CURRENT DRUG SHORTAGES WITH POSSIBLE IMPACTS TO HOSPICE PATIENTS

Estimated Updated Drug Details of Shortage Resupply Date Suggestions/Possible Alternatives 2/25/2021 Angiotensin The FDA issued recalls for specific lots of Still available HPS has had less than a handful of reports from pharmacies Receptor Losartan, Irbesartan and Valsartan due through some concerning supply of Losartan, Irbesartan and Valsartan. If Blockers: to the presence of nitrosamine manufacturers patient supplies are affected, consider changing to another Valsartan, impurities. Nitrosamine compounds medication in the same class of ARBs. It appears Olmesartan Irbesartan, have been linked to cancer in humans. (BENICAR™) and Candesartan (ATACAND™) supplies are not yet Losartan affected by the recall. Brand name product presentations of Valsartan (DIOVAN™), Irbesartan (AVAPRO™) and Losartan (COZAAR™) are also available as is Telmisartan (MICARDIS™). For more information please see https://www.fda.gov/drugs/drug-safety- and-availability/recalls-angiotensin-ii-receptor-blockers-arbs-including-valsartan- losartan-and-irbesartan 2/25/2021 Albuterol Oral Generic inhalers available through Par Lupin & Prasco Reserve inhaler devices for COVID positive patients. For COVID Inhalers (MDIs) and Cipla. Brand inhalers available on allocation; negative patients, transition to albuterol for nebulization. An through GSK (Ventolin), Merck Teva on alternative short-acting beta agonist is Levalbuterol - available (Proventil), and Teva (Proair). intermittent for nebulization or consider albuterol combination products back-order such as ipratropium/albuterol for nebulization.

2/25/2021 Famotidine oral It appears only brand name PEPCID™ Late-April 2021 Only brand name product available and only three NDC tablets products are available. numbers. Consider the OTC Pepcid Complete™ (Famotidine 10mg, Calcium Carbonate 800mg & Hydroxide 165mg chewable tablet) product as a good alternative where supplies are limited. 2/25/2021 Levetiracetam One manufacture (Accord) discontinued Many other No anticipated impact to home patients using oral formulations. (immediate production of the immediate release manufacturers No reports from pharmacies of any difficulty obtaining oral release, formulations. Two other manufacturers and formulations formulations of Levetiracetam. There is a small chance for extended (OWP & Torrent) have either available – no impact to patients that may be receiving the injectable release and discontinued production of the release dates formulation of Levetiracetam. injection) extended-release formulations or are published not selling product in the U.S.A.

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CURRENT DRUG SHORTAGES WITH POSSIBLE IMPACTS TO HOSPICE PATIENTS

Estimated Updated Drug Details of Shortage Resupply Date Suggestions/Possible Alternatives 2/25/2021 Supplies continue to improve although it One Alternative loop include Bumetanide (BUMEX™), injection remains on the shortage list. 12 of 18 manufacturer Torsemide (DEMADEX™) and Ethacrynic Acid (EDECRIN™). NDCs are available. 3 of 5 lists late - Bumetanide is currently on shortage (last updated 3-8) and manufacturers have supplies of product. February 2021, Torsemide appears to be only available at this time in oral another has preparations. Ethacrynic acid is not used as frequently due to product on risk of .1 If using Furosemide injection for /fluid intermittent back overload, may consider changing to oral formulations and the order and is addition of for increased efficacy. If using releasing as it Furosemide injection nebulized for dyspnea, may need to becomes consider alternate or alternate dyspnea management. available 2/25/2021 Midazolam Four manufacturers cite increased In hospice, midazolam injection used primarily for palliative Injection demand; one manufacturer cites June 2021 sedation. There are product presentations of Midazolam manufacturing delays. available at this time. Possible alternative may be Supplies of vials available – pre-filled 0.5-5mg every 1-2 hours orally, sublingually or intravenously.2 syringes more affected 2/25/2021 Propofol Four manufacturers report increased April 2021 to In hospice, propofol injection used primarily for palliative Emulsion demand as reason for shortage while 3rd quarter 2021 sedation. Currently, only brand name DIPRIVAN™ is available Injection one manufacturer cites shipping delays and other presentations with very limited supply. May consider due to COVID-19. alternative medication classes for palliative sedation including (, ); Neuroleptics (, Chlorpromazine); Benzodiazepines – Lorazepam

1Clinical Pharmacology powered by ClinicalKey® accessed online 4-09-2020 through University of Texas library system https://wwwclinicalkey.com.ezproxy.lib.utexas.edu/pharmacology/monograph/231?sec=monsup

2Care of the Imminently Dying, Ferrell, B. et. al. Publisher Oxford University Press Inc. 2015, Chapter 4 – Sedation for Refractory Symptoms

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CURRENT DRUG SHORTAGES WITH POSSIBLE IMPACTS TO HOSPICE PATIENTS

Estimated Updated Drug Details of Shortage Resupply Date Suggestions/Possible Alternatives 2/25/2021 3 of 4 available manufacturers have Release date Ketamine is only available in injection form. Hospice use of Injection Ketamine Injections available. One early April to Ketamine is limited and off-label for pain. No alternatives similar manufacturer reports shortage due to June 2021 to Ketamine if used for pain management. Changes to pain manufacturing delays and one management plan will be needed. discontinued 3 product presentations

2/25/2021 Morphine This product remains on the shortage There are multiple manufacturers with multiple product Injection list due to 4 manufacturers reporting April 2021 presentations available including preservative-free formulations delays in manufacturing or did not list (if needed for nebulized management of dyspnea). Reserve reason for shortage injection for pain pump use. Consider alternative routes of administration including oral.

2/25/2021 Hydromorphone Shortages due to increased demand and Late February There are multiple manufacturers with multiple product Injection manufacturing delays. 2021 presentations available. Reserve injection use for CADD/pain pumps. Oral hydromorphone is not affected and is available.

2/25/2021 Lorazepam February 2023 There are 3 manufacturers with injectable product available. Injection Both injectable and oral formulations Reserve use for status epilepticus. Consider alternative remain on the shortage listings. benzodiazepine injection or other formulation. Lorazepam oral Four manufacturers with multiple product presentations tablets March 2021 available. No reports of difficulties filling oral prescriptions.

2/25/2021 Dobutamine Pre-mixed infusion bag and injectable Only premixed infusion bag preparations are available from one injection vial product presentations are affected. April 2021 manufacturer. Strongly encourage a plan for weaning from Shortages due to both increased dobutamine. Milrinone does not appear to be affected by the demand and manufacturing delays shortage of dobutamine and may be an alternative

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CURRENT DRUG SHORTAGES WITH POSSIBLE IMPACTS TO HOSPICE PATIENTS

Estimated Updated Drug Details of Shortage Resupply Date Suggestions/Possible Alternatives 2/25/2021 Temazepam 14 product presentations are available, No estimated No reports of prescriptions not being able to be filled – no oral capsules 15 product presentations are not release dates reports of patients not receiving medication. available. Alternative sedative-hypnotic products available

2/25/2021 oral 3 of the 6 affected product No estimated There are 11 product preparations available from 5 tablets presentations are discontinued release dates one manufacturers. No reports of prescriptions not being able to be company is filled nor of patients not being able to receive medication. releasing supplies as they become available

Adapted from: https://www.ashp.org/Drug-Shortages. and FDA Drug Shortages https://www.accessdata.fda.gov/scripts/drugshortages/default.cfm Accessed online February 25, 2021

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