Sodium Thiosulfate

[Linda Gross]

Hello all. With case reports on the successful use of Na thiosulfate for calciphylaxis mounting, so too is the usage of this agent. Wondering about other centres and how they handle this drug.  Is it formulary? Who pays for it? Are there any restrictions on use (eg. is confirmation of calciphylaxis via skin biopsy required) or do you have an algorithm that must be followed?  Any info you can pass along would be greatly appreciated.

[Ian McDormand]

It is formulary within the Nova Scotia Health Authority.

Prior to us going to 2 HAs in NS, we had it on our formulary in our former DHA. We don’t require any confirmation of calciphylaxis. Physician diagnosis is sufficient.

The cost comes out of the RDU budget.  There is no cost to the patient until they are switched to po.  The compounded oral formulation is an exception status benefit under NS Pharmacare program.

[Stephanie Gilbreath]

Does anyone have an algorithm to follow when sodium thiosulfate is ordered (eg. when appropriate, given for how long, etc.)? Costs are rising with diagnoses rising (for whatever reason) so the HD department wants us to put some limits on the ordering. Thanks!

[Derrick Soong]

Sodium thiosulfate … the grey area med that some centres fully embrace or avoids entirely due to the lack of randomized data. At our centre in Windsor, we had a couple nephrologists skeptical of the evidence and a couple others either very agreeable or willing to give it a try.

In the past year, we have had 3 patients use it with mixed results. I think most of the literature will recommend a 25 g IV dose given three times a week for a duration of 3 months (or at least what ODB EAP will cover). I have applied for thiosulfate via NIHB (you must use the Pfizer product DIN: 02137186) with a similar dose and length of prescription.

One of the limitations is how well the patient will tolerate it … it commonly causes nausea when infused (in our experience), but can be managed it with anti-emetics.

The results we have locally are confounded since we have our patients run from three times a week to six times a week for calciphylaxis. So did the increased dialysis frequency and/or the thiosulfate improve their calciphylaxis lesions?

I’m still not convinced it really works but then again, I haven’t seen some of the miraculous results as one of our nephrologists has personally witnessed when he was in his residency.

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