Drug Shortages

Drug shortages can occur for a variety of reasons.The factors currently affecting drug supply are shortages of raw materials, quality control issues which led to voluntary withdrawal and longer production times for some products and competition among drug manufacturers. The problem is expected to ease somewhat with renewed production in some cases and takeover of supply by another company in others. For more details see the environmental scan on Drug Supply Disruptions recently posted on the CADTH website.

In the meantime, healthcare providers are responsible for ensuring patients continue to receive appropriate drug therapy. A general protocol to follow in handling drug shortages is offered below:

  1. Ensure there is a valid indication for the drug. Review the patient’s drug and medical history. For a checklist of criteria to consider, check the CPhA Drug Shortages Guide pg 4 - 6.
  2. Substitution of a different brand of the same drug (molecule):
    • Check the Saskatchewan Prescription Drug Plan (SPDP) Formulary for interchangeable brands of the same drug; then check for availability of these brands. (Call wholesalers, manufacturers)
    • If none are available, is there a non-interchangeable brand of the same drug.in the same dosage form? Obtain authorization for substitution from doctor, start at same dose or a reduced dose and titrate to desired effect (especially important if drug has a narrow therapeutic index) and monitor for beneficial and adverse effects. Follow-up with the patient in 24 – 48 hours, as indicated by kinetic and pharmacologic characteristics of the drug.
    • If no Formulary drug in the same dosage form is available, check Health Canada Drug Product Database for other brands that may be available and proceed as above.
    • If none available, is there a different dosage form of the same drug? Obtain authorization for substitution from doctor, start at appropriate dose and titrate to desired effect (especially if narrow therapeutic index) and monitor for beneficial and adverse effects. Follow-up with the patient in 24 – 48 hours as indicated by kinetic and pharmacologic characteristics of the drug.
    • If no Formulary drug is available, check Drug Product Database for other dosage forms that may be available and proceed as above.
    • As necessary, consult SPDP regarding coverage for substituted brand.
  3. If no other forms of the same molecule are available, substitution of another drug in the same therapeutic class can be considered. Check the references below for dose equivalence data. This information is not always available. Even when a therapeutically equivalent dose is administered, patients may react differently. Pharmacists should follow-up with the patient frequently until the patient is stabilized on the new medication.
    • Rx Files Charts - www.rxfiles.ca
    • e-therapeutics + (available at SHIRP)
    • Handbook of Clinical Drug Data , 2010, 11th edition - hardcopy text
  4. If there is not a therapeutic equivalent, check treatment guidelines and recommend a drug from another pharmacologic class. Monitor and titrate to desired effect.
  5. Compounding capsules or tablets in the desired doses when other strengths of drug are available or from bulk powders may be another option, especially in instances where there is not a readily available or acceptable substitute.

In order to provide greater information to health care practitioners and the general public, Canada’s Research Based Pharmaceutical Companies (Rx&D) and the Canadian Generic Pharmaceutical Association (CGPA) began collecting information on behalf of their individual member companies on current and impending drug shortages in the fall of 2011. Rx&D has now turned over its database architecture (i.e. the former Rx&D Drug Shortages Database) and opened its use to non-Rx&D members (i.e. all market authorization holders) who are authorized to sell medicines in Canada, and who may need to use the site to report a drug shortage.  Iinformation is being provided on a voluntary basis.  It does not necessarily include all pharmaceutical companies in Canada, and therefore there may be gaps in the data. The new database is called the Canadian Drug Shortages Database:

medSask is not responsible for the content of this database, and does not assume any liability that may arise from any use of or reliance on the information contained therein.  The information in the database been provided by drug manufacturers, and is presented here for reference purposes only.  There is no warranty, representation or guarantee with respect to the accuracy, timeliness or completeness of this information.  medSask accepts no responsibility for any errors or omissions, and expressly disclaims any such responsibility.

medSask cannot accept phone, email, fax, or other inquiries about the content of this information.  Inquiries regarding specific drug shortages should be directed to the appropriate drug manufacturer as identified.  Questions about alternatives for shorted drugs and drug plan coverage for alternatives may be directed to the appropriate provincial drug information service.

The following tables provide suggestions for handling shortages of specific drugs. This information is intended for use by healthcare providers for general informational purposes only.  It remains the responsibility of the healthcare provider to use professional judgment in evaluating this information in light of any relevant clinical or situational data.  This information is provided without warranty of any kind and medSask and the University of Saskatchewan assume no responsibility and/or legal liability whatsoever for any errors, omissions or inaccuracies contained therein.

PARENTERAL DRUGS

To check current availability status of parenteral drugs go to the Sandoz website and click on Product Supply Information for Healthcare Professionals.

Click on colored text to link to additional information.

DrugAvailability / Alternatives

Acyclovir

Injectable 50mg/ml  10 x 20ml no date for availability.

10 x 10 ml -no date for availability.

Both cream and ointment available.

Alternative route: oral tablets, oral liquid formulation.

Bretylium

Sandoz is the only manfucturer of bretylium.

Now available through McKesson


FOR INFORMATION CALL 800-361-3062

Indicated as last resort for life-threatening ventricular arrhythmia not responding to adequate doses of first-line antiarrhythmic agents. 

Ventricular Fibrillation - continue with lidocaine, epinephrine, defibrillation, magnesium, procainamide

Ventricular Tachycardia - procainamide is an alternative

Calcitonin, Salmon, Synthetic

Calcimar 200U/ml (2ml) INJECTION available.

All nasal spray calcitonin products have been withdrawn and discontinued from the market due to a small increased rate of cancer (up to2.4 %). DINs became inactive October 1st, 2013 at which time prescribing and dispensing should have ceased.  Calcitonin is no longer indicated for osteoporosis. For alternative treatment see ACFP Tools for Practice at http://www.acfp.ca/Portals/0/docs/TFP/20130923_085017.pdf.

Calcitonin (salmon synthetic) injectable remains on the market but is indicated only for Paget’s Disease and hypercalcemia. Due to the increased cancer risk the duration of treatment should be limited to the shortest period of time possible and the minimum effective dose.

Chlorpromazine injection

Sandoz, the sole supplier, has discontinued marketing injectable chlorpromazine in Canada.

Alternate formulations: oral tablets 25, 50 and 100 mg are available.

Bulk chemical is listed in Medisca catalogue.

Therapeutic alternatives: See PDF

Cisatracurium besylate injection

Cisatracurium besylate Injection 2mg/mL, multidose 10mL is now available on allocation from Omega Laboratories

Not available through McKesson

Therapeutic alternatives are discussed on the AHSP Shortages database at  http://www.ashp.org/menu/DrugShortages/CurrentShortages/bulletin.aspx?id=1072.

Clindamycin IV

SDZ 600mg 10 x 50ml available

Sandoz 150mg/ml 10 x 2ml, 10 x 4ml, 60ml and 120ml available

Dalacin C 150mg/ml 60ml, 25 x 2ml, 25 x 4ml, 25 x 6ml available.


FOR INFORMATION CALL 800-361-3062

Dalacin C phosphate IV is in stock and available through usual wholesalers.

Options:
Consider oral formulation if patient is not NPO -  bioavailability is almost 100 %
Step down from IV to oral as soon as possible

See PDF for therapeutic alternatives

Co-trimoxazole Injectable

Septra IV is now available.

If necessary Hospitals should contact Aspri Pharma’s Customer Service at (514) 868-8440 (Toll free: 1-855-868-8440) or Info@aspripharma.com.

See PDF document for shortage management suggestions. NB: Note that gentamicin, an alternative for Listeria, is currently also in short supply - see below.

Dacarbazine

Not available through McKesson.

Restrictions:
Existing dacarbazine stock only used to continue treatments that have already been initiated.
No new patients should be initiated on dacarbazine treatment, until further notice.

Daunorubicin

Cerubidine 20mg/4ml  (Erfa)  is available. 

Diltiazem

Sandoz formulations 5mg/ml 5 and 10ml size available and off allocation. 

Paroxysmal Supraventricular Tachycardia

1st line:
Adenosine 6 mg (0.1 mg/kg) rapid IV bolus

2nd line:
Calcium Channel Blockers
Verapamil 2.5-5 mg IV over 2 min (3 min in older patients).  May repeat 5-10 mg q15 min up to 20 mg

Beta Blockers
Metoprolol tartrate 5 mg IV q 5 min up to 15 mg
OR
Esmolol HCl 500 mcg/kg IV bolus over 60 s, followed by an infusion starting at 50 mcg/kg/min.  May repeat 500 mcg/kg bolus if inadequate response after 2-5 min
OR
Propranolol HCl 0.1 mg/kg divided into 3 doses given slowly at 2 min intervals.  May repeat dose once.

Rate Control of Atrial Fibrillation:

1st Line:
Calcium Channel Blockers

Diltiazem

Beta Blockers
Metoprolol tartrate 5 mg IV q 5 min up to 15 mg
    
OR
Esmolol HCl 500 mcg/kg IV bolus over 60 s, followed by an infusion starting at 50 mcg/kg/min.  May repeat 500 mcg/kg bolus if inadequate response after 2-5 min
OR
Propranolol HCl 0.1 mg/kg divided into 3 doses given slowly at 2 min intervals.  May repeat dose once.
     Sandoz (DIN 02225883)100% allocation


2nd Line:
Amiodarone HCl 5 mg/kg IV over 30 min, followed by 1200 mg over 24 hr
  
Digoxin 400-600 mcg IV single initial dose (if not taking digoxin).

Dimenhydrinate

Available

Alternate route (oral or rectal)

Therapeutic Alternatives:

  • Prochlorperazine 5 to 10 mg PO/IV/IM q6h PRN (max 40 mg/day)
  • Metoclopramide 5-20 mg PO/IV q6h PRN
  • Ondansetron 4-8 mg PO q8h prn

Dimethyl sulfoxide

Rimso - Myland brand (DMSO 50 % for irrigation) now available.

Sandoz brand discontinued.

See PDF for shortage management strategies.

Dobutamine

The source of dobutamine in Canada is Sandoz:

                Sandoz - 12.5mg/ml (10 x 20ml) available

           Therapeutic alternatives: Dopamine hydrochloride, norepinephrine bitartrate, milrinone.  See PDF for details.

Dopamine

Baxter dopamine hydrochloride and 5% dextrose injection is available from Baxter Canada (1-888-719-9955)

Available now from McKesson

Therapeutic alternative: norepinephrine

Doxorubicin

Restrictions:
Existing doxorubicin stock only used to continue treatments that have already been initiated.
No new patients should be initiated on doxorubicin treatment, until further notice.

Transition to the new product code (2344A002) is delayed due to manufacturing constraints.

DOXORUBICIN INJ VL 50MG 25ML TEVA - MANUFACTURER CANNOT SUPPLY FOR INFORMATION CALL 800-268-4127

Doxorubucin HCL, pegylated liposomal

Caelyx® 2mg/ml  (10 ml) available
ITEM Off ALLOCATION PLEASE CONTACT dgutier1@its.jnj.com for questions

Enalaprilat

McKesson has no inventory for either Sterimax or Sandoz product at this time.

See PDF for therapeutic alternatives. *Note that some of these agents are also in short supply or backordered e.g. phentolamine, esmolol*

Fentanyl

Sandoz 50mcg/ml 2ml size, 5ml size, 10ml size, 20ml size and 50ml size are currently available through McKesson.

Procedural sedation -SeePDF

Chronic pain - fentanyl patch - do NOT use in opioid naïve pts

Bulk powder - Medisca, Galenova (Currently unavailable)

Fludarabine

Available

Folic acid

Available

  • Oral:  5 mg tablets Available

             5 mg IV = 5 mg PO

ENTERAL: Dispersed tablets can be administered via enteral feeding tube

Furosemide

Available through McKesson 10mg/ml 2ml, 4ml and 25ml available

Alternative Manufacturers:

Omega – furosemide HCl 10 mg/ml available in 4ml and 25ml vials through McKesson.  2 and 4 ml vials are reserved for contract customers.  25 ml vials reserved for contract customers but Omega may distribute to non-customers depending on situation (case-by-case basis). Call Omega 1 800 363 0584.

Alternative Routes:
    
- oral:  20 mg IV = 40 mg PO
     - administration through enteral feeding tube.  It is reasonable to administer furosemide oral solution (can dilute with equal volume water if needed) through a feeding tube.  Caution with doses > 140 mg daily (14 ml) which contain nearly 10 g sorbitol.  10 g sorbitol per day may cause flatulence and bloating; 20 g daily may cause diarrhea and cramping. 

Therapeutic Alternatives:
Ethacrynic acid: 50 mg/vial (close to $500 acquisition cost per vial)
Bumetanide: IV available through Special Access?

Gentamicin

Sandoz 40mg/ml strength  and 10mg/ml strength -  Available

Glycopyrrolate

Sandoz  available

with preservative VL 0.2MG/ML 1X20ML

preservative free  VL 0.2MG/ML 10X2ML

Preoperative inhibition of salivation and excessive respiratory tract excretions:

  • Assess need for premedication on an individual patient basis. Routine use not recommended.
  • Atropine sulfate parenteral: Adult: 0.4 mg (range: 0.2–1 mg) SC, IM, IV 30 - 60 min prior to anesthesia Pediatric: 0.1 mg for children weighing 3 kg, 0.2 mg for 7 to 9 kg, 0.3 mg for 12 to 16 kg and 0.4 mg for those weighing more than 20 kg
  • Scopolamine hydrobromide parenteral : 0.3 mg to 0.6 mg SC, IM, IV 45 to 60 minutes prior to anesthesia
  • Scopolamine 1.5 mg transdermal patch: Apply 12 hours before surgery
  • Atropine (Other routes):
    • Oral solution (ophthalmic drops, compound) Pediatric dose: 0.02 mg/kg to 0/03 mg/kg. (Note: Significantly less effective than IV atropine for decreasing bronchial secretions)
    • Rectal solution (compound) - Pediatric dose: 0.05 mg/kg (Max 1.5 mg)

Intraoperative and postoperative use:

  • Atropine sulfate IV, scopolamine hydrobromide IV

Management of gastrointestinal disorders:

Hyoscine butylbromide (Buscopan), atropine sulfate, scopolamine hydrobromide SC. IM. IV

Haloperidol decanoate

Haloperidol 5mg/ml  (10 x 1ml) available

Alternative depot antipsyhotic: flupentixol, fluphenazine, paliperidone, pipotiazine, risperidone, zuclopenthixol (See Depot Antipsychotic Shortages PDF)

Heparin Sodium

LEO                        100 iu/ml      10 x 10ml  available
LEO and SDZ         1000 iu/ml     10 x 10ml  available
SDZ                      1000 iu/ml     10 x 30ml available
PFC                      1000 iu/ml      25 x 10ml  available
FRE                     10,000iu/ml     25 x 0.5ml available
PFC                     10,000iu/ml     25 x 1ml available
SDZ                     10,000iu/ml     10 x 1ml  available
SDZ                     10,000iu/ml     10 x 5ml  available
 

Hydromorphone

Available

Acute or chronic pain (See Switching Opioids)

  • ORAL: – IR tablet; solution, SR capsule
    1 mg IV = 2 mg PO opioid naïve pts, chronic pain
  • RECTAL  -  3 mg suppository
  • ENTERAL:  Syrup, dispersed IR tablets can be given through enteral feeding tube
  • COMPOUND STERILE SOLUTION for parenteral use (if facilities available) – powder can be purchased from Medisca
Alternative IV analgesics: morphine, fentanyl, methadone

Fentanyl patch for chronic pain only - do NOT use in opioid naïve patients

Indigo carmine

Indigo carmine 0.8% injectable is unavailable for an indefinite period. For a discussion of therapeutic options see the AHFS Drug shortage memo on indigo carmine at  http://www.ashp.org/menu/DrugShortages/CurrentShortages/Bulletin.aspx?id=861.

Methylene blue is an option for certain indications and McKesson currently has some in stock.

Ketorolac

Ketorolac 30 mg/ml -  25 x 1ml available. 

Toradol 10mg/ml (5 x 1ml) available.

While shortage is in effect, the following measures are suggested:

  1. Use lowest effective dose
  2. Step down to oral ketorolac or alternative NSAID as soon as therapeutically appropriate
  3. Use oral analgesic e.g. ibuprofen, naproxen if patient is able to eat and drink (See PDF)
  4. Use rectal analgesic or alternative parenteral analgesic if oral oute not available (See PDF)

Lidocaine 0.4% in Dextrose 5% for Injection

No longer stocked by McKesson.

Lorazepam

4mg/ml (10 x 1ml) available

  • See PDF for details on treatment alternatives

Meperidine

Available 50mg/ml (10 x 1ml) Sandoz brand

Alternative: IV analgesics e.g. morphine, hydromorphone (Use of oral meperidine not recommended)

See PDF for details.

Metoclopramide

Available 5mg/ml in 2ml and 30ml.

Oral dosage forms: tablets and solution available. (PMS)

Alternative Agents and Management: See AHSP Drug Shortages

Metronidazole

Baxter brand 5mg/ml (100ml) available.

See PDF for shortage management strategies.

Mitomycin

Mitomycin for injection 20mg available.

5mg not yet available

Hospitals seeking Mitomycin Injection 20mg on behalf of a patient should contact
Health Canada’s Special Access Programme (SAP), who will work with Teva to
identify any available product globally and determine if it is suitable to bring into
the Canadian market.

See PDF for shortage management strategies.

Morphine

Sandoz available in 0.5mg/ml, 1mg/ml, 2mg/ml, 10mg/ml, 15mg/ml, 50mg/ml.

Procedural sedation - See PDF for alternatives

Acute  or chronic pain

  • ORAL:  IR tablet; syrup, SR tablet/capsule
    10 mg IV = 20 mg PO opioid naïve pts, chronic pain
  • RECTAL: 5, 10, 20, 30 mg suppository
    10 mg IV = 10 mg PR
  • ENTERAL:  Syrup, dispersed IR tablets can be given through enteral feeding tube
  • COMPOUND STERILE SOLUTION for parenteral use (if facilities available) – powder can be purchased from Medisca, Galenova

Alternative IV analgesics: hydromorphone, fentanyl (See Switching Opioids)

Fentanyl patch for chronic pain only - do NOT use in opioid naïve patients

Naloxone

Sandoz 0.4mg/ml available (1ml and 10ml size)

Contact Poison Control for emergency information in the event naloxone is unavailable.

Neostigmine Methylsulfate

Now available

Reversal of Post-op NeuromuscularBblockade
- reduce/ avoid use of muscle relaxants when possible

Urinary Retention
- catheterization

Post-operative Ileus
-no specific therapy

Acute Exacerbation of Myasthenia Gravis
-treatment of underlying cause (e.g. Infection)
-pulmonary physiotherapy
-IVIg: 2 g/kg given over 5 days (400 mg/kg /day) or, if tolerated, over 3-4 days

Nitroglycerin

Omega brand Nitroject VL 5MG/ML 5X10ML available

Ischemia:

  • Sublingual nitroglycerin
    • 0.4 mg every 5 min x 3 doses
  •  I.V./oral beta blockers in absence of contraindication (if so consider non-dihydropyridine calcium channel blocker – avoid immediate release nifedipine)
    • Metoprolol 50 mg PO q12h   OR  if significant,  5 mg I.V. over 2 minutes q 5 minutes up to 15 mg.
    • Atenolol 25-50 mg PO q12h   OR  if significant,  5 mg I.V. over 5 minutes, repeat once after 10 minutes.
  • Morphine sulfate if ischemic pain not adequately treated.
  • Oral  long acting nitrate to prevent recurrent episodes of ischemia

Hypertensive Emergency (HE)/Intraoperative Hypertension (IH)

  • Labetalol (HE)
  • 20-80 mg I.V. bolus q 10 minutes until target BP

OR

  • 0.5-2 mg/minute I.V. infusion to target BP
  • Esmolol (IH)
  • 1.5 mg/kg bolus over 30 seconds.  Follow with 0.15 mg/kg/min.  Adjust rate as required up to 0.3 mg/kg/min to desired heart rate/BP.
  • Phentolamine (HE)
  •  5-15 mg I.V. bolus
  • Sodium nitroprusside  (HE)
  • 0.25 – 10 mcg/kg/minute as immediate I.V. infusion
  • Hydralazine (HE)
  • 10 – 20 mg I.V. q 20-30 minutes as needed for desired BP.

Paclitaxel

Not yet available through McKesson.

Paclitaxel can also be ordered directly from Biolyse Pharma 1-905-687-8008

No restrictions to use.

Pancuronium

Not available.

Alternatives: atracurium, cisatarcurium, rocuronium, vecuronium. Check for availability.

See Nondepolarizing Neuromuscular Blocking Agents for more information.

Pantoprazole

Sandoz brand powder for injection available 40mg/ml

Restriction: Active GI Bleed; dose restricted

Dose: 80 mg IV x 1 dose, followed by 40 mg IV q12h x 6 doses Note: Doses greater than this may be subject to autosubstitution

Alternatives:
Patients With No Active GI Bleed (i.e., do not meet restriction criteria):

Dose: Esomeprazole 40 mg PO or via NG once daily

Dose: Lansoprazole Fastabs 30 mg PO once daily (quick dissolving tabs)

Phentolamine Mesylate Injection

Rogitine 10mg/ml (5 x 1ml) MANUFACTURER CANNOT SUPPLY FOR INFORMATION CALL 866-340-1112 INDETERMINATE AVAILABILITY DATE

Phentolamine mesylate 5mg/ml (10 x 1ml) SDZ available

See PDF for information on therapeutic alternatives.

Phenytoin

Sandoz and Sterimax brands 50mg/ml 2ml and 5ml sizes available.

Alternatives to Phenytoin for Treatment of Status Epilepticus (In order of preference):

  • Phosphenytoin 20 mg/kg phenytoin equivalents IV at 150 mg/min
  • Lorazepam 1-2 mg/min IV to max 0.1 mg/kg 
  • Midazolam 10 mg IV bolus, then 0.05 – 0.4 mg/kg/h OR diazepam 5 mg/min IV to max dose of 0.25- 0.4 mg/kg OR diazepam 20 mg rectally if no IV access.
  • Phenobarbital  up to 20 mg/kg IV (50-75 mg/min)
  • Propofol 2-5 mg/kg IV bolus followed by infusion at 2-10 mg/kg/h

Alternatives to Injectable Phenytoin for Treatment
of Tonic Clonic (TC) or Partial/focal (P) Epilepsy:


1. Administer phenytoin orally

- phenytoin suspension can be administered via enteral feeding tube if patient can’t swallow

2. Use alternative oral anti-epileptics

Oral  Alternatives to Phenytoin for
Treatment of Tonic-Clonic or Partial Seizures

Drug

Seizure Type

Usual Daily Maintenance Dose
(Adults/Children)

Number of Doses per Day

NG Tube
Administration Feasible?

Carbamazepine

Tonic Clonic
Partial

800-1200 mg

2 to 4

Yes

10-40 mg/kg/day

Lamotrigine

Tonic Clonic
Partial

300- 400 mg

2 to 3

Yes – Chewables/dispersibles

10-12 mg/kg/day*

Valproic Acid

Tonic Clonic
Partial (2nd line)

750-1000 mg

2

Yes  - syrup

60-80 mg/kg/day

Levetiracetam

Tonic Clonic
(2nd line)
Partial

750-1000 mg

2

Yes

60 mg/kg/day**

Oxcarbazepine

Partial
(2nd line)

1200-2400 mg

2

No

20-50 mg/day

Topiramate

Tonic Clonic
(2nd line)
Partial (2nd line)

200-400 mg

2

Yes – tablets,
not contents of capsules

4-10 mg/kg/day

*Lamotrigine not indicated in children (<16yo) except for seizures associated with Lennox-Gastaut syndrome; dose is based on monotherapy.     **Not indicated in children        † See weight-based dosing in monograph


3. If parenteral is required:
Fosphenytoin dose as phenytoin equivalents.  For example, if dose of phenytoin had been 100 mg, dose of fosphenytoin will be 100 mg phenytoin equivalents.
Off-label routes: phenobarbital subcutaneous (i.e.: if need parenteral)
Seizure type – ether and UpToDate Epileptic syndromes and recommended antiepileptic drugs

Pipotiazine palmitate (Piportil L4)

Discontinued

Alternative depot antipsyhotic: flupentixol, fluphenazine, risperidone, halperidol long-acting, paliperidone (See Depot Antipsychotic Shortages PDF)

Prochlorperazine Injectable

Injectable formulation has been discontinued by Sandoz, sole Canadian distributor.

Alternate forms: 5mg and 10 mg oral tablets (available late January 2017); 10 mg rectal suppository (no availability date)

Therapeutic alternatives: See PDF

Promethazine Injectable

Injectable formulation has been discontinued by Sandoz, sole Canadian distributor.

Alternate forms: 50 mg oral tablets available.

Bulk chemical listed in Medisca catalogue.

Therapeutic alternatives: See PDF

Propofol

Available

 Alternatives:

Induction of anesthesia: ketamine, etomidate (SAP)

Procedural sedation - See PDF for alternatives

Ranitidine

Sandoz 25mg/ml (10 x 2ml) and Sandoz 25mg/ml 50ml size available.

Zantac 25mg/ml discontinued

Change to oral route whenever possible:
-ranitidine 50 mg IV = ranitidine 150 mg PO
-oral solution can be administered NG (Teva oral solution available DIN 02242940)

Change to alternative if required:
Alternative H2 antagonists:
-IV: famotidine (APX, Omega) – in short supply
-Oral: famotidine 40 mg ~ nizatidine 300 mg ~ ranitidine 150 mg BID or 300 mg  HS

Alternative PPIs:
IV: Pantoprazole (currently shorted)
Oral: Pantoprazole 40 mg ~ Lansoprazole 30 mg ~ Omeprazole 20 mg ~ Esomeprazole 40 mg ~ Rabeprazole 20 mg 
Nasogastric administration: lansoprazole, esomeprazole

Rocuronium

Currently available.

Alternatives: Vecuronium (intermediate/long), cisatracurium (intermediate). Check for availability.

See Nondepolarizing Neuromuscular Blocking Agents for more information.

Succinylcholine

Teligent brand 20mg/ml 20ml size available

Quelicin (Hospira's brand) 20MG/ML 25X10ML not available - PRODUCT UNDER ALLOCATION. FOR QUESTIONS ON ALLOCATED QUANTITIES, PLEASE CONTACT HOSPIRA 1-866-488-6088

Alternatives: rocuronium, vecuronium - see Nondepolarizing Neuromuscular Blocking Agents

Testosterone

Delatestryl (testosterone enanthate)  200mg/ml x 5ml available

Pfizer depo-testosterone cypionate 100mg/ml available.

Option: Testosterone enanthate and testosterone cypionate (100 mg/ml) can be substituted at same mg/dose and same frequency (Note different concentrations of testosterone cypionate products and Delatestryl - e.g. a patient receving 0.5 ml (100 mg) Delatestyl would require 1 ml (100 mg) of testosterone cypionate.)

Alternatives: Oral or topical formulations of testosterone (See PDF)

Thyrotropin alpha

Thyrogen currently no availability date.

Tirofiban .05mg/ml NS IV

Aggrastat - currently no availability date.

Vitamin B 12

Available

Reserve current stock for patients with cancer protocols which require periodic injections of vitamin B!2 to prevent toxicity

Restrict parenteral use to patients with severe neurologic involvement or with vomiting, diarrhea or bowel resection, or chidlren with severe deficiency when rapid restoration of stores is desired

Alternatives: Oral or sublingual route:

Adult - 1,000 to 2,000 mcg/day inititally to treat deficiency, followed by maintenance dose of 1000 mcg/day
Children - Not well defined. Doses of up to 1000 mcg/day orally are used for pernicious anemia.

Vitamin K

Baxter 10mg/ml, 10x1ml now available, 1.0mg/0.5ml available.

ORAL:   Vitamin K 5 mg tablets- Special Access Drug.  No restrictions per SAP.

COMPOUND: Vitamin K powder  available from Galenova, Medisca  - prepare capsules, powders, suspensions

ORAL and TOPICAL DRUGS

http://
DrugAvailability / Alternatives

Acetazolamide

AAPharma 250mg available.

Alternatives:
Glaucoma – methazolamide
Altitude sickness - dexamethasone
Migraine (off-label) - methazolamide

Acyclovir oral

All strengths available

Topical ointment and cream available.

GSK ZOVIRAX suspension 200MG/5ML 475ML - Available January 31, 2017

Allopurinol (Zyloprim)

All strengths and brands available from various manufacturers.

Zyloprim - all strengths available.

Discontinuation in patients with mild gout and no attacks for years may be considered.

Alternatives:
Xanthine oxidase inhibior: febuxostat (Uloric) 80 mg PO once daily. (new, $$)
2nd line prophylaxis:
Colchicine 0.6 - 1 mg PO once daily; reduce dose in elderly, renal impairment
Uricosuric agents: ineffective if CrCl <50 ml/min; not in urate over-producers; not if history of nephrolithiasis; liberal fluid intake required:
- Probenecid: inital dose 250 mg PO BID, titrate to 0.5 - 2 g / day in two to three divided doses
- Sulfinpyrazone: inital 100-200 mg PO BID, increase dose to 200 - 400 mg PO BID

Amitriptyline

All strengths of Elavil and all generic brands available.

Alternatives:
Nortriptyline (convert at roughly ½ the dose of amitriptyline and titrate as needed), Imipramine (convert at same dose as amitriptyline); beta-blockers (migraine prophylaxis); SSRIs, SNRIs

Amoxicillin-Clavulanate

Amoxicillin/Clavulanate 250/125 tablets, 500/125 tablets, 875/125 tablets available

Apo suspensions 125-31.25/5ml and 250-62.5/5ml available spring (May) 2017

Clavulin 125-31.25/5ml, 200mg-28.5mg/5ml, 250mg/62.5mg/5ml and 400mg-57mg/5ml suspensions available.


Options for amoxicillin clavulanate 875/125 mg:
500/125 mg TID or if BID dosing is desired, 500/125 mg BID PLUS amoxicillin 500 mg BID.

Therapeutic alternatives:
macrolides, clindamycin (but not if need Gram neg coverage), fluroquinolones, cefixime, cefuroxime

Ampicillin Oral Suspension

No manufacturers are currently marketing oral ampicillin suspension.

Ampicilllin 250 and 500mg capsules available.

Alternatives
Compound suspension from oral ampicillin capsules (See detail document)
Substitue a different antibiotic which is active against the organism causing the infection

Atenolol

25mg, 50mg and 100mg available from various manufacturers.
TEVA Atenolol / chlorthalidone combination available as well as Tenoretic.

See PDF for information on handling shortage.

Beclomethasone nasal spray Budesonide nasal spray Flunisolide nasal spray (Rhinalar)

Nasal Spray

Mylan-beclomethasone available.

Apo-beclomethasone available.

Mylan budesonide 64 ug and Rhinocort (ASTZEN) available.

Mylan - budesonide 100 ug now available

Apo-flunisolide 0.025 %  PRODUCT WILL BE AVAILABLE ON February 7, 2017


Alternatives:
Fluticasone
Ciclesonide (Omnaris)

Cabergoline

Dostinex available.

Co-Cabergoline indeterminate availability

See PDF for details.

Calcitonin nasal spray

All nasal spray calcitonin products have been withdrawn from the market and discontinured due to a small increased rate of cancer (up to2.4 %). DINs became inactive October 1st, 2013 at which time prescribing and dispensing should have ceased.  Calcitonin is no longer indicated for osteoporosis. For alternative treatment see ACFP Tools for Practice at http://www.acfp.ca/Portals/0/docs/TFP/20130923_085017.pdf.

Calcitonin (salmon synthetic) injectable remains on the market but is indicated only for Paget’s Disease and hypercalcemia. Due to the increased cancer risk the duration of treatment should be limited to the shortest period of time possible and the minimum effective dose.

Cefaclor

Ceclor discontinued by manufacturer.

No generics available through McKesson at present.

Alternatives:
trimethoprim-sulfamethoxazole; fluoroquinolones

Cefixime

Suprax 20mg/ml 50ml available

Suprax 400mg tablets available

Auro brand tablets 400mg available.

Therapeutic alternatives: ceftriaxone IM, azithromycin PO

See PDF for details

Cephalexin

Tablets available 250mg and 500mg.

Suspensions - available

Alternatives:
Cellulitis: cloxacillin
UTIs: TMP/SMX, nitrofurantoin, fluoroquinolone
Skin infections: cloxacillin, clarithromycin, azithromycin, clindamycin

Charcoal, Activated Suspension

McKesson lists Omega Charac-50 suspension as available

No availability date for the Pharmascience product

Tablets are available.

Premeasured activated charcoal powder can be ordered from McKesson or Galenova. See PDF

Chlorthalidone

AA Pharma 50mg (single ingredient) available.

Other brands are only combination products.

Teva atenolol/chlorthalidone 100/25 and 50/25 available. 

NYC azilsartan/chlorthalidone available.

Tenorectic 50/25 available.

Alternatives:
If also on atenolol and strengths match, can go to the combination product (Tenoretic, generics)
Hydrochlorothiazide at equivalent dose for hypertension or edema

Clindamycin palmitate granules for solution

Dalacin C granules for solution 75mg/5ml is available

Options: capsules (150, 300 mg) can be opened up and mixed with water of food (not an approved method of administration) - see PDF for more details; parenteral injection for severe infection

Therapeutic alternatives - See PDF

Clobazam

APO - available

Frisium - available

Alternatives: clonazepam (or other benzodiazepine); anticonvulsant appropriate for seizure disorder

Clobazam must be tapered before stopping if not switching to another BZD - see PDF.

The Canadian League Against Epilepsy has also issued a document

Clomiphene

Clomid - discontinued

Serophene available

Alternatives: compounded by compounding pharmacy or pharmacological alternatives.

Cloxacillin

Capsules currently available in both strengths. 

TEVA 125mg/5ml (100ml size) suspension available.

Alternatives:
Cephalexin is an appropriate alternative for an infection in which cloxacillin is indicated:
abscess (breast)/mastitis (mild); carbuncles (mod-severe); bursitis, septic; cellulitis (extremities and facial); dacrocystitis in adult; impetigo (mod-severe); osteomyelitis (step down in children)

Cotrimoxazole

All strengths of tablets and suspensions now available from either Teva or Apotex

Options: Use other methods of administration.

Alternatives: A different antibiotic with a similar spectrum of activity

Dantrolene

Dantrolene sodium capsules 25mg(Dantrium®) available.

100mg discontinued.

Options:  Parenteral product is available (Dantrium Intravenous®).  Extemporaneous compouding via bulk powder through Medisca is an option.

See PDF for details about alternatives.

Desipramine

All strengths available.

Alternatives:
Nortriptyline and desipramine are both secondary amine TCAs and generally better tolerated than tertiary amine TCA's (convert to nortripytline at roughly ½ the dose of desipramine and titrate as needed), Imipramine, amitriptyline, clomipramine (convert at same dose as desipramine); beta-blockers (migraine prophylaxis); SSRIs, SNRIs

Diazepam

All strengths are currently available.

Alternatives for 2 mg:
Use ½ x 5mg tablet short term; 0.5mg lorazepam approximately equivalent to 2.5 mg diazepam (may require shorter dosing interval due to shorter half-life compared to diazepam)

Diflucortolone valerate topical

Nerisone Oily Cream available. 

Nerisone Regular Cream and Ointment - discontinued by manufacturer.

Alternatives:
Another Class IV moderate corticosteroid: clobetasol 17-butyrate 0.05% cream; desoximetasone 0.05% cream, oint; hydrochortisione 17-valerate ointment; mometasone furoate 0.1 % cream, oint; triamcinolone acetonide 0.1 % cream, oint.

Diltiazem

Diltiazem CD - all strengths available - manufacturers vary.

Tiazac XC available in all strengths.

Teva Diltiazem ER available in all strengths.

Alternatives:
Same daily dose of alternative dilitazem formulations
Hypertension: verapamil, amlodipine, felodipine and nifedipine XL
Stable angina: amlodipine, nifedipine, and verapamil IR are indicated. IR diltiazem and IR nifedipine not recommended for monotherapy.

Divalproex sodium

Apo and Teva brands - 125mg, 250mg and 500mg available

Epival 250mg and 500mg available.

Alternative:
Substitute same strength valproic acid formulation. May be increased GI adverse effects - take with food. Monitor for continued control of seizures / mood.

Erythromycin

Available: Erythromycin Base 250mg tablets, Eryc 250mg and 333mg capsules (Erythromycin enteric coated delayed release pellets)

Erythro S (stearate) 250 mg and 500mg available.
Erythromcin ophthalmic ointment NOW available
Erythromycin Estolate 250mg/5ml suspension (100ml) available
Erythromycin IV is also available.

Erythromycin Ethylsuccinate suspensions - Discontinued by manufacturers

Alternatives: other macrolides are available as liquid formulations ie. Azithromycin, Clarithromycin. Compounding not recommended as cost-prohibitive, lack of formulas readily accessible and other options readily available.

Ethosuximide

Zarontin 250 mg capsules available

Zarontin 50 mg/ml syrup available

Alternatives: switch to another anticonvulsant- monitor for tolerability and seizure control

Fenofibrate

Fenofibrate Micro 200mg available from various manufacturers.

145mg (EZ) Nanocrystal formulations and 160mg (Supra) Microcoated, micronized formulations are equivalent to the 200mg micronized formulations and are available from various companies.

Fenofibrate 48mg and 100mg available.

Fiorinal

All strengths available.

Generics available

Important considerations:

  • Dependence and withdrawal can be severe - see PDF for details
  • Medication overuse headache - see PDF for details

Flecainide

50 mg and 100 mg strengths available from AA Pharma.

Name brand Tambocor - discontinued.

In case of shortage, refer to proprafenone document. 

In the likely event both fleicanide and propafenone are short, no blanket recommendation can be made.  Please phone medSask for individual assessment and include as much patient history as possible including - but not limited to: the type of arrhythmia being treated; current medications, past medications for the arrythmia and reason for discontinuation, if known; other medical conditions; allergies. 

Folic Acid

5mg tablets available.

Fosfomycin

Fosfomycin (Monurol 3g satchet) available

It is a one-dose oral antibiotic indicated only for uncomplicated UTI in females. There are no other one-dose oral antibiotics for UTI currently available.

Framycetin sulfate / gramicidin / dexamethasone

Sofracort Eye/Ear Drops available.

Proctosedyl, Proctol, Proctosone and Proctomyxin ointment and suppositories currently available.

Nasal Spray available.

Soframycin ointment is discontinued.

Sandoz Opticort is discontinued.

Sofratulle bandage not available - McKesson says no date for availability

Alternatives: Blephamide (sulfacetamide/prednisolone) ophth oint; Ciprodex (ciprofloxacin/dexamethasone) otic susp; Maxitrol (polymyxin B/neomycin/dexamethasone) ophth susp and oint; Tobradex (tobramycin/dexamethasone) ophth susp.

Gemfibrozil

TEVA gemfibrozil 300mg and 600mg available.

Apo-gemfibrozil 300mg and 600mg backordered until June 2017.

Other brands discontinued.

Therapeutic alternatives: fenofibrate, bezafibrate, statins, niacin, fish oil (See PDF for details)

Gliclazide MR

All brands and strengths available.

Alternatives:
Gliclazide 80 mg immediate release (various brands) - to substitute for MR, start with 80 mg IR per 30 mg MR. Doses higher than 160 mg daily should be divided BID. Dose should be adjusted based on blood glucose monitoring after switch.

Hydroxyzine

Apotex 10mg, 25mg and 50mg strengths currently available.

Atarax 10mg/5ml available.

PMS brand no  available date

Iron Dextran

Infufer 50 mg/ml discontinued by manufacturer.

Feraheme 30mg/ml Discontinued by manufacturer.

Ferrlecit 12.5mg/ml available

Dexiron 50 mg/ml available.

Venofer available

Isosorbide Dinitrate

AA Pharma has taken over marketing from Apotex. Now available.

Alternatives:
isosorbide mononitrate, nitroglycerin

Ketorolac Ophthalmic

Acular LS 0.40 available.

Acular 0.5% (5 and 10ml) available.

Acuvail 0.45% available

Ketorolac AAA brand 10ml available. 5ml available.

Alternatives:

  • Diclofenac
  • Nepafenac
  • Dexamethasone
  • Fluoromethalone

See PDF for details.

Medroxyprogesterone acetate

All strengths available.

Options: Compound capsules from bulk powder

Alternatives: micronized progesterone, norethindrone acetate, megestrol acetate, estradiol/progestin combinations
(See PDF for detailed information.)

Methotrimeprazine (Nozinan & generics)

All strengths available.

Alternatives:
Chlorpromazine, haloperidol (note do not have analgesic effects)

Misoprostol

100mg AA Pharma brand available
200mg AA Pharma brand available

Therapeutic alternatives: See PDF

Naproxen

Solid dosage forms are available in all strengths.

Naprosyn suspension has been discontinued by Hoffman LaRoche. 

Pediapharm Naproxen Suspension 25 mg/ml available.

Options:

Alternate dosage forms - naproxen 500 mg suppositories

Crushing tablets, extemporaneous suspensions (See PDF)

Therapeutic Alternatives: ibuprofen, acetaminophen

Nitrofurantoin

TEVA Macrocrystals 50mg capsules  - available

AA Pharma  50mg and 100mg tablets - available May 7, 2017

Nystatin Oral Suspension

Available

Alternatives:
Refer to compounding pharmacy
Therapeutic alternatives: fluconazole, gentian violet, clotrimazole

Ofloxacin 0.3 % ophthalmic solution

All brands of tablets discontinued

Allergan Ocuflox 0.3% ophthalmic available

Apo-ofloxacin 0.3% ophthalmic available May 8, 2017.

See PDF for suggestions on therapeutic alternatives.

Opium and Belladonna Rectal Suppositories

Available

Therapeutic Alternatives: Hyoscine (Buscopan) injectable, morphine suppositories, NSAID suppositories - See PDF for more details.

Paromomycin (Humatin)

Only manufacturared by Erfa. 

Humatin 250mg capsules now available.

FOR INFORMATION CALL 888-922-3133

Alternatives:

Dientamoeba fragilis
No treatment required if asymptomatic.Symptomatic: iodoquinol* 650 mg PO TID (adult) or 30-40 mg/kg/day PO div TID (max 650 mg/dose, children) x 20 days
Alternative: metronidazole^ 500-750 mg PO TID (adult) or 35-50 mg/kg/day PO div TID (children) x 10 days
^High failure rate to metronidazole

Entamoeba histolytica (Amoebiasis)
Asymptomatic: iodoquinol* 650 mg PO TID (adult) or 30-40 mg/kg/day PO div TID (max 2g/day, pediatric) x 20 days or paromomycin
Symptomatic: metronidazole 500-750 mg PO TID (adult) or 35-50 mg/kg/day PO div TID (pediatric) x 7-10 days Followed by iodoquinol (dose as above) x 20 days or paromomycin

Giardia lamblia / duodalis / intestinalis (Giardiasis)
First line treatment is metronidazole 250 mg PO TID (adult) or 15 mg/kg/kday PO div TID (pediatric) x 5-7 days Alternatives: paromomycin, nitazoxanide (available through Special Access Programme), quinacrine (available through Special Access Programme)

*Iodoquinol (Diodoquin) is made by Glenwood as 210 mg and 650 mg tablets.  As of Feb.17, 2014, only the 210 mg tablets are available.  Diodoquin is not available through McKesson but is distributed through Khol and Frisch, AmerisourceBergen, Procurity, uniPHARM.

Penicillin V

300mg tablets currently available.

Suspension 125mg/5ml and 300mg/5ml not currently available - resupply anticipated May 8, 2017.

Alternatives:
Grp A Strep throat : amoxicillin, cephalexin, clindamycin, azithromycin, clarithromycin

Grp A vulvovaginitis: clindamycin

Dental infection prophylaxis and treatment: clindamycin (alternative for penicillin V +/- metronidazole)

Pentoxifylline

Currently available.

Trental name brand discontinued.

Alternatives: aspirin, clopidogrel, dipyridamole, ticlopidine

Permethrin 5% cream and lotion

Kwellada-P Lotion 5% available.

Nix 5% Cream available.

Alternative to commercial products - permethrin 5 % lotion or cream can be extemporaneously compounded, however, bulk permethrin is currently not available from compounding pharmacy suppliers.

Therapeutic alternatives (see PDF for details):

  • Crotamiton 10 % cream (Eurax) - also in short supply
  • Sulfur 5 - 10 % in petrolatum (once daily application for 3 to 7 days)
  • Ivermectin - may be available on a case-by-case basis through the Special Access Program

Perphenazine

APO-Perphenazine 2, 4 and 8 mg tablets currently available.

Therapeutic alternatives: See PDF

Phenytoin

All strengths of all oral dosage forms are available.

Alternatives: Infatabs, oral suspension, injectable.
Important - see PDF for instructions on switching.

Pizotifen (Sandomigran)

Sandomigran 1mg available.

Sandomigran 0.5mg discontinued.

Polymyxin B + Gramicidin Ophthalmic

The ophthalmic ointment has been discontinued by the makers of both Polysporin and Optimyxin

Polysporin pink eye drops available.

Ear drops with lidocaine are available

Optimyxin and Cortisporin products have been discontinued.

Therapeutic alternatives:

- No OTC alternatives for ophthalmic ointment; consider ophthalmic solution

- RX alternatives: tobramycin, ciprofloxacin or erythromycin ophth ointment

Polytrimethoprim Ophth. Drops

Sandoz brand now available.

Alternative:
Polysporin Eye/Ear Drops

Propafenone

Both 150mg and 300mg available from various manufacturers.

Rythmol 150mg and 300mg available.

In the likely event both fleicanide and propafenone are short, no blanket recommendation can be made.  Please phone medSask for individual assessment and include as much patient history as possible including - but not limited to: the type of arrhythmia being treated; current medications, past medications for the arrythmia and reason for discontinuation, if known; other medical conditions; allergies. 

Pyrantel pamoate suspension

Combantrin suspension has been discontinued. Combantrin 125 mg tablets are available.

For patients unable to take tablets, the tablet can be crushed and mixed with a soft food immediately before administering. 

Salbutamol Nebules for Inhalation

SALBUTAMOL SOL 1MG/ML 20X2.5ML TEVA available

PMS available March 2017

Ranitidine oral solution (15mg/ml)

Generics available.

Zantac brand discontinued

If dose corresponds to tablet strength (75, 150, 300 mg), tablet can be crushed and mixed with soft food such as applesauce immediately before administering.

Extemporaneous compounding: See PDF for details

Sulfasalazine

PMS Sulfasalazine 500mg  available.

SALAZOPYRIN EN-TABS TB EC 500MG 100 PRODUCT WILL BE AVAILABLE ON : 2016/09/30

SULFASALAZINE EC TB 500MG AVAILABLE ON : 2016/10/09

Verapamil

All strengths currently available from various manufacturers.

Alternatives:
Immediate release at same daily dose (or as close as possible)
Hypertension: amlodipine, diltiazem (CD, Tiazac reg, Tiazac XC), felodipine , nifedipine (XL)
Stable angina: amlodipine, diltiazem and nifedipine XL are indicated. IR diltiazem and IR nifedipine not recommended for monotherapy.

Zostavax

Check with manufacturer - MSD 1-800-463-7251

Also available through McKesson.

PDFs