CURRENT DRUG SHORTAGES WITH POSSIBLE IMPACTS TO HOSPICE PATIENTS
May 7, 2020
Estimated Updated Drug Details of Shortage Resupply Date SUGGESTIONS/POSSIBLE ALTERNATIVES 5/4/20 Angiotension The FDA issued recalls for specific lots of Not all lots HPS has had less than a handful of reports from pharmacies Receptor Losartan, Irbesartan and Valsartan due affected, but concerning supply of Losartan, Irbesartan and Valsartan. If Blockers: to the presence of nitrosamine difficult to patient supplies are affected, consider changing to another Valsartan, impurities. Nitrosamine compounds determine medication in the same class of ARBs. It appears Telmisartan Irbesartan, have been linked to cancer in humans. resupply dates (MICARDIS™) and Candesartan (ATACAND™) are not yet affected Losartan by the recall. Brand name product presentations of Valsartan (DIOVAN™), Irbesartan (AVAPRO™) and Losartan (COZAAR™) are also available. 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 5/7/20 Albuterol Oral All generic manufacturers either have Release dates Reserve inhaler devices for COVID positive patients. For COVID Inhalers products on back order or are allocating mid-May 2020 to negative patients, transition to albuterol for nebulization. An supplies in response to increased late 3rd quarter alternative short-acting beta agonist is Levalbuterol - available demand. The only product readily 2020. for nebulization or consider albuterol combination products available at this time is Proventil™ HFA such as ipratropium/albuterol for nebulization. 6.7gram metered dose inhaler. 5/7/2020 Famotidine oral One manufacturer discontinued Fourth quarter Only 2 manufacturers report available product with one of them tablets famotidine tablets in all presentations, 2020 being the brand name, PEPCID™ 40mg. Appears that 40mg other manufacturer sites increased strength more available than 20mg strength. It is unknown if demand – likely due to the FDA OTC product presentations are affected. Ranitidine recall 4/03/20 Ranitidine Oral FDA requests removal of all ranitidine None listed Other H-2 receptor antagonists for gastric acid reduction include Capsules and products (ZANTAC™) from market – Famotidine (PEPCID™) and Cimetidine (TAGAMET™). Patients Tablets both prescription and OTC preparations currently taking Ranitidine are urged to stop taking and dispose due to probable human carcinogen of current supply. For more information: contaminant. https://www.fda.gov/news-events/press-announcements/fda- requests-removal-all-ranitidine-products-zantac-market
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CURRENT DRUG SHORTAGES WITH POSSIBLE IMPACTS TO HOSPICE PATIENTS
May 7, 2020
Estimated Updated Drug Details of Shortage Resupply Date SUGGESTIONS/POSSIBLE ALTERNATIVES 5/4/20 Fluticasone Flovent™ Diskus and HFA hand-held None listed For hospice patients that are COVID negative, nebulized Propionate Oral inhalers; corticosteroids or oral corticosteroids are preferred. If hospice Inhalers Sole manufacturer is allocating supply to patients are COVID positive, use hand-held inhalers. Possible wholesale customers; insufficient supply alternative corticosteroid inhalers include: Fluticasone for usual ordering. (ARNUITY™ ELLIPTA), Budesonide (PULMICORT™), Mometasone (ASMANEX Twisthaler™) or Beclomethasone (QVAR™ Redihaler) 5/1/20 Furosemide Only 5 of 17 NDCs show available. Mid-May – June Alternative loop diuretics include Bumetanide (BUMEX™), injection Shortages due to various reasons 2020 Torsemide (DEMADEX™) and Ethacrynic Acid (EDECRIN™). including shipping delays, manufacturing Bumetanide is currently on shortage (last updated 3-8) and delays and increased demand. Torsemide appears to be only available at this time in oral preparations. Ethacrynic acid is not used as frequently due to risk of ototoxicity.1 If using Furosemide injection for edema/fluid overload, may consider changing to oral formulations and the addition of Metolazone for increased efficacy. If using Furosemide injection nebulized for dyspnea, may need to consider alternate diuretic or alternate dyspnea management.
4/21/20 Multiple I.V. Doxycycline Hyclate, Tobramycin various Hospice agencies may need to be aware of the shortage of Antibiotics – Powder for Solution, Gentamicin, several antibiotic injection formulations used intravenously and Injection Piperacillin/Tazobactam, Ceftazidime, some intramuscularly especially for any new admission referrals. Formulations Azithromycin, Meropenem Alternatives will depend on culture and sensitivity results and type of infection.
4/08/20 Midazolam Two manufacturers cite increased Late April – June In hospice, midazolam injection used primarily for palliative Injection demand; one manufacturer cites 2020 sedation. There are product presentations of Midazolam manufacturing delays and two available at this time. Possible alternative may be Lorazepam manufacturers gave no reason. 0.5-5mg every 1-2 hours orally, sublingually or intravenously.2
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
May 7, 2020
Estimated Updated Drug Details of Shortage Resupply Date SUGGESTIONS/POSSIBLE ALTERNATIVES 4/02/20 Propofol Three manufacturers all report None listed In hospice, propofol injection used primarily for palliative Emulsion increased demand as reason for sedation. Currently, only brand name DIPRIVAN™ is available Injection shortage. and other presentations with very limited supply. May consider alternative medication classes for palliative sedation including Barbiturates (Phenobarbital, Pentobarbital); Neuroleptics (Haloperidol, Chlorpromazine); Benzodiazepines – Lorazepam
4/2/20 Fentanyl Citrate Two manufacturers report April - May 2020 Consider alternate opioid injection product for use in CADD Injection manufacturing delays and pump or alter pain management plan to not rely on CADD supply/demand issues. pumps. Update on 4/2/2020: Only 4 NDC numbers of Fentanyl Citrate injection available. Please note generic transdermal Fentanyl is not currently affected and is available for pain management regimens.
3/25/20 Ketamine 2 of 4 manufacturers have Ketamine The 50mg/10ml Ketamine is only available in injection form. Hospice use of Injection Injections available; one manufacturer vial from Pfizer Ketamine is limited and off-label for pain. No alternatives similar reports shortage due to manufacturing on back order; to Ketamine if used for pain management. Changes to pain delays. Release date management plan will be needed. January 2021
3/20/20 Morphine Five of seven product presentations May There are multiple manufacturers with multiple product Injection unavailable due to discontinuation and presentations available including preservative-free formulations. are primarily the preservative-free Reserve injection for pain pump use. Consider alternative routes formulations. of administration including oral. May consider alternative preservative-free opioid formulation if used for nebulized administration for management of dyspnea.
3/6/20 Hydromorphone Shortages due to increased demand and May There are multiple manufacturers with multiple product Injection manufacturing delays. One presentations available. Reserve injection use for CADD/pain manufacturer has discontinued one pumps. Oral hydromorphone is not affected and is available. formulation.
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CURRENT DRUG SHORTAGES WITH POSSIBLE IMPACTS TO HOSPICE PATIENTS
May 7, 2020
Estimated Updated Drug Details of Shortage Resupply Date SUGGESTIONS/POSSIBLE ALTERNATIVES 3/14/20 Lorazepam Shortages due to increased demand and April There are multiple manufacturers with product available. Injection manufacturing delays. Reserve use for status epilepticus (anticipated need for certain hospice diagnoses). Consider alternative benzodiazepine injection or other formulation.
2/20/20 Atropine Homatropine ophthalmic solution is only None listed Atropine ophthalmic solution is used orally in hospice for Ophthalmic product affected - manufacturing delays. excessive secretions. Consider available oral options including Solution Hyoscyamine tablets.
Adapted from: https://www.ashp.org/Drug-Shortages. and FDA Drug Shortages https://www.accessdata.fda.gov/scripts/drugshortages/default.cfm Accessed online May 7, 2020
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