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Pharmacy Shortages – February 27, 2015 (Updated monthly, if not more often)
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].
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 February 2015. 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. Azithromycin IVPB NS 250mL and D5W 250 mL– Due to shortage of both NS and D5W
250mL Pharmacy is asking providers to limit use of IV Azithromycin and if azithromycin is truly needed consider oral dosage forms. . If continued
use continues this may impact other IV medications that need to be in NS or D5W 250mL solutions (i.e. amiodarone IV, pressors, antibiotics, etc.). Currently all three manufactures, Baxter, BBraun, and Hospira have all presentation on allocations. It is unknown at this time when the companies can provide a release date.
2. Neostigmine injection – Has been on/off backorder for a while reducing stock in pharmacy slowly. Supply is not consistent but has improved over recent weeks. Pharmacy is using a combination of vials that ae released plus compounded syringes from Pharmedium. Primarily affect anesthesia and separate communications have been sent out to anesthesia leadership. Continue to reduce use if appropriate. May be able to augment neostigmine use with the combination of atropine and edrophonium (Enlon). Current estimates are ~3 weeks on hand, slowly improving.
3. Norepinephrine pre-made IV solutions – Currently on allocation from Pharmedium due to lack of D5W 500 mL bags, not due to drug. All pre-made bags are limited to ED first dose orders only which are still in the Pyxis machines. We have enough pre-made bags on hand to supply only ED first doses. All other Pyxis machine locations where pre-made bags are located have been removed. Vial supply is currently stable but increases in reserves have been obtained.
4. Pipercillin/Tazobactam injection (Zosyn) – Out of stock at the wholesaler. Limited ability to obtain directly from manufacture and from secondary markets. Pharmacy received an allocated amount each week. With using alternatives (see below) we have been able to stretch the use of Zosyn and limit use to primarily CCU patients as well as those patients consulted by an Infectious Disease physician. Alternatives for Zosyn were approved by Infectious Disease, Dr. Clance (Epidemiologist) and Pharmacy Leadership are included below.
Indication Antibiotic to change to
Soft tissue (empiric) Unasyn +/- levofloxacin if needed for pseudomonas coverage
Intra-abdominal Cefoxitin or Cefepime + metronidazole
HCAP Cefepime + metronidazole
Sepsis Cefepime
Neutropenic fever Cefepime
NICU Dr. Clance to work with directly
5. Medications out of stock include – ammonium chloride, droperidol vials, epinephrine preservative
free ampules, hydroxyzine injection, indigo carmine injection, methyldopa injection, nitroglycerine IV vial, pancuronium injection, and phentolamine mesylate injection.
6. New shortage products – ketorolac injection
Pharmacy Shortages – February 27, 2015 (Updated monthly, if not more often)
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].
7. Medications discontinued by manufacture – caffeine benzoate IV, phentolamine, pralidoxime
injection and sodium thiosulfate IV
8. Resolved – calcium gluconate injection, digoxin 250 mcg/mL injection, erythromycin injection, indocyanine green, lidocaine 3.5% ophthalmic ointment (Atken), and proparacaine 0.5% ophthalmic solution.
Pharmacy Shortages – February 27, 2015 (Updated monthly, if not more often)
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].
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. Caffeine benzoate IV vials – 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.
3. Caffeine Citrate Oral Solution – Out of stock of oral solution at wholesaler since mid-December 2014. IV solution no issues obtaining at this time. Primarily used in NICU.
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. Droperidol – American Regent sole manufacture and currently not making for various manufacturing reasons. Pharmacy is out of stock since November 2012.
7. Epinephrine preservative free ampules – Manufacturing delays in producing product causing the delay plus an increase demand. Pharmacy is out of stock since November 2012.
8. Hydralyzine injection – out at the wholesaler. Only able to receive product directly on allocation from the manufacture. AAMC has about 7-10 days on hand at present.
9. Hydroxyzine IV – all sizes are not available from wholesaler and Pharmacy is out of stock of this medication. Pharmacy has a limited supply of single dose 10 mL vials that are drawn up as needed but this too is dwindling fast.
10. Indigo carmine injection – Currently only one manufactured left supplying the market limiting supply. Pharmacy has zero vials on hand.
11. Methyldopa IV – Sole manufacture, American Regent had recalled the product in 2011. None currently available.
12. 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 1st quarter 2015.
13. Neostigmine injection – Has been on/off backorder for a while reducing stock in pharmacy slowly. Supply is not consistent but has improved over recent weeks. Pharmacy is using a combination of vials that ae released plus compounded syringes from Pharmedium.
14. Nitroglycerine IV Vial – Current none on hand. Limited availability of nitroglycerine bottles but appear available for time being. Limited to one manufacture which cannot keep up with demands.
15. Norepinephrine pre-made IV solutions – Currently on allocation from Pharmedium due to lack of D5W 500 mL bags, not due to drug.
16. Oxycodone/acetaminophen 5/325 solution (Roxicet) – Manufactures are validating new source of raw materials thus causing the delay. Estimated release date mid-April 2015 (updated).
17. Pancuronium IV – Long term backorder with manufacture (6/2012), no estimated release date at this time.
18. 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. Per manufacture, this product has been discontinued.
Pharmacy Shortages – February 27, 2015 (Updated monthly, if not more often)
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].
19. Pipercillin/Tazobactam injection (Zosyn) – Out of stock at the wholesaler. Limited ability to obtain directly from manufacture and from secondary markets. Pharmacy received an allocated amount each week.
20. Pralidoxime chloride (Protopam) – All stock expired and manufactured have stopped making. 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. 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. Consider other standard methods for alkalosis reversal (bicarbonate drips, dialysis). Out of stock.
2. Caffeine benzoate IV vials – 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.
3. Caffeine Citrate Oral Solution – IV solution available and can be used as an oral solution for the NICU (primary use).
4. Calcium chloride injection – Zero vials remain in AAMC, but Pharmacy has increased the compliment of syringes to compensate use.
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-sodium-phosphatecurrent020112TABLEONE.aspx Table 2 Alternative to Dexamethasone in Selected Situations: http://www.ashp.org/DocLibrary/Policy/DrugShortages/dexamethasone-sodium-phosphatecurrent020112TABLETWO.aspx
6. Droperidol – Pharmacy is currently out of stock of this medication. 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.
7. Epinephrine preservative free ampules – 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. No estimation from manufacture on return of product.
8. Hydralyzine injection – AAMC currently has limited amount on hand, approximately 7-10 days. Alternatives to consider are oral hydralyzine, IV labetalol, and IV enalaprilat
9. 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.
10. 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.
Pharmacy Shortages – February 27, 2015 (Updated monthly, if not more often)
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].
11. Methyldopa IV – None available at AAMC, consider alternatives: IV hydralyzine or IV labetolol. 12. Morphine PF injection – conserve preservative free morphine as much as needed. May need to
purchase other concentrations to help out usage. 13. Neostigmine injection – Primarily affect anesthesia and separate communications have been sent
out to anesthesia leadership. Continue to reduce use if appropriate. May be able to augment neostigmine use with the combination of atropine and edrophonium (Enlon). Current estimates are ~3 weeks on hand, slowly improving.
14. 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.
15. Norepinephrine pre-made IV solutions – All pre-made bags are limited to ED first dose orders only which are still in the Pyxis machines. All other Pyxis machine locations pre-made bags were removed. AAMC currently has about 70 pre-mixed bags on hand in the Pharmacy. Until next supply is obtain this may only last about 5-7 days. Vial supply is currently stable but increases in reserves have been obtained.
16. Oxycodone/acetaminophen 5/325 solution (Roxicet) – if not able to tablets an alternative alert is currently directing prescriber to acetaminophen/oxycodone individual components as liquids or hydrocodone elixir. Main Pharmacy is out and Clatanoff Pharmacy has limited amount on hand.
17. Pancuronium IV – None available at AAMC. Alternatives include succinylcholine, cisatracurium, and/or vecuronium.
18. 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. An alternative alert is active in EPIC directing prescribers to the alternative.
19. Pipercillin/Tazobactam injections (Zosyn) – With using alternatives (see below) we have been able to stretch the use of Zosyn. Limiting use to primarily CCU patients as well as those patients consulted by an Infectious Disease physician. Alternatives for Zosyn were approved by Infectious Disease, Dr. Clance (Epidemiologist) and Pharmacy Leadership are included below.
Indication Antibiotic to change to
Soft tissue (empiric) Unasyn +/- levofloxacin if needed for pseudomonas coverage
Intra-abdominal Cefoxitin or Cefepime + metronidazole
HCAP Cefepime + metronidazole
Sepsis Cefepime
Neutropenic fever Cefepime
NICU Dr. Clance to work with directly
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. 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.
