Download Pharmacy Shortages – September 6, 2013 (Updated monthly, if not

Pharmacy Shortages – September 6, 2013 (Updated monthly, if not more often)
Dear Colleagues,
Below and the following link http://www.aahs.org/medstaff/?page_id=3269 (which has the complete
AAMC Drug Shortage list) are the AAMC Critical Drug Shortages for September 2013. As everyone
knows this is a moving target and changes often. The most critical items are the ones listed below with
the complete list including the ones below see link above. Please forward to your colleagues since many
may not see or receive this e-mail. If anyone wishes to be added please let me know and I will add to
the group.
1. Multivitamin injection - Currently out of stock at the wholesaler and Baxter the primary
manufactured of IV MVI does not expect release until late September 2013. About ~90 doses
left of IV MVI. Need to limit x1 time dose in “banana bags” and other IV MVI doses to a one
time order and consider replaced with either tablet or liquid formulation. Several components
exist as IV formulations and can be ordered as individual ingredients once the MVI runs out
(ascorbic acid, folic acid, pyridoxine, and thiamine). TPN/PPN formulations are also limited to
Monday/Wednesday/Friday use only. Adults will use a modified MVI formulation using the
above individual components. Pediatrics and NICU can continue to use the pediatric MVI –
currently no impact on this.
2. Sincalide (Kinevac) injection - Radiology has been notified of the shortage. None currently left
in house. This product used primarily for diagnostic testing of gallbladder. Both AAMC and
Bowie radiology location are aware this product is out of stock currently until late September or
early October per the manufacture.
3. Medications out of stock include – acetylcysteine 10% vials, ammonium chloride, droperidol
vials, epinephrine preservative free ampules, hydroxyzine injection, indomethacin injection,
methylene blue, nitroglycerine IV vial, pancuronium injection, papaverine injection, rifampin
injection, sodium phosphate IV, sodium thiosulfate IV and tromethamine injection.
4. New shortage products – Adacel (diphtheria/tetanus toxoids/pertussis vaccine), cisatracurium
injection, erythromycin injection
5. Medications discontinued by manufacture – caffeine benzoate IV
6. Resolved – acyclovir injection, dobutamine vials, fentanyl 2mL amps, methylergonovine
injection, prednisone tablets
Please forward to staff and colleagues as needed. If you have further questions about this please do not
hesitate to ask or e-mail me, Jared Calish, PharmD, Pharmacy Clinical Coordinator [email protected].
Pharmacy Shortages – September 6, 2013 (Updated monthly, if not more often)
Situation:
To inform all healthcare personnel about imminent or already occurring medication shortages facing AAMC.
Background:
Due to a variety of reasons AAMC is currently faced with the following medication shortages listed below with
alternatives or other information provided as needed or known to the Pharmacy Department.
Assessment:
Medication currently designated as critical shortages for AAMC are listed below:
1. Acetylcysteine 10% – The 10% size is out of stock. Acetylcysteine 20% is in stocked in limited quantities.
2. Adacel (diphtheria/tetanus toxoids/pertussis vaccine) – Currently only available from manufacture as a
direct purchase and limited to allocation only.
3. Ammonium chloride vials – Long term back order since July 2011, out of stock.
4. Atropine Syringes – Emergency syringes are slowing becoming available. Pharmacy is receiving a limited
amount from the wholesaler at this time. See below regarding vials.
5. Atropine vials (adult concentrations) – Limit stock available. We have received one order of vials in the
year. Syringes are available, see above.
6. Atropine vial (pediatric concentration) – This concentration (0.4mg/mL) on/off backorder and has been
very limitedly available from wholesaler.
7. Caffeine benzoate IV – Out of stock at the wholesaler, caffeine citrate is available. No estimate release
date is known; only one manufacturer exist – American Regent and may discontinued production; no
release date given.
8. Calcium chloride injection – all three manufactures are reporting delays in manufacturing. Release dates
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for all three companies is sometime 2 quarter 2013. Currently out of stock in vial and limited amount
of syringes on hand.
9. Cisatracurium injection – Wholesaler currently out of stock. Pharmacy left with limited amount of smaller
vials (primarily used by anesthesia) and Pharmacy also has the larger dose vials used primarily for drips
when needed.
10. Droperidol – American Regent sole manufacture and currently not making for various manufacturing
reasons. Out of stock at wholesale level. Pharmacy is out of stock.
11. Epinephrine preservative free ampules – Manufacturing delays in producing product causing the delay
plus an increase demand. ZERO ampules on hand.
12. Erythromycin injection – Recall from manufacture has pulled stock out of circulation and returned.
Currently none on hand.
13. Fat emulsion – Several recalls and backorders of fat emulsion. Currently no presentation available from
wholesaler and only available on allocation directly from manufacturer.
14. Hydroxyzine IV – The smaller 2mL vial not available from wholesaler and Pharmacy is out of stock of this.
Pharmacy has a very limited supply of single dose 10mL vial to use.
15. Indomethacin injection – Manufacture has stopped making product until production lines are back up and
running. It is listed as out of stock and pending production as capacity permits with Bedford Laboratories.
16. Magnesium sulfate – All manufactures are experiencing delays in producing this product. Companies are
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estimating a 2 quarter release dates.
17. Mannitol vials – Limited supply left in the main pharmacy. Out of stock at wholesaler. Receiving direct
orders but at very irregular intervals.
18. Methyldopa IV – Sole manufacture, American Regent had recalled the product in 2011. Since then AAMC
has received on shipment of 20 vials. This is currently all we have in stock.
19. Methylene Blue – Currently out of stock in Pharmacy. Wholesaler out of stock. Direct orders placed with
manufacture now waiting for orders to be filled.
20. Multivitamin injection – Currently out of stock at the wholesaler and Baxter the primary manufactured of
IV MVI does not expect release until late September 2013. About 90 vials remain.
21. Nitroglycerine IV Vial – Current none on hand. This does not seem to affect premade nitroglycerine.
22. Pancuronium IV – Long term backorder with manufacture, none available at AAMC.
Please forward to staff and colleagues as needed. If you have further questions about this please do not
hesitate to ask or e-mail me, Jared Calish, PharmD, Pharmacy Clinical Coordinator [email protected].
Pharmacy Shortages – September 6, 2013 (Updated monthly, if not more often)
23. Papaverine injection – Long term back order. Bedford and Sandoz manufacturers have discontinue
manufacturing leaving American Regent who has temporarily suspended distribution of drug supplies.
American Regent cannot estimate a release date at this time. Pharmacy is out of stock.
24. Rifampin IV – Product is on backorder from 3 out of the 4 manufactures. Akorn the only currently
supplying cannot meet the demand and its product is too backordered. Out of stock.
25. Sincalide injection – Currently on manufacture backorder until late September or early October of this
year.
26. Sodium phosphate injection – Increase demand of product. Pharmacy is now out of this preparation.
27. Sodium thiosulfate vials – Not available from wholesaler at this time. Pharmacy out of stock.
28. Tromethamine – Manufacture backorder from Hospira. Hospira estimates a release date of September
2013. Pharmacy is out of stock on this item.
29. Tuberculin purified protein derivate for intradermal injection – Sanofi Pasteur and JPH states shortage is
due to supply and demand issues.
Recommendations:
1. Acetylcysteine 10% – This primarily affects respiratory and a separate communication was sent to them
earlier this year. Pharmacy is making 4 mL syringes for Respiratory Therapy to use. The 4 mL 20% vials
from the manufacturer are no longer being made or available. Acetylcysteine 10% vials are now out of
stock. Acetylcysteine shortage does not affect the commercially available Acetadote IV for
acetaminophen overdose.
2. Adacel (diphtheria/tetanus toxoids/pertussis vaccine) – Enough supply remains within AAMC for about 23 weeks until supply catches up to allocation amount received. Estimated end of allocation period is early
October.
3. Ammonium chloride vials – AAMC has very little historical use, primarily used for treatment of
hypochloremia or hypochloremic metabolic alkalosis for patients who cannot receive sodium chloride and
in end-stage renal disease. Out of stock.
4. Atropine Syringes – Syringe supply is beginning to look better, stock is improving. Syringes are replacing
vials in Pyxis machines and anesthesia as needed. No affect on crash carts (adult, Broslow, and NICU).
5. Atropine vials (adult concentrations) – Pharmacy has a supply but stock continues to dwindle (~75 vials or
~3-4 week supply). Unsure when drug will be released
6. Atropine vial (pediatric concentration) – Pharmacy has limited amount of manufactured vials. Clatanoff
Pharmacy has been using the Pharm-Medium compounded 1mg/2.5mL syringes to help supplement the
pediatric OR areas (Anesthesia).
7. Caffeine benzoate IV – Primarily used to treat emergency respiratory failure associated with CAN
depressant overdoses. It has off-label uses for treatment in the overdose of CNS depressant agents;
although no longer the preferred agent for this indication. Caffeine benzoate was more commonly used
for postdural puncture headache and in combination of ECT to prolong seizure duration. The Caffeine
citrate formulation is use for neonates for apnea.
8. Calcium chloride injection – Currently not affecting code cart supply, but may be impacting parenteral
nutrition availability. Consider oral when appropriate and/or calcium gluconate IV. A supply of calcium
chloride syringes are being kept in reserved for crash carts.
9. Droperidol – There are other antiemetic alternatives to consider if such as: ondansetron, metoclopramide,
promethazine, and prochlorperazine (IV now available). Most of these medications are available as an
injection, oral, and rectal formulations. Pharmacy is out of stock.
10. Cisatracurium injection – Anesthesia leadership was made aware of this shortage. Atracurium is also
backordered and not available. Other paralytic agents do not appear affected at this time.
11. Epinephrine preservative free ampules – The preservative free vial primarily used in the operating room.
Regular non-preservative free vials are appropriate to use based on the package insert. An alternative is
the regular epinephrine vials/ampules. These vials contain 0.1% sodium bisulfate but are compatible for
ophthalmic use. No estimate from manufactures on return of product.
12. Erythromycin injection – IV erythromycin primary used as a GI motility agent here at AAMC. Other drug
to consider metoclopramide. As for antimicrobial options other agents in that class are available
(azithromycin – IV and PO, clarithromycin – PO, for example).
Please forward to staff and colleagues as needed. If you have further questions about this please do not
hesitate to ask or e-mail me, Jared Calish, PharmD, Pharmacy Clinical Coordinator [email protected].
Pharmacy Shortages – September 6, 2013 (Updated monthly, if not more often)
13. Fat emulsion – Limited supply available. Pharmacy is receiving limited amount of supply is on an irregular
basis. Adult and pediatric parenteral nutrition is no longer affected by this shortage.
14. Hydroxyzine IV – Currently none on hand except for what is left in our Pyxis machines. Please consider
alternatives such as diphenhydramine or cetirizine for urticaria/atopic dermatitis/pruritus.
15. Indomethacin injection – Pharmacy out of stock. The neonatologists are aware and looking into other
possibilities such as using Neoprofen. The use of IV Indomethacin is for patent ductus arteriosus (PDA) to
help with heart problems for babies shortly after birth.
16. Magnesium sulfate – This shortage is affecting both us and area compounders that make out magnesium
piggybacks. For now minimal affect on Labor & Delivery magnesium drips seemed to be affected. No
affect on small 1gm vials used in crash carts but limited amount of multi-dose vials are available. 4gm
premixed bags may be going on backorder soon as well and will need to be compounded (primarily used
in Clatanoff in Labor and Delivery). The large volume magnesium drips (20gm/500mL or 40gm/1000mL)
are experiencing even higher backer order demands; these too may need to be compounded soon.
17. Mannitol vials – Limited supply of vial and plenty of 20% 500mL IV bags of mannitol available for use. The
bags are less concentrated so more volume would need to be given to equal the amount of mannitol
needed to treat if used.
18. Methyldopa IV – Very limited amount exist in AAMC. Alternatives include IV hydralyzine or IV labetolol.
19. Methylene Blue – Used primarily for breast sentinel node biopsy procedures, GI fistula and other GI
diagnostic procedure. Also used for methemoglobinemia treatment. Alternatives for breast procedure
include: Lymphazurin (also out of stock – non-formulary at AAMC) and indigo carmine. The Breast team
which is the largest and nearly sole user of this product is aware.
20. Multivitamin injection – Currently ~90 doses left of IV MVI. Need to limit x1 dose in “banana bags” and
other IV MVI doses to a one time order and consider replaced with either tablet or liquid formulation.
Several components exist as IV formulations and can be ordered as individual ingredients once the MVI
runs out (ascorbic acid, folic acid, pyridoxine, and thiamine). TPN/PPN formulations are also limited to
Monday/Wednesday/Friday use only. Adults will use a modified MVI formulation using the above
individual components. Pediatrics and NICU can continue to use the pediatric MVI.
21. Nitroglycerine IV Vial – Considering use premade nitroglycerine drips.
22. Pancuronium IV – None available at AAMC. Alternatives include succinylcholine, cisatracurium, and/or
vecuronium.
23. Papaverine injection – No presentation available. Possible alternatives may be nitroglycerine for
vasodilatation, but this may not be a good option due to its limited availability – see above.
24. Rifampin IV – ID physicians and our Director of epidemiology have been informed of this shortage. Please
consult ID if you believe your patient may need this product. If truly needed brand rifampin is available
but at brand cost ($$$$).
25. Sincalide injection – Radiology has been notified of the shortage. Approximately 30 vials remain in stock.
This product used primarily for diagnostic testing of gallbladder. Both AAMC and Bowie radiology location
are aware this product may run out before supply returns.
26. Sodium phosphate injection – CAPS, our compounder of parenteral nutrition products has already issued
an alert us asking to no longer order/use sodium phosphate. Use potassium phosphate as the IV
phosphate of choice for replacement. This agent is of particular importance because renal patients could
not tolerate the potassium phosphate as an option. Consider oral phosphate if the patient can tolerate.
27. Sodium thiosulfate vials – Currently found as an individual agent and in combination with our Cyanide
antidote kits. This product is out of stock. Information was forwarded to AAMC Emergency Preparedness
Department and our local strategic stockpile liaison. Alternative is hydroxocobalamin as an antidote.
28. Tromethamine – Primarily used for metabolic acidosis with pediatrics and NICU here at AAMC. Sodium
bicarbonate would be an alternative.
29. Tuberculin purified protein derivate for intradermal injection – AAMC has limited quantity on hand of
JPH’s product Aplisol and Sanofi’s Tubersol. Currently all PPD products are limited to Employee Health,
Pathways, and for those patients where drug treatment indicated PPD testing (i.e. Humira, Remicade).
Pharmacy is allocated this product on a very limited basis.
Please forward to staff and colleagues as needed. If you have further questions about this please do not
hesitate to ask or e-mail me, Jared Calish, PharmD, Pharmacy Clinical Coordinator [email protected].