Download Pharmacy Shortages November 2015

AAMC Critical Drug Shortages – Thursday, November 12, 2015(Updated monthly, if
not more often)
Dear Colleagues,
Due to a variety of reasons, AAMC is currently faced with multiple medication shortages. Manufacturing delays
and increased demand have resulted in a nationwide critical shortage. An alphabetical listing of medications
experiencing imminent or ongoing sporadic, supply issues is summarized on the next pages. The most urgent
concerns to highlight are listed below.
 Albuterol 2.5 mg/0.5 mL Neb
 Eptifibatide (Integrilin) 10 mL bolus vials
 Fenoldopam injection
 Lidocaine 4% injection
Recommendations for restricted use and/or alternative therapies are provided in this memo. Additional details
regarding the status of medication availability is provided through alternative alerts in Epic, on the AAMC
Pharmacy Drug Shortage site (http://www.aahs.org/medstaff/?page_id=3269), and on the American Society of
Health-System Pharmacy (ASHP) drug shortage site (www.ashp.org/DrugShortages/Current).
Medications out of stock include – ammonium chloride, droperidol vials, epinephrine preservative free ampules,
fomepizole injection, hydroxyzine injection, indigo carmine injection, methyldopa injection, and pancuronium
injection.
New shortage products – albuterol 2.5 mg/0.5 mL nebs, fenoldopam injection, eptifibatide (Integrilin) 10 mL bolus
vials, lidocaine 4% injection, and prednisolone acetate (Blephamide) ointment 10-0.2%
Medications discontinued by manufacture – phentolamine, pralidoxime injection sodium, scopolamine injection
Resolved drug shortages – Ampicillin/Sulbactam (Unasyn) [all sizes], meropenem injection, metoprolol injection,
and phytonadione syringes
For additional information or therapeutic considerations, please contact the Pharmacist on Duty, or myself, Jared
S. Calish, PharmD, Pharmacy Clinical Coordinator via e-mail: [email protected].
We appreciate your understanding as we strive to treat our patients during drug shortages.
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AAMC Critical Drug Shortages – Thursday, November 12, 2015(Updated monthly, if
not more often)
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Albuterol 2.5 mg/0.5 mL nebs
a. Out of stock at wholesaler, able to obtain limited amount from secondary markets.
b. Respiratory has been notified and Pharmacy has obtained the 0.83% 2.5mL neb to use if needed
this is a larger volume and requires longer RT time to administer.
Ammonium chloride vials
a. Long term back order since March 2011, out of stock.
b. 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.
Consider other standard methods for alkalosis reversal (bicarbonate drips, dialysis).
Cefotaxime vials [all sizes]
a. Shortage is due to reduction in number of manufactures from 3 to 2, causing a decrease in supply
th
on the market. Best guess of when product is to be released is 4 quarter 2015.
b. AAMC has cefotaxime restricted to pediatrics and Infectious Disease. This medication is used
very sparingly by both services; an alternative would be ceftriaxone or pipercillin/tazobactam
(Zosyn).
Droperidol
a. American Regent sole manufacture and currently not making for various manufacturing reasons.
Pharmacy is out of stock since November 2012.
b. 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.
Epinephrine Emergency Cardiac Syringe
a. Wholesaler currently out of stock and only able to obtain direct orders from manufactures when
available at this time.
b. This item is almost exclusively found on the emergency code cart. In the interim Pharmacy will
be placing in prepackage bags a standard epinephrine emergency syringe with an 18 gauge 3 ½
inch needle that can be attached to the epinephrine syringe if needed.
Epinephrine preservative free ampules
a. Manufacturing currently not producing. Pharmacy is out of stock since November 2012,
returned briefly in July 2015 and now out of stock again.
b. The preservative free vials 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 or ampules. These vials contain 0.1% sodium bisulfate which is compatible for
ophthalmic use.
Eptifibatide (Integrilin) 10 mL bolus vials
a. Only the 10 mL bolus vials appears to be affected with expected resolution end of 2015.
b. Partnering with the Cardiac Cath Lab nurses they will draw up the bolus from the infusion vial to
administer to the patient. A chart with bolus information is being prepared and added into the
EPIC system for the Cardiac Cath Lab nurses.
Fenoldopam injection
a. Hospira has drug on shortage due to manufacturing delays, no estimate on availability.
b. Pharmacy is down to a limited supply (<5 vials) left in house. Other alternatives include but not
limited to: nicardipine, labetalol, and/or metoprolol to help treat hypertension crisis.
Fomepizole vials (30 vial 10 mL)
a. FDA recall caused the shortage of this product earlier in 2015 and now the manufacture reports
another FDA recall.
b. Primarily used to treat antifreeze overdose. Recommend discuss with Maryland Poison Center
first (1-800-222-1222). There is an alternative regimen but obtaining the appropriate ethanol
concentrations are difficult to come by.
10. Hydroxyzine IV
a. All sizes are not available from wholesaler and Pharmacy is out of stock of this medication since
3/2013. Manufacturer estimated time to release has been updated to April 2015.
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AAMC Critical Drug Shortages – Thursday, November 12, 2015(Updated monthly, if
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Alternatives include but not limited to diphenhydramine or cetirizine for urticaria/atopic
dermatitis/pruritus.
Imipenem-Cilastatin (Primaxin) injection (all strengths)
a. All three manufactures have various delays of product. Estimated release potentially is late
October or November 2015.
b. Pharmacy currently has none on hand. An alternative alert is currently in developed to display in
EPIC to guide providers. Please note Primaxin is restricted to Infectious Disease providers only
and have been notified.
Indigo carmine injection
a. Currently only one manufactured left supplying the market limiting supply. Pharmacy has zero
vials on hand. Shortage originated 3/2014.
b. 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.
Lidocaine 4% injection
a. Hospira is the only manufacture and currently on back-order. It was reported release will be
November 2015.
b. Respiratory is the primary user of this product to help with bronchoscopy exam. Lidocaine 4%
jelly is one alternative. Looking into others at this time as well.
Methyldopa IV
a. Sole manufacture, American Regent had recalled the product in 2011. None currently available.
b. Consider alternatives: IV hydralyzine or IV labetolol.
Morphine PF injection
a. Out of stock at wholesaler of the 25mg/mL and 50mg/mL concentration. Limited amount left in
nd
AAMC. Expected release now changed to 2 quarter 2015.
b. Conserve preservative free morphine as much as needed. May need to purchase other
concentrations to help out usage.
Mupirocin (Bactroban) nasal ointment
a. Manufacture back order for unknown reason with no release date known.
b. AAMC uses the bulk tubes for MRSA prophylaxis, so this indication of use will continue
uninterrupted.
Phenylephrine (Neosynephrine) nasal spray 0.25% and 0.5%
a. Patent was bought by another manufacture causing the shortage until product is available for
wholesalers to sell. Currently waiting for new product to arrive.
b. Pharmacy has about a dozen left in stock. All primary stack holders have been notified. Stocking
up on 1% as well as oxymetazoline (Afrin) as an alternative if needed.
Ofloxacin 0.3% 5mL OTIC
a. Reason cannot be provided by manufacture.
b. Our current supply will last until mid to end of October and if no further otic product is available
then we will use ofloxacin ophthalmic for otic use. Ofloxacin ophthalmic if NON-FORMULARY for
ophthalmic use. Moxifloxacin and ciprofloxacin are formulary for this class of drugs for
ophthalmic use.
Oxycodone/acetaminophen 5/325 solution (Roxicet)
a. Manufactures are validating new source of raw materials thus causing the delay. Update, now
no release date. Main Pharmacy is out and Clatanoff Pharmacy has limited amount on hand.
b. An alternative alert is currently directing prescriber to acetaminophen/oxycodone individual
components as liquids or hydrocodone elixir.
Pancuronium IV
a. Long term backorder with manufacture (6/2012), no estimated release date. Out of stock.
Alternatives include succinylcholine, cisatracurium, and/or vecuronium.
Phentolamine mesylate injection
a. Out of stock at wholesaler and both manufactures have stopped making for now. Unknown if
they will resume. Pharmacy has ZERO vials on hand. Manufacture discontinued this product.
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AAMC Critical Drug Shortages – Thursday, November 12, 2015(Updated monthly, if
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b.
An alternative for use for extravasations includes terbutaline as a ratio of 1:9 with saline as the
base solution. IV Therapy is aware and this alternative was approved by P&T in 2012.
22. Pralidoxime chloride (Protopam)
a. All stock expired and manufactured have stopped making. None available at AAMC.
b. 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 6/2014.
23. Scopolamine injection
a. No longer being manufactured. Pharmacy is currently out of stock of this item since 3/2015. See
web site for more information: http://www.fresenius-kabi.us/images/documents/ourproducts/Scopolamine_Supply_Letter_Feb_2015_vF.pdf
b. Alternatives atropine and glycopyrrolate injection can be used in place of. Anesthesia has been
notified in separate communication already.
24. Sulfaetamide-prednisolone acetate (Blephamide) ointment 10-0.2%
a. Out of stock at wholesaler. Estimated arrival is December 2015
b. Other forms of prednisolone acetate may be able to be used, ophthalmic drops.
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