Failure to do so will perpetuate the misgivings of our market based healthcare system and continue to place profit ahead of patient interests.



Yoram Unguru, MD, MS, MA, is a core faculty member of theJohns Hopkins Berman Institute of Bioethics and a practicing pediatric hematologist/oncologist at The Herman and Walter Samuelson Children’s Hospital at Sinai.

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Yoram Unguru

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