Download Pharmacy Shortages – Update January 17, 2013 (Updated monthly

Pharmacy Shortages – Update January 17, 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. Acyclovir IV – Out at the wholesaler, approximately 50 vials remain.
2. Acetylcysteine 10% and 20% vials – all sizes of both concentrations are on backorder. Limited number of
20% 30mL on hand.
3. Amikacin IV – None available from wholesaler or manufacturer currently, limited quantity in stock.
4. Aminophylline IV – Out of stock at wholesaler, historically low use at AAMC.
5. Ammonium chloride vials – Long term back order since July 2011
6. Atracurium IV – Bedford Laboratories, the manufacture of atracurium has stopped making due to
manufacturing plant issues. Unknown at this time when production will be restarted.
7. Atropine Syringes – Emergency syringes are currently unavailable from IMS and Hospira.
8. Atropine vials (pediatric and adult concentrations) – Both concentrations are out of stock at the wholesale
level. Receiving limited amount via through direct orders.
9. Azithromycin IV and tablets – Increase demand for winter flu season may be linked to backorder for both
IV and oral entities.
10. Bumetanide – Smaller size (4mL vial) unavailable from wholesaler and limited amount of 10 mL are
currently available.
11. Caffeine benzoate IV – Out of stock at the wholesaler, caffeine citrate is available.
12. Calcium gluconate – All sizes of this type of calcium salt out wholesaler and AAMC.
13. Cyanocobalamin vials (B-12) – APP manufacturer recalled multiple lots causing the drug shortage.
American Regent had suspended making of this product but recently restarted. Manufacturer currently
not able to keep up with demand.
14. Dextrose 50% Syringes – Backordered at wholesale level, plenty of vials on hand.
15. Dobutamine vial – Various manufacturing delays from all three manufactures affect supply.
16. Doxapram IV – Long term back order with Bedford Pharmaceuticals. Baxter sold its product to Westward
and awaiting start up.
17. Droperidol – Out of stock at wholesale level. Limit amount on hand in Pharmacy.
18. Enalaprilat IV – None currently available at wholesale level. Two of the four companies have suspended
or discontinue production of this product. Demand greater than the supply currently.
19. Epinephrine preservative free ampules – Manufacturing delays in producing product causing the delay
plus an increase demand.
20. Epinephrine Cardiac Syringes – Emergency syringe are currently unavailable from IMS and Hospira.
21. Fat emulsion – Several recalls and backorders of fat emulsion. Currently no presentation available from
manufacturer or wholesaler.
22. Fosphenytoin IV – None at wholesaler plus a manufacture recall leading limited amount left at AAMC.
23. Furosemide IV – Out of stock at wholesaler. Using reserves with approximately 7-10 supply on hand.
24. Homatropine ophthalmic solution 2 & 5% - discontinued by Alcon pharmaceuticals with no other
manufacturer producing.
25. Leucovorin IV – Long term backorder with one manufacture currently supply with limited amount
available.
26. Lidocaine 2% syringes – Hospira and IMS manufactures out of stock. Currently using reserve stock.
27. Methyldopa IV – Sole manufacture, American Regent had recalled the product in 2011 and has not yet
begun production. All supply at AAMC was affected by the recall leaving none left.
28. Methylene Blue – Out of stock at McKesson (wholesaler). Less than 5 vials each 1 mL and 10 mL vials.
29. Multivitamin IV – Manufacture backorder, leaving limited IV supply of IV multivitamins.
30. 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 – Update January 17, 2013 (Updated monthly, if not more
often)
31. Prochlorperazine IV – Sole manufacture Bedford in long term backorder.
32. Propofol vials – Limited amount of 100 mL vial available affecting primarily CCU/ED. Small amount of 50
mL vials are on hand. AAMC is allocated to 120 vials of 20mL size daily. These are the primary size used in
the OR area.
33. Ropivacaine Vials – None currently available at wholesaler and less than 5 vials left in house.
34. Sodium bicarbonate IV – Several companies were making this product of which one of them, American
Regent discontinued this line. Thus affecting the other manufactures with the increase demand.
35. Sodium chloride 23.4% – Out of stock at wholesaler, limited number of vials on hand in the Pharmacy.
36. Tromethamine – Manufacture backorder from Hospira. Hospira estimates a release date of September
2013.
Recommendations:
1. Acyclovir IV – Oral acyclovir is an alternative once the patient is able to tolerate. IV formulation available
but in limited quantities.
2. Acetylcysteine 20% vials – this primarily affects respiratory and a separate communication was sent to
them. Pharmacy is making 4mL syringes for Respiratory Therapy to use. The 4 mL vials from the
manufacturer are no longer being made or available. Acetylcysteine shortage does not affect the
commercially available Acetadote IV for acetaminophen overdose.
3. Amikacin IV – Consult Infectious Disease (ID) if needed. ID services are aware of shortage. AAMC has very
limited amount of 2 and 4 mL vials on hand.
4. Aminophylline IV – consider alterative oral theophylline if needed. Limited amount of IV is available.
5. 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.
6. Atracurium IV – Product switched out from atracurium to cisatracurium. Pyxis as well as the anesthesia
trays will carry only cisatracurium. Any atracurium that is left has been sequestered in the main
pharmacy for use as needed. EPIC entries for cisatracurium have been updated – injection as well as drip.
An alternative alert will fire as well for those who order atracurium directing the prescriber to
cisatracurium. Cisatracurium is in the Simbiq drug library for CCU, ED, and PACU if needed.
7. Atropine Syringes –Pharmacy is currently using reserves of vial to fill crash carts. Atropine is found in
Pyxis machines are being removed or quantity being limited.
8. Atropine vials (pediatric and adult concentrations) – Pharmacy has a supply but stock continues to
dwindle. Increase use also secondary linked to neostigmine on/off backorder.
9. Azithromycin IV and tablets – Limited amount of vial available, consider starting on oral therapy or when
possible convert to oral azithromycin therapy.
10. Bumetanide – Limited supply of 10mL vial available. Consider oral bumetanide or IV furosemide – see
below.
11. Caffeine benzoate IV – Primarily used to treat emergency respiratory failure associated with CAN
depressant overdoses. The Caffeine citrate formulation is use for neonates for apnea.
12. Calcium gluconate – Consider oral replacement or calcium chloride – please make sure patient has central
or PICC line to run due to potential extravasation risk if run peripherally.
13. Cyanocobalamin vials (B-12) – Please consider redoing patient as an outpatient or using an oral multivitamin to help in supplementation. Pharmacy has a limited number on hand.
14. Dextrose 50% Syringes – D50 vial available. Vials may replace syringes on the crash carts once supply
becomes more limited.
15. Dobutamine vial – This shortage not affecting premixed bags of dobutamine. The vials are exclusively
used for double concentrated bags when volume is an issue.
16. Doxapram IV – Irregularly available, please check with Pharmacy if needed.
17. Droperidol – There are other antiemetic alternatives to consider if such as: ondansetron, metoclopramide,
promethazine, and prochlorperazine (PO/Rectal). Most of these medications are available as an injection,
oral, and rectal formulations.
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 – Update January 17, 2013 (Updated monthly, if not more
often)
18. Enalaprilat IV – Consider other alternative IV formulation for blood pressure control such as hydralyzine,
labetolol, metoprolol, and clonidine for example. Consider oral enalapril if patient can tolerate or
applicable to clinical setting.
19. Epinephrine preservative free ampules – The preservative free vial primarily used in the operating room.
Those who use will need to conserve use to get through the shortage of product. No estimate from
manufactures on return of product.
20. Epinephrine Cardiac Syringe – the supply left will expire or be placed in crash carts soon. Pharmacy will be
packaging a regular epinephrine and the appropriate size needle together to replace the commercially
available item in the crash cart.
21. Fat emulsion – Supply that is left is reserved for patients with bupivacaine toxicity, Lipid reversal. All adult
and pediatric TPN/PPN formulation will not carry fat emulsion until shortage is resolved (est. March
2013). Fat emulsion that is left at out outsourced compounding company is limited to NICU patients.
22. Fosphenytoin IV – Stock low in AAMC, continue to reserve for pediatric use only.
23. Furosemide IV – Currently carrying more of the 2mL size than the normal 4mL dose typically ordered but
that is what is available or in reserve. Consider alternatives (see bumetanide) like oral route of
administration.
24. Homatropine ophthalmic solution 2 & 5% - Product used mostly by eye doctors in the OR. Will need to
consider other alternatives that are ophthalmic antimuscarinics, such as atropine, cyclopentolate,
mydriacyl and/or tropicamide ophthalmic products. The 2% strength is now out of stock at Pharmacy.
25. Leucovorin IV – Limited amount of vials on hand. Please check with Pharmacy if needed prior to ordering.
26. Lidocaine 2% syringes – Primarily limited to coded carts and in the OR’s. Could consider drawing up
lidocaine from 2% lidocaine vials is needed for non-code events.
27. Methyldopa IV – No supply exist in AAMC. Alternatives include IV hydralyzine or IV labetolol.
28. Methylene Blue – Used primarily for GI fistula and other GI diagnostic procedure. Also used for
methemoglobinemia treatment.
29. Multivitamin (MVI) IV – Use of IV MVI will be limited to one dose for the patient to help ration supply.
Alternatives are oral and liquid MVI. Other vitamins are available as well in IV form if needed (ascorbic
acid, cyanocobalamin, folic acid, pyridoxine, and thiamine). All TPN/PPN preparation will limit MVI to
Monday/Wednesday/Friday.
30. Pancuronium IV – None available at AAMC. Alternatives include succinylcholine, cisatracurium, and/or
vecuronium.
31. Prochlorperazine IV – consider other antiemetic agents such as ondansetron, promethazine, or
metoclopramide. Limit amount of IV prochlorperazine acquired (~200 vials). If patient needs
prochlorperazine rectal and oral formulations are available.
32. Propofol vials – All parties are aware of the backorder/shortage of all types of propofol. Regular
reminders are sent to stake holders providing detailed updates on number of current patients and exactly
the number of vials on hand. Alternatives are being considering plus aggressive weaning trials.
33. Ropivacaine Vials – Anesthesia was made aware beginning of this month and bupivacaine 0.25% is
recommended as the alternative at this time.
34. Sodium bicarbonate IV – All sizes/strengths/products affected. No alternatives to recommend at this
time. APP, Amphastar and Hospira both estimate they will have more product late March/early April.
Code carts will contain several vials to replaces syringes that are normally stocked in the cart. More
information to follow if current situation becomes more critical.
35. Sodium chloride 23.4% – Not a high moving item, primarily used for lags cramps in dialysis patients and
sometime for IV fluid compounding of exotic nature.
36. Tromethamine – Primarily used for metabolic acidosis with pediatrics and NICU here at AAMC. Sodium
bicarbonate would be an alternative.
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].