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\begin{document}

\title{Quantification of Chemotherapy Drug Wastage and incurred financial loss
in Paediatric Cancer Care: a Cross-sectional Study at a Tertiary Care
Public Hospital in India}



\author[1]{Shweta Ghate}%
\author[1]{Swati  Patil}%
\author[1]{Neha  Kadhe}%
\author[1]{Rutuja Fulsoundar}%
\author[1]{Sudhir Pawar}%
\affil[1]{Lokmanya Tilak Municipal Medical College and General Hospital}%


\vspace{-1em}



  
  \date{May 26, 2024}


\begingroup
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\selectlanguage{english}
\begin{abstract}
Aim:The evolving chemotherapy landscape continually introduces effective
agents, but escalating costs call for an evaluation of drug wastage and
financial consequences to enhance resource utilization. This study seeks
to estimate chemotherapy drug wastage and its economic loss in
paediatric cancer care. Methods: In this cross-sectional study of
paediatric cancer patients receiving parenteral chemotherapy, we
evaluated both the drug used and wasted during each administration. The
monetary value of drug loss was calculated using the formula: Cost =
Proportion of drug wasted X Cost of drug vial. Result: 100 paediatric
cancer patients who received 140 parenteral drug administrations of 22
chemotherapy drugs were studied. Wastage amounted to 19.61\% of the
procured drugs in varying proportions. The total estimated cost of
chemotherapy stood at 110,143.1 INR (1,328.7 USD), with cost wastage
accounting for 31,929.95 INR (385.19 USD), equivalent to 28.98\% of the
total expenditure. Notably, doxorubicin (37.4\%) exhibited the highest
drug wastage, followed by cytarabine (35\%) and l-asparaginase (26.9\%),
primarily prescribed for acute lymphocytic leukaemia. Cytarabine
resulted in the highest financial loss. Dose rounding occurred in 22
cases (15.71\%), while vial sharing was observed in only 5 cases
(3.57\%) during drug administrations. Methotrexate, doxorubicin, and
cytarabine doses never matched available vial sizes. Conclusions: In
resource-limited healthcare settings, implementing centre-specific
measures like vial sharing and drug categorization can reduce drug
wastage and financial losses. Evaluating the viability of optimizing
vial sizes and producing multidose vials is essential.%
\end{abstract}%



\sloppy


\textbf{INTRODUCTION}

The incidence of childhood cancers in India is alarmingly high, with 75
to 150 childhood cancers per million children, comprising about 20\% of
all paediatric cancers worldwide.{[}1{]} As per GLOBOCAN 2020, India
records one million new cancer diagnoses annually, of which 3\% occur in
children.{[}2{]} However, life-saving cancer treatments are expensive
and can put a significant financial burden on families, leading to
further disruptions in family dynamics. In India, patients bear almost
68\% of their healthcare expenditure, which is much higher compared to
the world average of 18\% where the majority is under insurance
coverage. Additionally, medicines account for 70\% of the out-of-pocket
expenditure on healthcare by individuals and families in India, making
it a significant barrier to healthcare access, particularly for those
with a lower socioeconomic status.{[}3{]}

As per current chemotherapy practices, the dosing of drugs is determined
by several factors, including the type of cancer, stage, treatment
protocol, weight or body surface area of the patient, age,
comorbidities, and general health of the patient. Therefore, there may
be variations in chemotherapy drug doses among patients using the same
protocol for the treatment of the same cancer {[}4{]}. However, most
chemotherapy formulations are available as single-dose packages, which
can lead to drug wastage if the amount of drug required does not match
the amount of the drug in the vial. This is mainly caused by
administering chemotherapy drugs from vials containing larger amounts
than required and not using the remaining portion of the vial, leading
to drug wastage. This contributes to the increasing overall burden of
cancer care{[}5{]}. However, limited vial size options and drug
stability can restrict the potential of vial sharing between patients.

According to studies conducted by Gopi Shankar et al., 2019 {[}6{]} and
Truong et al., 2017 {[}7{]}, drug wastage and its economic implications
significantly add to the cost of cancer care without providing any
incremental value to patients. Research in this field has suggested
options such as vial sharing, rounding of doses, and batching of
patients as per pathology to curb wastage and decrease costs {[}8{]}.

Most studies on drug wastage for chemotherapy drugs have focused on
their use in adult oncology care. Hence, this study aimed to estimate
drug wastage specifically in the treatment of paediatric malignancies at
our hospital. Additionally, the economic impact of this wastage was
estimated, and existing measures (if any) for decreasing drug wastage
were noted.

\textbf{METHODS}

The study was conducted as a single-centre, cross-sectional,
observational study in the paediatric oncology day care unit of a
tertiary care hospital in India from November 2019 to May 2021. A sample
size of 100 patients was targeted based on published literature {[}4{]}.
Ethical approval was obtained from the Institutional Ethics Committee
(IEC) with the IEC number IEC/381/19, and written informed consent and
assent were obtained from all participants before enrolling them in the
study.

The study included paediatric cancer patients (less than 18 years of
age) who were scheduled to receive parenteral chemotherapy drugs.
Patients whose chemotherapy details were recorded once were excluded
from the study. The details were recorded based on the information
obtained from the patient and their medical record. The information
recorded included the chemotherapy drug, dose (mg/m2), total calculated
dose, formulation details, actual drug consumed (mg), drug wasted (mg),
the total cost of the drug (INR), cost of the wasted drug (INR), and
measures taken to reduce drug wastage (if any), such as rounding off the
dose or sharing of the vial. All this information was recorded on a case
record form. The cost of one unit was obtained from the hospital
pharmacy, outside pharmacies, or NGOs. If provided by NGOs, the retail
price for that brand was noted by the pharmacy, and an expense
assessment was

conducted.

Our independent analysis of drug wastage included the following
scenarios: 1) Calculation of the unused dose by subtracting the
prescribed dose from the total amount of drug in the vial in mg; 2)
Estimation of the total cost of the drug in INR and the cost of the
wasted drug; 3) Determination of the frequency of sharing vial or
rounding off dose if applicable.

We also estimated whether the prescribed doses for different
chemotherapy drugs matched the vial size availability at our hospital
pharmacy and outside pharmacies as per CIMS 2022.

\emph{Statistical analysis} : All collected data was entered into
Microsoft Excel 2016. Continuous variables were expressed as mean \selectlanguage{ngerman}±
standard deviation (SD), and categorical variables were expressed as
percentages and frequency. The percentage of drug wastage was determined
at a 95\% confidence interval.

\par\null

\textbf{RESULTS}

Our analysis included 100 patients who received 140 parenteral
chemotherapy drug administrations of 22 different drugs. The mean (±SD)
age of patients was 6.67 (±3.63) years, with a male predominance of 67
(67\%) compared to females, who were 33 (33\%).

Hematological malignancies were observed in 89\% of our study population
(n=100) compared to solid tumors, which were observed in 11\%
(\textbf{Table 1} ).

\textbf{Table 1: Percentage of cancer distribution(n=100)}\selectlanguage{english}
\begin{longtable}[]{@{}lll@{}}
\toprule
Cancer Type & Cancer & Percentage (\%)\tabularnewline
\midrule
\endhead
Haematological malignancies(n=89) & Acute lymphocytic leukaemia &
74\tabularnewline
& Acute myeloid leukaemia & 7\tabularnewline
& Hodgkin's lymphoma & 5\tabularnewline
& Non-Hodgkin lymphoma & 2\tabularnewline
& Langerhans cell histiocytosis & 1\tabularnewline
Solid Tumour(n=11) & Germ cell tumour & 2\tabularnewline
& Rhabdomyosarcoma & 2\tabularnewline
& Clear cell sarcoma of kidney & 1\tabularnewline
& Primitive neuroectodermal tumour & 1\tabularnewline
& Medulloblastoma & 1\tabularnewline
& Neuroblastoma & 1\tabularnewline
& Optic Glioma & 1\tabularnewline
& Retinoblastoma & 1\tabularnewline
& Wilms Tumour & 1\tabularnewline
\bottomrule
\end{longtable}

We categorized the 140 prescriptions recorded as frequently prescribed
drugs (i.e., drugs with \textgreater{}3 prescriptions) and infrequently
prescribed drugs. Of the frequently administered drugs (n=119),
L-asparaginase (22.14\%) and vincristine (20.71\%) were the most
commonly prescribed. Among the 22 infrequently administered drugs (drugs
with [?]3 prescriptions), etoposide (2.14\%) was the most commonly
prescribed.

All parenteral chemotherapy drugs studied were available either as a
single-use liquid (52.14\%) or powder (47.85\%) formulation.

\emph{Drug wastage}

Out of the total amount of drug procured for 140 administrations, which
was 25515mg, 5004.9mg of the drug were wasted, accounting for an overall
wastage of 19.61\% of the drug procured. The wastage for individual
drugs ranged from 9.6\% to 37.4\% in our study, as shown in\textbf{Table
2} and \textbf{Table 3} .

\textbf{Table 2: Drug Wastage for Frequently Prescribed Drugs (n=119)}\selectlanguage{english}
\begin{longtable}[]{@{}llllll@{}}
\toprule
\begin{minipage}[b]{0.16\columnwidth}\raggedright\strut
Drug name\strut
\end{minipage} & \begin{minipage}[b]{0.16\columnwidth}\raggedright\strut
Number of drug administrations (n)\strut
\end{minipage} & \begin{minipage}[b]{0.16\columnwidth}\raggedright\strut
The total amount of available drug in vial (mg)\strut
\end{minipage} & \begin{minipage}[b]{0.16\columnwidth}\raggedright\strut
Total amount of drug consumed (mg)\strut
\end{minipage} & \begin{minipage}[b]{0.16\columnwidth}\raggedright\strut
Total amount of drug wastage (mg)\strut
\end{minipage} & \begin{minipage}[b]{0.16\columnwidth}\raggedright\strut
Percentage of drug wastage (95\% CI)\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Doxorubicin\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
6\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
300\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
187.8\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
112.2\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
37.4(16.67-58.12)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Cytarabine\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
8\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
800\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
442.5\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
280\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
35(0-62.5)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
L-Asparaginase*\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
31\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
305000\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
222200\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
83400\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
27.34(20.27-33.52)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Daunorubicin\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
8\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
160\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
121.4\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
38.6\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
24.13(13.68-28.48)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Methotrexate (IT)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
26\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
390\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
300\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
90\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
23.08(2.50-19.3)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Vincristine\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
29\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
44\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
36.1\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
8.2\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
18.63(3.73-29.71)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Cyclophosphamide\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
6\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
4900\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
4015\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
885\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
18.06(5.96-34.86)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Methotrexate (IV)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
5\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
10000\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
9040\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
960\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
9.6(20.06-26.08)\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

*: -drug amount in IU

Our analysis revealed that doxorubicin (37.4\%) had the highest amount
of drug wastage, followed by cytarabine (35\%) and L-asparaginase
(26.9\%), which were prescribed for acute lymphocytic leukaemia.

For infrequently prescribed drugs, single administrations of irinotecan
for primitive neuroectodermal tumours and fludarabine for acute myeloid
leukaemia resulted in 85\% and 68\% of drug wastage, respectively.
However, no drug wastage was observed for bortezomib, carboplatin,
dactinomycin, and ifosfamide, as shown in \textbf{Table 3} .

\textbf{Table 3: Drug wastage for infrequently prescribed drugs (n=22)}\selectlanguage{english}
\begin{longtable}[]{@{}llllll@{}}
\toprule
\begin{minipage}[b]{0.16\columnwidth}\raggedright\strut
Drug name\strut
\end{minipage} & \begin{minipage}[b]{0.16\columnwidth}\raggedright\strut
Total number of drug administrations (n)\strut
\end{minipage} & \begin{minipage}[b]{0.16\columnwidth}\raggedright\strut
Total amount of available drug in vials (mg)\strut
\end{minipage} & \begin{minipage}[b]{0.16\columnwidth}\raggedright\strut
Total amount of drug consumed (mg)\strut
\end{minipage} & \begin{minipage}[b]{0.16\columnwidth}\raggedright\strut
Total amount of drug wastage (mg)\strut
\end{minipage} & \begin{minipage}[b]{0.16\columnwidth}\raggedright\strut
Percentage of drug wastage (\%)\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Irinotecan\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
1\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
100\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
15\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
85\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
85\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Fludarabine\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
1\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
50\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
16\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
34\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
68\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Etoposide\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
3\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
300\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
100\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
200\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
67\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Cisplatin\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
2\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
100\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
40\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
60\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
60\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Vinorelbin\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
1\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
50\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
20\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
30\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
60\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Vinblastine\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
1\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
10\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
4.2\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
5.8\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
58\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
HD cytarabine\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
3\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
5000\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
2835\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
2165\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
43.3\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Arsenic trioxide\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
1\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
3\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
2.5\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.5\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
17\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Idarubicin\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
1\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
5\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
4.4\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.6\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
12\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Gemcitabine\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
1\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
1000\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
950\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
50\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
5\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Bortezomib\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
1\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
1\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
1\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Carboplatin\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
2\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
300\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
300\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Dactinomycin\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
2\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
2\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
2\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Ifosfamide\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
1\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
2000\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
2000\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

Economic burden of drug wastage

All drugs used in our study were procured from the NGO, and their
costing was noted from the hospital pharmacy. The total expenditure for
drug procurement was 110143.1 INR (1328.7 USD), out of which 31929.95
INR (385.19 USD) was the cost of wasted drugs, amounting to 28.98\% of
the economic loss as shown in\textbf{Table 4} .

\textbf{Table 4: Cost for wastage for frequently prescribed
drugs(n=119)}\selectlanguage{english}
\begin{longtable}[]{@{}lllll@{}}
\toprule
\begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
Drug name\strut
\end{minipage} & \begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
Total number of drug administrations (n)\strut
\end{minipage} & \begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
Total cost of drug INR (USD)\strut
\end{minipage} & \begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
Total cost of drug wasted INR (USD)\strut
\end{minipage} & \begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
Percentage of cost of drug wastage (95\% CI)\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Cytarabine\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
8\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
1600 (19.30)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
681 (8.22)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
42.56(18-62.5)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Doxorubicin\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
6\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
9240 (111.47)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
3301.36 (39.83)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
35.73(13.72-57.74)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
L-Asparaginase*\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
31\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
43400 (523.55)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
12054 (145.41)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
27.77(21.33-34.21)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Daunorubicin\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
8\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
3184 (38.41)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
768 (9.26)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
24.12(15.72-32.52)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Methotrexate (IT)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
26\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
1254.5 (15.13)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
289.27 (3.49)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
23.06(20.05-26.07)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Vincristine\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
29\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
1720 (20.75)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
328 (3.96)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
19.07(11.38-24.83)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Cyclophosphamide\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
6\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
935 (11.28)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
186.25 (2.25)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
19.92(5.97-34.87)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Methotrexate (IV)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
5\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
14400 (173.71)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
1382.4 (16.68)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
9.6(5.97-34.87)\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

*: -drug amount in IU

For infrequently administered drugs, the single administration of
irinotecan and fludarabine resulted in a financial loss of 3305 INR
(39.87 USD) and 6204 INR (74.84 USD), respectively. The financial loss
with wastage of all infrequently prescribed drugs is provided as a
tabulation in \textbf{Supplementary Table 1} .

\textbf{Supplementary Table 1: Percentage of cost wastage of
infrequently prescribed drugs(n=22)}\selectlanguage{english}
\begin{longtable}[]{@{}lllll@{}}
\toprule
\begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
Drug name\strut
\end{minipage} & \begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
Total number of drug administrations (n)\strut
\end{minipage} & \begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
Total cost of drug INR (USD)\strut
\end{minipage} & \begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
Total cost of drug wastage INR (USD)\strut
\end{minipage} & \begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
Percentage of cost of drug wastage (\%)\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Irinotecan\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
1\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
3889 (46.91)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
3305 (39.87)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
85\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Fludarabine\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
1\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
9124 (110.07)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
6204.3 (74.85)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
68\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Etoposide\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
3\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
600 (7.24)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
400 (4.83)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
67\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Cisplatin\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
2\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
1022 (12.33)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
613.2 (7.40)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
60\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Vinorelbin\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
1\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
1000 (12.06)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
600 (7.24)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
60\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Vinblastine\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
1\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
250 (3.02)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
145 (1.75)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
58\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
HD cytarabine\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
3\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
3840 (46.32)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
1310.4 (15.81)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
34.12\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Arsenic trioxide\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
1\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
160.62 (1.94)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
26.77 (0.32)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
17\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Idarubicin\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
1\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
500 (6.03)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
60 (0.72)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
12\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Gemcitabine\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
1\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
5500 (66.35)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
275 (3.32)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
5\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Bortezomib\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
1\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
1500 (18.10)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Carboplatin\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
2\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
4600 (55.49)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Dactinomycin\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
2\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
1780 (21.47)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Ifosfamide\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
1\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
644 (7.77)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}



\emph{Strategies to curb wastage}

Among the total 140 drug prescriptions, measures to curb wastage were
observed in 27 (19.29\%) of the administrations. Measures such as
sharing of vials were adopted in 5 (3.57\%) of the administrations while
rounding was done in 22 (15.71\%) of them.

\emph{Comparison of drug doses with available vial sizes for each drug}

When the doses of drugs prescribed to the vial strength available at our
setup (as shown in \textbf{Table 5} ), the highest frequency of dose
matching the vial size was seen for L-asparaginase. For 31
L-asparaginase administrations, the dose perfectly matched the vial size
available in 5 cases (10000 IU). However, for drugs with high wastage,
such as doxorubicin, the median dose prescribed in our study, i.e., 33.9
mg (range 16-48), did not match the vial strengths available at our
hospital (10, 50 mg).

\textbf{Table 5:} \textbf{Details of available vial strengths and
matching with prescribed dose. (n=140)}\selectlanguage{english}
\begin{longtable}[]{@{}lllllll@{}}
\toprule
\begin{minipage}[b]{0.14\columnwidth}\raggedright\strut
Drug name\strut
\end{minipage} & \begin{minipage}[b]{0.14\columnwidth}\raggedright\strut
Total number of drug administration (n)\strut
\end{minipage} & \begin{minipage}[b]{0.14\columnwidth}\raggedright\strut
Commonest dose prescribed (mg)\strut
\end{minipage} & \begin{minipage}[b]{0.14\columnwidth}\raggedright\strut
Median dose prescribed mg(range)\strut
\end{minipage} & \begin{minipage}[b]{0.14\columnwidth}\raggedright\strut
Frequency of vials matching prescription dose(n)\strut
\end{minipage} & \begin{minipage}[b]{0.14\columnwidth}\raggedright\strut
Formulation available in our setup (mg)\strut
\end{minipage} & \begin{minipage}[b]{0.14\columnwidth}\raggedright\strut
Formulation available in the Indian market (mg)\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
L-Asparaginase*\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
31\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
10000\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
6800(4000-10000)\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
5\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
5000, 10000\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
5000, 10000\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Vincristine\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
29\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
1.5\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
1.3(0.5-2.25)\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
2\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
1\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
1, 2\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Cyclophosphamide\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
6\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
NA\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
600(150-2068)\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
1\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
500, 1000\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
50, 100, 200, 500, 1000\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Methotrexate (IV)\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
5\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
2820\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
1410(1000-2820)\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
1\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
500\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
25, 50, 1000\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Cytarabine\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
8\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
NA\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
63(37.5-80)\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
0\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
100, 1000\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
100, 500, 1000\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Doxorubicin\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
6\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
16\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
33.9(16-48)\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
0\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
10, 50\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
10, 20, 50, 200\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Daunorubicin\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
8\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
14\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
14(13.7-21)\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
0\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
20\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
20, 50, 200\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Methotrexate (IT)\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
26\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
12\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
12(8-12)\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
0\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
15\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
15\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

*: -drug amount in IU

NA: -not applicable, as all patients received a varying dose

\textbf{DISCUSSION}

Distress financing pays for the majority of hospitalizations for
paediatric cancer care patients in both rural (over 60\%) and urban
(40\%) areas {[}9{]}. Given the enormous economic burden posed by
anticancer drug treatment, it is unacceptable to bear the incremental
cost of drug wastage. In this study, we audited parenteral chemotherapy
drug wastage and estimated the economic loss incurred due to it at our
paediatric oncology day care unit.

Our study evaluated 100 patients who received 140 parenteral drug
administrations of 21 different chemotherapy drugs. We found that
19.61\% of the parenteral chemotherapy drug was wasted, which is similar
to the study conducted by Gopi Shankar et al. {[}6{]}. In their study,
they prospectively quantified chemotherapy drug wastage in adult
patients and observed significant drug wastage of 19.72\% in 3 months
and 17.14\% in 1 year for 313 patients attending the oncology unit.
Several other studies conducted in oncology units have reported
significant, but highly variable, drug wastage ranging from 1\% to
33.8\% {[}10{]},{[}11{]}, {[}12{]}, {[}13{]}, {[}14{]}. However, most of
the reported studies were conducted on adult cancer patients, and there
is sparse data on paediatric patients.

In our study, we observed that the amount of wasted drugs, i.e.,
19.61\%, resulted in an economic loss of 31929.95 INR (385.19 USD),
which accounted for 28.98\% of the total drug cost. Similarly, in a
study conducted by Gopi Shankar et al. {[}6{]}, the cost due to drug
wastage was found to be 17.14\% of the total expenditure on drugs over
one year. In a drug waste study by D'Souza et al. {[}4{]}, 6.1\% of the
reconstituted drugs were wasted, and the cost analysis amounted to
11.1\% of the total drug cost. The lesser amount of wastage observed in
D'Souza's study suggests that some strategies for waste reduction may be
already in place in their setup, although this was not clarified in the
study results.

We found that doxorubicin (37.4\%, 95\% CI: 16.67-58.12) had the highest
amount of drug wastage followed by cytarabine (35\%, 95\% CI: 0-62.5)
and L-asparaginase (27.34\%, 95\% CI: 20.27-33.52) which were prescribed
for ALL. The economic loss due to this wastage was 3301.36 INR (39.83
USD) for doxorubicin, 681 INR (8.22 USD) for cytarabine, and 12054 INR
(145.41 USD) for L asparaginase. So the baseline cost of a single unit
results in more financial loss for even smaller wastage as seen with L
asparaginase. Other drugs frequently used in the treatment of ALL like
intrathecal methotrexate administration (n=26) and vincristine (n=29)
administrations also contributed to wastage of 23.08\% and 18.63\% and
financial loss of 289.27 INR (3.49 USD) and 328 INR (3.96 USD)
respectively. The individual drug wastage seen in our study cannot be
compared to other studies as the majority of the reported studies were
conducted in adult cancer patients with different drug use spectrums.

In our study, the drug wastage and financial loss encountered for the
single administration of irinotecan prescribed for primitive
neuroectodermal tumours and fludarabine prescribed for acute myeloid
leukaemia were 85\% and 68\%, respectively. The financial loss for
irinotecan was 3305 INR (39.87 USD), and for fludarabine, it was 6204
INR (74.84 USD). However, there was no drug wastage observed in
bortezomib, carboplatin, dactinomycin, or ifosfamide administrations
since the dose administered matched the amount available in the vial
exactly.

Various mitigation approaches can significantly reduce chemotherapy drug
wastage. For instance, a study by Fasola et al found that using
multidose vials with stability for up to 24 hours, scheduling
chemotherapy sessions by grouping patients as per pathology or drug,
rounding by 5\%, and using appropriate vial size as per the estimated
daily usage of each drug reduced drug waste expenditure by 45\%
{[}15{]}. These cost and waste containment strategies have been proven
effective and can be implemented to optimize resource utilization in
cancer care. For commonly used drugs such as l-asparaginase, intrathecal
methotrexate, and vincristine in ALL treatment, waste mitigation
strategies such as pathology-wise batching or drug-wise batching can be
considered. However, the cost-effectiveness of these approaches needs to
be evaluated in further studies before implementation.

In vial sharing, the remainder from each vial is retained and can be
used for the next patient while dose rounding is a method that either
increases or decreases a prescribed dose to the nearest whole vial
strength available {[}16{]}. However, our study found that vial sharing
and rounding of dose were used in only 19.29\% (n= 27) of drug
administrations. Rounding was done in 15.71\% and sharing was done in
3.57\% of drug administrations. To ensure safety and effectiveness, each
institution should establish its criteria for automatic dose rounding,
allowable percentage, and processes for operationalizing and documenting
any modifications to the original prescribed dose. Additionally,
exceptions to the dose-rounding policy should be determined a priori
{[}8{]}

It is worth noting that all drug formulations available at your pharmacy
were single-dose vials as per the manufacturer's label because they lack
preservatives. Therefore, each shared vial must be appropriately logged,
unpackaged, and stored, and its sterility must be ensured for later use.
As two or more patients are treated from a single vial, the chances of
microbial contamination cannot be negated, and proper precautions must
be taken to minimize the risk of infections {[}16{]}. Vial-sharing
challenges can be eased through drug vial optimization (DVO), which
extends drug sterility and stability up to 7 days using closed-system
drug transfer devices (CSTDs). These devices move drugs between
containers, like vials to syringes, without contamination or
environmental release. In an international survey by Gilbar et al., only
India and Japan among 12 countries denied using DVO for anticancer
injections {[}8{]}.

For doxorubicin, cytarabine, methotrexate (intrathecal), and
vincristine, the prescribed doses did not align with the available vial
sizes. Regarding l-asparaginase (n=31), only 5 drug administration's
perfectly matched the vial sizes. Bach et al. suggested that
policymakers should urge manufacturers to offer drug packaging in
various sizes to minimize wastage. Additionally, further research into
disease-specific body surface areas and weights could provide insights
into ideal vial size options for waste reduction. Establishing
guidelines, such as limiting wastage to a specified percentage of the
vial size based on average patient body surface area or weight derived
from disease-specific population data, could incentivize pharmaceutical
companies to package drugs in sizes that reduce excessive wastage
{[}12{]}.

The limitations of our study are that monoclonal antibodies and small
molecules were not routinely used at our institute which is unlike the
private sector where they are now widely used. Also, to devise a
comprehensive strategy to minimize the drug wastage it would be
appropriate to estimate wastage encountered with specific cancer like
ALL in our setup.

\emph{Conclusion}

In the realm of paediatric oncology care, a holistic approach is
essential to effectively address drug wastage and the associated
financial implications. One strategy involves encouraging pharmaceutical
manufacturers to tailor vial sizes to meet the unique needs of the
paediatric population. Additionally, exploring the feasibility of
multi-dose vials with extended stability could prove advantageous.
Healthcare providers can also play a crucial role by developing
institution-specific protocols for dose rounding and vial sharing,
informed by the stability data provided in the package insert. This
balanced approach can help optimize resources and improve the efficiency
of paediatric oncology drug administration.

\textbf{Ethical Approval:} The study was approved by Institutional
Ethics Committee(IEC) number 381/19 dated 28/10/2019

\textbf{Acknowledgment:} We acknowledge Department of paediatric for
their constant support

\textbf{Funding:} None

\textbf{Competing interests:} There are no competing interest to
declare.

\textbf{Data Availability Statement:} The data that support the findings
of this study are available from the corresponding author upon
reasonable request.

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