*Purpose: RSV is a leading cause of viral infections in lung transplant recipients and is associated with significant morbidity and mortality. While the role of ribavirin as the primary treatment of RSV infections in this patient population is still unclear, the cost of inhaled ribavirin therapy is significantly higher than a comparable oral regimen. The guidelines were updated at our institution in order to provide recommendations for the appropriate use of inhaled and oral ribavirin. The purpose of this study is to evaluate the economic impact and dosing of oral ribavirin therapy in RSV treatment for lung transplant recipients.

*Methods: This was a retrospective cohort study of lung transplant recipients treated with inhaled or oral ribavirin for RSV, from 2013 to September 2018. Patients were excluded if less than 18 years of age, allergic to ribavirin, pregnant, or receiving didanosine concomitantly. The primary endpoint evaluated the economic impact of oral ribavirin compared to inhaled ribavirin. Additional data was collected to evaluate appropriate ribavirin utilization and clinical outcomes.

*Results: A total of 14 lung transplant recipients were included in the study; 14.3% (n=2) received inhaled ribavirin, 78.6% (n=11) received oral ribavirin and 7.1% (n=1) received both inhaled and oral ribavirin therapy. Of the 14 patients, 50% were diagnosed with a lower respiratory tract infection and 50% required inpatient therapy for a median of 6 days (IQR 5.5-8.5). The average cost of therapy was $38,171.50 for patients receiving inhaled ribavirin and $605.90 for patients receiving only oral ribavirin. It was determined that only 38.5% of patients received the appropriate ribavirin dosing regimen and monitoring. For appropriate prescribing, areas identified for improvement were creatinine clearance (58.3%) and weight (66.7%). When looking at patient specific outcomes, 4 patients (28.6%) had worsening of their bronchiolitis obliterans syndrome grade.

*Conclusions: The cost per treatment course was higher with inhaled ribavirin. Implementation of treatment guidelines reduced use of inhaled ribavirin, resulting in cost avoidance of $89,000 per year, with no changes in outcomes. This study identified opportunities for improving dosing of oral ribavirin, these being patients with impaired renal function and obese patients.

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