Download Pharmacy Shortages – December 11, 2014 (Updated monthly, if not

Pharmacy Shortages – December 11, 2014 (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 December 2014. 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. Phentolamine mesylate injection – Out of stock at wholesaler and manufactures (2 of them) have
stopped making for now. Unknown if they will resume. Pharmacy has ZERO on hand. An
alternative for use for extravasations includes terbutaline as a 1:9 ratio with saline as the base
solution. IV Therapy is aware and this alternative was approved by P&T back in 2012.
2. Medications out of stock include – ammonium chloride, droperidol vials, epinephrine preservative
free ampules, hydroxyzine injection, indigo carmine injection, lidocaine 3.5% ophthalmic ointment,
methyldopa injection, nitroglycerine IV vial, pancuronium injection, and phentolamine mesylate
injection.
3. New shortage products – no new additions at this time
4. Medications discontinued by manufacture – caffeine benzoate IV, pralidoxime injection and
sodium thiosulfate IV
5. Resolved – no new resolved issues to note
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 – December 11, 2014 (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. Ammonium chloride vials – Long term back order since March 2011, out of stock.
2. Atropine vial (pediatric concentration) – This concentration (0.4mg/mL) on/off backorder and has
been very limitedly available from wholesaler since November 2011.
3. 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. No release date given.
4. Calcium chloride injection – Wholesaler is out of stock of vials but able to supply with pre-filled
syringes. Pharmacy has no vials on hand only syringes.
5. Dexamethasone 4mg/mL 1mL injection vials – Out at wholesaler. Larger size vials available on
limited basis. Obtaining from secondary markets.
6. Digoxin 250mcg/mL injections - Out at wholesaler. Obtaining from secondary markets. Release
date late January 2015.
7. Droperidol – American Regent sole manufacture and currently not making for various
manufacturing reasons. Pharmacy is out of stock since November 2012.
8. Epinephrine preservative free ampules – Manufacturing delays in producing product causing the
delay plus an increase demand. Pharmacy is out of stock since November 2012.
9. Erythromycin injection – This form is not currently available from the wholesaler. Pharmacy has
limited number on hand (~60 vials). Manufacture releasing limited amount of product. AAMC has
had little use lately reason why able to build up stock.
10. Hydroxyzine IV – The smaller 2mL vial not available from wholesaler and Pharmacy is out of stock
of this. Pharmacy has a limited supply of single dose 10 mL vials that are drawn up as needed.
11. Indigo carmine injection – Currently only one manufactured left supplying the market limiting
supply. Pharmacy has zero vials on hand.
12. Indocyanine green – Currently out of stock at wholesaler. Pharmacy has limited (~20 ampoules)
remaining for use in the OR. Sporadic availability on grey markets.
13. Lidocaine 3.5% ophthalmic ointment (Atken) – Wholesaler cannot provide and manufacture is
unable to keep up with demand at present. Estimated release date is now February 2015.
14. Methyldopa IV – Sole manufacture, American Regent had recalled the product in 2011. None
currently available – no vials or premixed bags are available.
15. Morphine PF injection – Out of stock at wholesaler of the 25 and 50mg/mL concentration. Limited
amount left in AAMC. Expected release now changed to February 2015.
16. Nitroglycerine IV Vial – Current none on hand. Limited availability of nitroglycerine bottles but
appear available for time being. Limited to one manufacture and cannot keep up with demands.
17. Oxycodone/acetaminophen 5/325 solution (Roxicet) – Manufactures are validating new source of
raw materials thus causing the delay. Estimated release date is January 2015.
18. Pancuronium IV – Long term backorder with manufacture (6/2012), no estimated release date at
this time.
19. Phentolamine mesylate injection – Out of stock at wholesaler and both manufactures have stopped
making for now. Unknown if they will resume. Pharmacy has ZERO vials on hand. Release date
unknown.
20. Pralidoxime chloride (Protopam) – All stock expired and manufactured have stopped making.
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 – December 11, 2014 (Updated monthly, if not more often)
21. Prochlorperazine injection – One manufacture that supplies this medication closed in early 2014.
This leaves one sole manufacture to supply; therefore demand is exceeding production of this
product. Limited stock available due to complications with bar code.
22. Proparacaine 0.5% ophthalmic solution – Out at wholesaler. Obtaining from secondary market.
23. Phytonadione syringes – Currently wholesaler out of stock. Estimated release date is October 2014.
24. Sodium thiosulfate vials – Not available from wholesaler at this time (3/2013). Pharmacy out of
stock.
Recommendations:
1. 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.
2. 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). Release date unknown by manufacture.
3. 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.
4. Calcium chloride injection – Zero vials remain in AAMC, but Pharmacy has increased the
compliment of syringes to compensate. Calcium is now available for IV nutrition patients
(TPN/PPN, adult/pediatric/neonatal).
5. Dexamethasone 4mg/mL 1mL injection vials – Trying to prioritize what stock is left for the OR.
For additional information please the following links:
Table 1 Glucocorticoid Comparison:
http://www.ashp.org/DocLibrary/Policy/DrugShortages/dexamethasone-sodiumphosphatecurrent020112TABLEONE.aspx
Table 2 Alternative to Dexamethasone in Selected Situations:
http://www.ashp.org/DocLibrary/Policy/DrugShortages/dexamethasone-sodiumphosphatecurrent020112TABLETWO.aspx
6. Digoxin 250mcg/mL injections – Oral and liquid formulation are unaffected at this time. If digoxin is
needed to load consider loading with oral. A recommend load for oral is: 0.5 mg orally once daily
for 2 days followed oral maintenance dose (Package insert).
7. Droperidol – There are other antiemetic alternatives to consider: ondansetron, metoclopramide,
promethazine, and prochlorperazine (IV limited availability). Most of these medications are
available as an injection, oral, and rectal formulations. Pharmacy is currently out of stock of this
medication.
8. 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.
9. Erythromycin injection – Consider alternative antimicrobials or oral erythromycin. Alternatives to
erythromycin lactobionate injection in selected situations may include but not limited to:
Situation
Recommendation
Comments
Gastroparesis
Metoclopramide 10 mg orally or IV QID
administered 30 minutes before meals.
Erythromycin 250 mg orally TID
Alvimopan 12 mg orally 30 minutes to 5 hours
before surgery, then 12 mg orally twice daily for
Side effects such as drowsiness and tardive
dyskinesia may limit the utility of
metoclopramide.
May only be used in hospitals. Hospitals must
be enrolled in the Entereg Access Support
Gastroparesis following partial
large or small bowel resection
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 – December 11, 2014 (Updated monthly, if not more often)
surgery with primary anastomosis
Premature Rupture of Membranes
(PROM)
up to a maximum of 15 doses
Ampicillin 2 gram IV Q6H and erythromycin 250
mg IV Q6H for 48 hours then give oral doses of
amoxicillin and erythromycin for 5 days.
* Some presentations may be on nation-wide backorder.
and Education (EASE) program.
Limited information available for
azithromycin.
10. Hydroxyzine IV – Currently none on hand. Please consider alternatives such as diphenhydramine
or cetirizine for urticaria/atopic dermatitis/pruritus. No estimated time of release updated to
February 2015.
11. Indigo carmine injection – There is no single dye that can replace indigo carmine. Potential options
include methylene blue and indocyanine green. Choice of alternative agent will depend on type of
procedure and prescriber discretion, as well as product availability. Many of the marker dyes are
on back-order. See “Dye Agent Alternatives” on the drug shortage site for more information.
12. Indocyanine green – Conserve and use only when truly needed. Please see “Dye Agent
Alternatives” on the drug shortage site for more information.
13. Lidocaine 3.5% ophthalmic ointment (Atken) – Primarily used in the OR setting. OR ophthalmology
team leads have been notified. AAMC currently has approximately 12 vials left in house all in Pyxis
at present time (OR-Eye). This is a slow mover.
14. Methyldopa IV – None available at AAMC, consider alternatives: IV hydralyzine or IV labetolol.
15. Morphine PF injection – conserve preservative free morphine as much as needed. May need to
purchase other concentrations to help out usage.
16. Nitroglycerine IV Vial – Considering use premade nitroglycerine drips. Consider oral, sublingual, or
topical applications when applicable. Pharmacy is drawing syringes for Cath Lab use as needed.
17. Oxycodone/acetaminophen 5/325 solution (Roxicet) – It patient cannot tolerate tablets;
alternatives include ordering and linking them in EPIC as their separate component, morphine elixir,
and hydrocodone elixir. Pharmacy estimates to run out ~mid-December 2014
18. Pancuronium IV – None available at AAMC. Alternatives include succinylcholine, cisatracurium,
and/or vecuronium.
19. Phentolamine mesylate injection – An alternative for use for extravasations includes terbutaline as
a 1:9 ratio with saline as the base solution. IV Therapy is aware and this alternative was approved
by P&T in 2012.
20. Pralidoxime chloride (Protopam) – None available at AAMC. Use in conjunction to treat
organophosphate insecticide toxicity and cholinesterase inhibitor toxicity. Alternatives include
using Mark-1 auto-injector. AAMC Emergency Management Director has already been notified
21. Prochlorperazine injection – Limited stock available at AAMC (~10 vials). Several alternatives exist
in several formulations (oral, injections, SL, liquid, and rectal). Several alternatives include:
ondansetron, promethazine, and metoclopramide.
22. Proparacaine 0.5% ophthalmic solution – consider other ophthalmic local anesthetic such as
tetracaine. Pharmacy has on hand 12 vials plus approximately ~20 in Pyxis. This is a slow mover.
23. Phytonadione syringes – Primarily used through the Clatanoff Pharmacy for new born babies.
Currently using adult strength ampoules as alternative for now.
24. 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 Director and our local strategic stockpile liaison. Alternative antidote:
hydroxocobalamin.
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].