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.
Injectable 50mg/5ml 10 x 10 ml -no date for availability.
Both cream and ointment available.
Alternative route: oral tablets, oral liquid formulation.

Bretylium

Currently available.
Sandoz is the only manufacturer of bretylium.
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

Bupropion

XL  formulations should be available near the end of October/ beginning of November 2018 according to McKesson.

If switching from XL to SR in light of a shortage of the XL formulation, the total daily dose is the same, but the interval changes. 
E.g. Bupropion XL 300mg daily = Bupropion SR 150mg BID.  They are not considered equivalent and there may be clinical differences when switching, however it may be the only option until the XL shortage is resolved.
https://pdf.hres.ca/dpd_pm/00039160.PDF


XL formulations are 150mg - 300mg once daily.
SR fomulations have a shorter duration and are twice daily 100mg - 150mg twice daily.
http://www.rxfiles.ca/rxfiles/uploads/documents/members/cht-Psyc-Antidepressant.pdf

If switching from XL 150mg to SR 150mg the administration is SR150mg once daily.
Doses of bupropion SR greater than 150 mg/day should be administered BID preferably with at least 8 hours between successive doses. 
https://pdf.hres.ca/dpd_pm/00040677.PDF

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 25mg, 50mg and 100mg 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

Sandoz and Pfizer (name brand) all currently available.
FOR INFORMATION CALL 800-361-3062 (Sandoz)

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.  MANUFACTURER CANNOT SUPPLY FOR INFORMATION CALL 877-827-1306.
According to McKesson - indeterminate availability.
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
See PDF for indications and alternatives

Dimethyl sulfoxide

Rimso - Mylan discontinued.
Xenex and Galenova DMSO currently available.
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 - check catalogue for availability.

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.

Doxorubucin HCL, pegylated liposomal

Caelyx® 2mg/ml  (10 ml) available

Enalaprilat

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

Epinephrine / Epipen

Epipen 0.3 mg (adult) indeterminate availability.
Epipen Jr (0.15 mg) currently available.
Auvi-Q is an autoinjector being imported from the US as per an Interim Order. See details from SCPP
Auvi-Q 0.15 mg - not yet listed at McKesson
Auvi-Q 0.3 mg - currently available

Epinephrine 1mg/ml ampules available.
Epipen alternative - epinephrine anaphylaxis kits prepared in pharmacy. See PDF.

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. 
FOR QUESTIONS ON ALLOCATED QUANTITIES, PLEASE CONTACT SANDOZ 1-800-361-3062.
Oral dosage forms available.

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?

Glycopyrrolate

Sandoz  available
with preservative VL 0.2MG/ML 1X20ML
preservative free  VL 0.2MG/ML 10X2ML
Also available in 1mg/5ml oral solution (Cuvposa - Pediapharm)
See PDF for
  • Preoperative inhibition of salivation and excessive respiratory tract excretions
  • Intraoperative and postoperative use
  • Management of gastrointestinal disorders

Haloperidol decanoate

Haloperidol 5mg/ml  (10 x 1ml) available
Haloperidol LA 100mg/ml (5ml) available
Alternative depot antipsyhotic: flupentixol, fluphenazine, paliperidone, pipotiazine, risperidone, zuclopenthixol (See Depot Antipsychotic Shortages PDF)

Heparin Sodium

All strengths available through McKesson from various manufacturers
 

Hepatitis A (inactivated) and Hepatitis B (recombinant) vaccine (Twinrix)

Twinrix (720/20) 1.0ml prefilled syringe and Twinrix Jr. (360/10) 0.5ml prefilled syringe available
For  ages  1 - 15 an alternate 2 dose schedule can be used -  Twinrix (720/20) at 0 months and second dose at 6 to 12 months
Single ingredient vaccines can be used, however all are intermittently available.

Once a HAHB vaccine series is started, it is preferable to complete the series with HAHB vaccine. A monovalent HB vaccine may be used to complete a HB series started with HAHB vaccine. A HAHB vaccine may be used to complete a HB vaccine series that has been started with a monovalent product using the recommended schedule (0, 1, 6 months).
Monovalent HA vaccine may be used to complete a HA series started with HAHB vaccine.
References:
1. https://www.canada.ca/en/public-health/services/publications/healthy-living/canadian-immunization-guide-part-4-active-vaccines/page-7-hepatitis-b-vaccine.html
2. https://www.canada.ca/en/public-health/services/publications/healthy-living/canadian-immunization-guide-part-4-active-vaccines/page-6-hepatitis-a-vaccine.html

Hydromorphone

Available
Some strengths under allocation.
FOR QUESTIONS ON ALLOCATED QUANTITIES, PLEASE CONTACT SANDOZ 1-800-361-3062 INFO.CLIENTS@SANDOZ.COM
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 -  10 x 1ml available, 25 x 1ml available
Toradol 10mg/ml (5 x 1ml) available.
If shortages occur, 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)

Lorazepam

4mg/ml (10 x 1ml) available
2mg/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.

Methotrimeprazine Injection 25mg/ml

Sanofi-Aventis is the sole Canadian supplier of parenteral methotrimeprazine, Nozinan 25mg/ml (10 x 1ml). Available.
Oral tablets available in 2 mg, 5 mg, 25 mg, and 50 mg
See PDF for therapeutic alternatives for parenteral methotrimeprazine.

Mitomycin

Mitomycin for injection 20mg 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

Moxifloxacin Injectable

Moxifloxacin IV no longer available from McKesson. Avelox I.V. discontinued.
Oral moxifloxacin may be suitable. See document for details and alternative agents.

Naloxone

McKesson currently listing:

Sandoz 0.4 mg/ml 10 ml multiuse vial (Stable for 28 days after 1st use)  AVAILABLE

Teligent brand 0.4mg/ml 10 x 1ml available

Sandoz -  0.4 mg/ml 10 x 1 ml ampoules available

            -  1 mg/ml 2 ml vials availabile

             - preservative-free AMP 0.4MG/ML 10 X1ml available 

NALOXONE KIT WITH 2 VIALS - available through McKesson

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

Pharmacies may provide naloxone kits to patients or their caregivers. At this time kits can only be purchased through a company call the Control Group

Information on PAS (Members) website: https://www.skpharmacists.ca/pharmacists/resources/naloxone

Naloxone Kits are available to Saskatchewan residents without a prescription. Residents may access free health region funded naloxone kits at the following locations. Kits may also be purchased from the following pharmacies

Neostigmine Methylsulfate

Now available

Reversal of Post-op Neuromuscular Blockade
- 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 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

Sandoz brand 6mg/ml x 50ml available.
Paclitaxel can also be ordered directly from Biolyse Pharma 1-905-687-8008

Pancuronium

Not available.
Available Alternative: rocuronium
See Nondepolarizing Neuromuscular Blocking Agents for more information.

Pantoprazole

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

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.

Piperacillin and Tazobactam

Anticipated shortage -  Pip/Tazo manufacturers (e.g. SDZ, Sterimax, Teligent) may have supply issues as one API manufacturing plant is not in production (explosion at the plant) which means that all API has to come from the sole remaining API manufacturer which is challenged in covering the global market.

McKesson currently lists Sterimax brand as available.

Pipotiazine palmitate (Piportil L4)

Discontinued

See Depot Antipsychotic Shortages PDF

Prochlorperazine Injectable

Injectable formulation discontinued by manufacturer.
Alternate forms: 5mg and 10 mg oral tablets  available
10 mg rectal suppository Available
Therapeutic alternatives: See PDF

Promethazine Injectable

Injectable formulation has been discontinued by manufacturer
Alternate forms: 50 mg oral tablets indeterminate availability. FOR INFORMATION CALL 866-926-7653
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.

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.
See Nondepolarizing Neuromuscular Blocking Agents for more information.

Sodium Bicarbonate Injection 8.4%

Sodium Bicarbonate Syringe 8.4% 10 x 50ml, 25 x 50ml, 4.2% 10 x 10ml available.
PRODUCT UNDER ALLOCATION. FOR QUESTIONS ON ALLOCATED QUANTITIES, PLEASE CONTACT PFIZER 1-800-267-2553 X4410 (Deborah King) allocation@pfizer.com
Refer to document developed by PA Parkland Health Region
For more information on recalled lots and predicted availability dates:
June 20, 2017 Client Letter (download PDF, 798KB)
June 21, 2017 Second Notification (download PDF, 798KB)

Succinylcholine

Teligent brand 20mg/ml  available
Alternatives: rocuronium - 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 0.9mg/ml Kit available

Tirofiban .05mg/ml NS IV

Aggrastat - MANUFACTURER CANNOT SUPPLY FOR INFORMATION CALL 610-833-6050

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, 1.0mg/0.5ml available November 2, 2018.
Other brands - indeterminate availability.
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
See PDF from Saskatchewan Health Authority

ORAL and TOPICAL DRUGS

http://
DrugAvailability / Alternatives

Acebutolol

According to McKesson:

Teva brand 100mg and 200mg indeterminate availability. According to  McKesson website FOR INFORMATION CALL 800-268-4127.
Apotex brand 100mg, 200mg and 400mg available  November 8, 2018
Sanofi-Aventis Sectral 100mg no availability listed on McKesson
Sanofi-Aventis Sectral 200mg no availability listed on McKesson
See PDF for alternatives.

Health Canada approved indications for acebutolol:
Mild to moderate hypertension
Angina

Uses without Health Canada approval:
Arrhythmia

Acetazolamide

AAPharma 250mg available.

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

Aliskiren

Rasilez and Rasilez HCT are no longer available through McKesson.
There are no generics and no other Renin Inhibitors available.
Now distributed by Innomar Strategies; 1-888-996-9049 ordered directly or through Kohl & Frisch wholesale.
There is a $250 ordering minimum or a $20 fee if below minimum.

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

Amantadine

Amantadine capsules 100MG - Available
Amantadine Syrup 50MG/5ML 500ML - Available

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
Clavulin 125-31.25/5ml, 200mg-28.5mg/5ml, 250mg/62.5mg/5m and 200mg/28.5mgl  suspensions available.
Apo suspensions 125-31.25/5ml,  250-62.5/5ml and 400mg/57mg available November 8, 2018.
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.

Atropine Eye Drops

Minims Atropine Sulphate 1% 20 x 0.5ml (B & L) currently available.
Alternatives:

Agent                                     Peak Mydriasis                        Peak Cycloplegia           Time to Recovery

Cyclopentolate (Cyclogyl)          25 to 75 minutes                      25 to 75 minutes              24 hours

Tropicamide   (Mydriacyl)          20 to 40 minutes                      20 to 35 minutes              1 to 6 hours

Phenylephrine  (Mydfrin)           20 to 90 minutes                      not cycloplegic              3 to 8 hours

Compare to Atropine                 30 to 40 minutes                      1 to 3 hours                     >14 days

Mydriatics, such as tropicamide and cyclopentolate, relax the iris sphincter which is innervated by the parasympathetic nervous system.

Mydriatics such as phenylephrine, dilate the iris through stimulation of alpha adrenoreceptors which are part of the sympathetic nervous system. 

Cabergoline

Dostinex: Available
Apotex brand available November 8, 2018 - now listed as a benefit on SK Formulary
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.

Cefixime

Auro Pharma cefixime 400mg tablets available
SUPRAX SUSP 20MG/ML 50ML available.
Therapeutic alternatives: ceftriaxone IM, azithromycin PO
See PDF for details

Charcoal, Activated Suspension

Charac-25 SUSP PED 125ML available
Charac-50 SUSP 225ml available
Charactol-50 250ml suspension available
No availability date for the Pendopharm products
Tablets and powder 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 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

Frisium - available. Lundbeck the manufacturer of Frisium has discontinued production of the name brand Frisium. Current inventory is expected to be depleted by August 2018. 
For more information Lundbeck’s Medical Information at 866‑880‑4636 will address questions or concerns.
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 and Serophene - discontinued
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)

Co-trimoxazole (sulfamethoxazole/trimethoprim)

Both DS and regular strength tablets available from either Teva or Apotex
Suspensions TEVA - MANUFACTURER CANNOT SUPPLY FOR INFORMATION CALL 800-268-4127 INDETERMINATE AVAILABILITY DATE
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

Diltiazem

Diltiazem CD, ER - all strengths available - manufacturers vary.
Tiazac XC available in all strengths.
See medSask Hot Topic: Comparison of Long-Acting Diltiazem Products (293 KB) August, 2016
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

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

Erythromycin

Erythromycin Base 250mg tablets, Eryc 250mg and 333mg capsules (Erythromycin enteric coated delayed release pellets) Available
Erythro S (stearate) 250 mg undeterminate availabilty.
Erythromcin ophthalmic ointment (Aurium brand) available on November 7, 2018.
Pendopharm ophthlamic ointment available November 5, 2018.


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.

Fenofibrate

Fenofibrate Micronized Capsule 200mg (Apotex) currently available.
The following fenofibrate formulations are considered to have equivalent bioavailability:
  • 100 mg capsule equals 67 mg of the micronized capsule.
  • 300 mg capsule equals:
    • 200 mg micronized capsule.
    • 160 mg micronized or microcoated tablet.
    • 145 mg nanocrystal tablet or three 48 mg nanocrystal tabletshttps://www.e-therapeutics.ca/search
Reference: Fibric Acid Derivatives (CPhA Monograph) from https://www.e-therapeutics.ca/search

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.  Ideally consult cardiology; if unavailable, 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.

Framycetin sulfate / gramicidin / dexamethasone

Sofracort Eye/Ear Drops  - available November 7, 2018 according to McKesson
Proctosedyl ointment (suppositories d/c), Proctol, Proctosone and Proctomyxin ointment and suppositories currently available.
Nasal Spray available.
Soframycin ointment is discontinued.
Sandoz Opticort is discontinued.
Sofratulle bandage not available through McKesson.
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 available November 8, 2018 according to McKesson.
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.

Hyoscine butylbromide (Buscopan(R))

Buscopan 10 mg tablets backordered to Dec. 23, 2018.
Sandoz hyoscine butylbromide injection available; much more expensive than oral tablets.
Therapeutic alternatives: dicyclomine, pinaverium, trimebutine, peppermint oil.

Iron Dextran

Ferrlecit 12.5mg/ml - available
Dexiron 50 mg/ml -available
Venofer 20mg/ml - available

Infufer 50 mg/ml and Feraheme discontinued by manufacturer.

Isosorbide mononitrate (ISMN)

Available

Lithium Carbonate

150mg and 300mg Lithium Carbonate - available

Bulk powder is not listed in the catalogues for either Medisca or Xenex.

In general, when switching from IR lithium to SR, the total daily dose of lithium is the same. Lithmax given either BID or at HS can be used.
The CPhA Product Monograph states that: Once patients are stabilized on a maintenance dose, the dosage schedule may be changed to a once-daily regimen.
The Product Monograph for LITHMAX ( https://www.aapharma.ca/downloads/en/PIL/2016/Lithmax-PM.pdf) states that: Lithium carbonate sustained-release tablets should be swallowed whole or broken in half. They should not be chewed or crushed. N.B.: Blood samples for serum lithium determination should be drawn prior to the next dose and when lithium concentrations are relatively stable (i.e. 10 to 14 hours after the previous dose of lithium). Total reliance must not be placed on serum levels alone. Accurate patient evaluation requires both clinical assessment and laboratory analyses.

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.)

Misoprostol

100mg and 200mg AA Pharma brand available

Therapeutic alternatives: See PDF

Nabilone

TEVA brand FOR INFORMATION CALL 800-268-4127 
Cesamet  FOR INFORMATION CALL 800-361-4261
According to McKesson 
VALEANT - Cesamet  0.25mg, Cesamet 0.5mg currently available.
Cesamet 1mg indeterminate availability.


TEVA/ACT - Activis for INFORMATION CALL 800-268-4127 
Nabilone 0.25mg , Nabilone 0.5mg , Nabilone 1mg availability is intermittent.
Pharmascience (PMS) No availability date for either strength

Naproxen suppositories

All brands of naproxen suppositories are unavailable.

Therapeutic alternatives: See PDF.

NIfedipine XL (Adalat)

Adalat XL 20 mg tablets currently available.
Currently Adalat XL 30 mg and 60 mg tablets also available.
See document for information regarding switching to a different calcium channel blocker.

Nimodipine

Nimotop 30 mg tablets (BAY) under allocation; contact Bayer at 1-800-268-1432

Nitrofurantoin

MacroBID- available 
TEVA Macrocrystals 50mg and 100mg capsules  - available
AA Pharma nitrofurantoin 50mg and 100mg tablets - available

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 indeterminate availability.
See PDF for suggestions on therapeutic alternatives.

Opium and Belladonna Rectal Suppositories

Indeterminate availability

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

Oxybutynin

DitropanXL 5 and 10mg available.
Gelnique 10% oxybutynin gel and Oxytrol transdermal patches are available.
Oxybutynin 2.5mg PMS brand indeterminate availability according to McKesson
Oxybutynin 5mg tablets - all brands: Interrmittent and Indeterminate availability - check McKesson daily.

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 Kohl & Frisch, AmerisourceBergen, Procurity, uniPHARM.

Penicillin V

300mg tablets currently available.

Suspension 125mg/5ml and 300mg/5ml not currently available - resupply - no date for availability according to McKesson catalogue

Alternatives:
Grp A Strep throat : amoxicillin, amoxicillin-clavulanate, 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.

Therapeutic alternatives (see PDF for details):

  • Crotamiton 10 % cream (Eurax)
  • 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

Polysporin Pink Eye drops and Ear drops with lidocaine are available
Ophthalmic ointment d/c
Therapeutic alternatives:  RX alternatives: tobramycin, ciprofloxacin or erythromycin ophth ointment

Potassium Chloride (Slow-K)

Slow-K (NPN 80040226) 600 mg KCl (8 mEq K+) slow release matrix tablets have been discontinued. 

Alternative long acting tablets providing 8 mEq K+:
Euro-K600 (NPN 02246734) 600 mg long acting tablet
Apo-K (NPN 00602884) 600 mg long acting tablet
Jamp K-8 (NPN 80013005) 600 mg long acting tablet

Note
: These products contain the same strength of KCl in a similar dosage form to Slow-K and are the closest alternatives. However, the products are not interchangeable. If patient is near the high or low ends of the potassium reference range or if patient has a history of frequent fluctuations, closer monitoring after transition is prudent. 
Note: Inventory of the above products seems to fluctuate frequently.  

Alternative solid dosage forms providing 8 mEq K+:
Micro-K Extencaps (NPN 02042304)
Note: Micro-K contains the same strength of KCl in a different, yet still modified release, dosage form. If patient is near the high or low ends of the potassium reference range or if patient has a history of frequent fluctuations, closer monitoring after transition is prudent.

KCl Oral Solution providing 1.33 mEq/ml: 
PMS-Potassium Chloride (NPN 02238604 )
Note: Because the absorption pattern will be quite different between Slow-K and the liquid, closer monitoring of all patients after transition is prudent.

Alternative long acting tablets providing 20 mEq K+:
Euro-K20 (NPN 02242261)
Odan K-20 (NPN 80004415)
JAMP K-20 (NPN 80013007) 

Promethazine 50mg

Histanil 50mg tablets available
See PDF for injectable promethazine for alternatives

Propafenone

Apotex 150mg and 300mg available.
SANIS 150mg available October 12, 2018; 300mg available November 8, 2018.
Mylan 150mg currently available, 300 mg available October 13, 2018.
Rythmol (BGP) 150mg and 300mg available October 13, 2018.

In the likely event both fleicanide and propafenone are short, no blanket recommendation can be made.  Ideally consult cardiology; if unavailable, 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

Jamp Pharma Pyrantel Pamoate suspension 50mg/ml and 125mg tablets are available.
Combantrin suspension has been discontinued.
Combantrin 125 mg tablets available.
For patients unable to take tablets, the tablet can be crushed and mixed with a soft food immediately before administering. 
Vermox (mebendazole) 100mg by prescription available.
Ivermectin is not indicated for single agent treatment of pinworm and is only available through the Special Access Programme - https://www.canada.ca/en/health-canada/services/drugs-health-products/special-access/drugs.html
The physician must apply for the medication (on-line or if an emerg, by phone)

Ranitidine oral solution (15mg/ml)

Generics available
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

Sodium Phosphate effervescent tablets

Phosphate-Novartis - discontinued
Jamp-Sodium Phosphate 500mg - available
See PDF for alternatives.

Sotalol

Both 80mg and 160mg availalbe from various manufacturers.
Alternatives depend on the indication for which sotalol is being used.
See PDF for management suggestions.

Spironolactone

TEVA brand available.
Pfizer Aldactone 25mg and 100mg indeterminate availability
See updated PDF for more information on alternatives.

Sulfasalazine

Pfizer SALAZOPYRIN EN-TABS TB EC 500MG 100 available
PMS SULFASALAZINE EC TB 500MG 100 PMS available
Non-enteric tablets 500mg (PMS) -Indeterminate availability

Thyroid (dessicated)

Thyroid 125mg - available 
Thyroid 30mg -available
Thyroid 60mg - available

Valsartan

Various brands of valsartan have been recalled  by Health Canada.
Supply of valsartan only tablets seems limited, if available at all. Check with your wholesaler. Currently several brands of valsartan/HCTZ are available.
See document  for information about switching to a different ARB.

Trandolapril

Mavik 0.5mg, 1mg and 4mg available

Trifluridine

Viroptic ophthalmic solution 1%  For information call 800-361-4261. According to McKesson product will be available on November 8, 2018.
No other topical ophthalmic antivirals are currently available in Canada.
Viral conjunctivitis does not usually require treatment, however, cold compresses and ocular lubricants may be used.
If absolutely necessary - oral ttreatment can be tried. 
Reference: RxTx. https://www.e-therapeutics.ca/. CTC Red eye

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.

PDFs