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 lead 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 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:
- 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.
- 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 prescriber, 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 Health Canada Drug Product Database for other dosage forms 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 prescriber, 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.
- As necessary, consult SPDP regarding coverage for substituted brand.
- 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
- If there is not a therapeutic equivalent, check treatment guidelines and recommend a drug from another pharmacologic class. Monitor and titrate to desired effect.
- e-therapeutics+
- RxFiles
- Others, e.g. Healthcare Network Clinical Guidelines, National Guideline Clearinghouse, etc.
- 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. Information 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 Drug Shortages Database Canada:
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 has 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.
Specific Drug Shortages
To check current availability status of Sandoz parenteral drugs go to the Sandoz website.
| Drug | Availability / Alternatives | ||||||||||||||||||||
| Acebutolol |
Currently acebutolol hydrochloride is not available except for Apotex and Teva brands (all strengths available), due to discontinuation of the production of the active ingredient. |
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| Acetazolamide |
AAPharma 250mg available. Alternatives: |
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| Alfacalcidol 2 mcg/ml |
2mg/ml 0.5 ml and 1ml amps - currently no inventory listed as available according to McKesson.
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| Amantadine |
Amantadine capsules 100MG - Available |
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| Amitriptyline |
All strengths of Elavil and all generic brands available. Alternatives: |
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| Amoxicillin-Clavulanate |
Generics and name brand Clavulin - currently all strengths available. Therapeutic alternatives: |
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| Ampicillin oral suspension |
No manufacturers are currently marketing oral ampicillin suspension. |
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| ASA/Butalbital/Caffeine/Codeine (Fiorinal®) |
All strengths available. Dependence and withdrawal can be severe. Medication overuse headache See PDF for details |
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| Atenolol |
Available in all strengths. See PDF for information on handling shortage. |
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| Atropine eye drops |
Minims Atropine Sulphate 1% 20 x 0.5ml (B & L) currently available. Alternatives:
Mydriatics, such as tropicamide and cyclopentolate, relax the iris sphincter which is innervated by the parasympathetic nervous system. |
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| Bupropion |
Wellbutrin XL available. |
| Drug | Availability |
| Cabergoline |
Dostinex available. Apotex and Teva Cabergoline available Jan/Feb, 2020 according to McKesson See PDF for details. |
| Calcitonin nasal spray | All nasal spray calcitonin products have been discontinued due to a small increased rate of cancer (up to 2.4 %). DINs became inactive October 1st, 2013. 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. Available July 7, 2019 according to McKesson. 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. |
| Calcitonin, Salmon, synthetic |
Calcimar 200U/ml (2ml) INJECTION available |
| Carbamazepine |
All dosage forms currently available |
| Cefixime |
Available. |
| Chlorpromazine injectable |
Sandoz, the sole supplier, has discontinued marketing injectable chlorpromazine in Canada. |
| Chlorthalidone |
AA Pharma 50mg (single ingredient) available. |
| Cisatracurium besylate injectable |
Cisatracurium besylate Injection 2mg/mL, multidose 10mL is now available on allocation from Omega Laboratories |
| Clindamycin injectable |
Sandoz FOR INFORMATION CALL 800-361-3062 and Pfizer (name brand) currently available. |
| Clindamycin palmitate granules for solution |
Dalacin C granules for solution 75mg/5ml available. |
| Clobazam |
Frisium (Lundbeck) is discontinued. Lundbeck’s Medical Information at 866‑880‑4636 for questions or concerns. |
| Clomiphene |
Clomid and Serophene - discontinued |
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Co-trimoxazole (sulfamethoxazole/ trimethoprim) oral |
Both DS and regular strength tablets available from either Teva or Apotex |
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Co-trimoxazole injectable |
Septra IV currently available. |
| Drug | Availability |
| Dacarbazine | Not available through McKesson. Restrictions: Existing dacarbazine stock only used to continue treatments that have already been initiated. See PDF for information of how to manage |
| Danazol |
Cyclomen - indeterminate availability 50mg available November 15, 2019 according to McKesson |
| Dantrolene | Dantrolene 25mg (Dantrium®) available. Options: Parenteral product is available (Dantrium Intravenous®). Extemporaneous compouding via bulk powder through Medisca is an option. See PDF for details for alternatives. |
| Daunorubicin | Cerubidine 20mg/4ml Indeterminate availability See PDF for information of how to manage. |
| 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 See PDF for alternatives |
| Diltiazem injectable | Sandoz formulations 5mg/ml 5 and 10ml size available |
| Diltiazem oral | Diltiazem CD, ER - all strengths available - manufacturers vary. Tiazac XC 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. See PDF. |
| Dimethyl sulfoxide | Rimso - currently available Xenex and Galenova DMSO currently available. See PDF for shortage management strategies. |
| Divalproex sodium | Available. Alternative if necessary: Substitute same strength valproic acid formulation. May be increased GI adverse effects - take with food. Monitor for continued control of seizures / mood. |
| 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). Therapeutic alternative: Norepinephrine See PDF for alternatives |
| 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. See PDF for management |
| Doxorubicin HCl, pegylated liposomal | Caelyx® 2mg/ml (10 ml) available See PDF for management |
| Drug | Availability |
| 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) available - however, supply is unstable Epipen Jr (0.15 mg) 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 - currently available. Auvi-Q 0.3 mg - currently available Epipen alternative - epinephrine anaphylaxis kits prepared in pharmacy. See PDF. |
| Erythromycin | Erythromycin Base 250mg tablets, Eryc 250mg and 333mg capsules (Erythromycin enteric coated delayed release pellets) Available Erythro S (stearate) 250 mg undeterminate availabilty. Ophthalmic ointment available Erythromycin IV is also available. Erythromycin Ethylsuccinate suspensions - Discontinued by manufacturers Compounding not recommended as cost-prohibitive, lack of formulas readily accessible and other options readily available. Other macrolides are available as liquid formulations i.e. azithromycin, clarithromycin. See PDF for alternatives |
| Fenofibrate | Fenofibrate Micronized Capsule 200mg (Apotex) currently available. The following fenofibrate formulations are considered to have equivalent bioavailability:
Fibric Acid Derivatives (CPhA Monograph) from https://www.e-therapeutics.ca/search |
| Fentanyl injectable | Sandoz 50mcg/ml currently available through McKesson. Procedural sedation -See PDF Chronic pain - fentanyl patch - do NOT use in opioid naïve pts Bulk powder - Currently unavailable. See Switching Opioids |
| Flecainide | Generics available in 50mg and 100mg. Name brand Tambocor - discontinued. In case of shortage, refer to proprafenone PDF. 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. |
| Fludarabine | Available December 12, 2019. See PDF for management |
| Fludricortisone |
Florinef 0.1mg currently available. In the event of a shortage see PDF |
| Fluphenazine decanoate | Both brand name (Modecate®) and generic products have been discontinued. See PDF for alternative antipsychotic depot injectables. |
| Folic acid injectable | ORAL: 5 mg tablets Available 5 mg IV = 5 mg PO ENTERAL: Dispersed tablets can be administered via enteral feeding tube. See PDF |
| Framycetin sulfate / Gramicidin / Dexamethasone | Sofracort Eye/Ear Drops - available. Proctosedyl ointment, Proctol and Proctosone ointment and suppositories - available. Soframycin Nasal Spray - available. Sofratulle bandage not available - listed as dormant on Health Canada Drug Product Database. 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. |
| Furosemide injectable |
Available.
Ethacrynic acid: 50 mg/vial (close to $500 acquisition cost per vial) Bumetanide: IV available through Special Access? |
| Gemfibrozil | Teva 600mg available. Apotex and Teva 300mg discontinued. Therapeutic alternatives: Fenofibrate, bezafibrate, statins, niacin, fish oil (See PDF for details). |
| Glycopyrrolate injectable | 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. |
| Drug | Availability |
| Haloperidol decanoate | Haloperidol 5mg/ml (10 x 1ml) available Haloperidol LA 100mg/ml (5ml) available. Alternative depot antipsychotic: aripiprazole, flupentixol, paliperidone, risperidone, zuclopenthixol See PDF |
| Hepatitis A (inactivated) and Hepatitis B (recombinant) vaccine (Twinrix®) | Twinrix (720/20) 1.0ml prefilled syringe currently available. Twinrix Jr. (360/10) 0.5ml prefilled syringe currently 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:
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| Herpes Zoster vaccine (non-live recombinant, AS01B adjuvanted) | Shingrix Currently available. For information call GSK 1-800-387-7374 Patients who have received the first Shingrix dose should wait until Shingrix is available again, regardless of how long the interval between doses is extended. Delaying the 2nd dose beyond 6 months following the first dose is not expected to reduce effectiveness of the vaccine series; in fact, the Canadian Immunization Guidelines propose providing the 2nd dose at 12 months may improve adherence. Zostavax II should not be used to substitute for the 2nd dose of Shingrix. If vaccination for herpes zoster is desired before Shingrix becomes available, Zostavax II can be used in those who have no contraindications. The Zostavax II series consists of only one dose; if Shingrix becomes available and is desired by a patient who received Zostavax II, a period of one year should elapse between the dose of Zostavax II and the first dose of Shingrix. |
| Hydromorphone injectable | 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. |
| Hyoscine butylbromide | Buscopan 10 mg tablets available. Sandoz hyoscine butylbromide injection available; much more expensive than oral tablets. Therapeutic alternatives: dicyclomine, pinaverium, trimebutine, peppermint oil. See PDF for alternatives |
| 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. |
| Isosorbide mononitrate (ISMN) | Available. See PDF for alternatives |
| Ketorolac injectable | Ketorolac 30 mg/ml - 25 x 1ml available Toradol 10mg/ml (5 x 1ml) available. If shortages occur, the following measures are suggested: - Use lowest effective dose - Step down to oral ketorolac or alternative NSAID as soon as therapeutically appropriate - Use oral analgesics e.g. ibuprofen, naproxen if patient is able to eat and drink - Use rectal analgesic or alternative parenteral analgesic if oral route not available - See PDF for alternatives |
| Drug | Availability |
| Liothyronine |
Cytomel 5ug and Cytomel 25ug - available. There are no single ingredient alternatives to liothyronine. For information call Pfizer at 1-800-387-4974 |
| Lithium carbonate | Available. 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. |
| Lorazepam injectable | 4mg/ml (10 x 1ml) available 2mg/ml (10 x 1ml) available See PDF for details on treatment alternatives. |
| Losartan | Teva-Losartan/HCTZ 50/12.5 mg has been recalled due to impurities. Various other brands have voluntarily recalled their product; check the Health Canada website for products affected. Currently only Hyzaar 50/12.5mg, 100/12mg and Hyzaar DS 100/25mg may have intermittent availability. Should all brands of losartan and/or losartan-hydrochlorothiazide become shorted, see PDF for information about switching to a different ARB |
| Medroxyprogesterone acetate |
All strengths available. |
| Misoprostol |
100mg and 200mg AA Pharma brand available
Therapeutic alternatives: See PDF. |
| Meperidine injectable | 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 injectable | Available 50mg/ml (10 x 1ml) Sandoz brand 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 injectable | 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 | Avelox I.V. available. Oral moxifloxacin may be suitable. See PDF for alternatives |
| 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. |
| 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 available - 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. |
| Naproxen suppositories | Discontinued. Therapeutic alternatives: See PDF for details. |
| Neostigmine methylsulfate | 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. |
| Nifedipine extended-release | Adalat XL 20 mg and 60mg tablets not currently available. Adalat XL 30mg currently available. Other brands indeterminate availability. See PDF for information regarding switching to a different calcium channel blocker. |
| Nitroglycerin injectable | Omega brand Nitroject 5MG/ML 5X10ML available Ischemia:
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| Nystatin | Available Alternatives: Refer to compounding pharmacy Therapeutic alternatives: fluconazole, gentian violet, clotrimazole. See PDF for alternatives |
| Ofloxacin ophthalmic solution | All brands of tablets discontinued Allergan Ocuflox 0.3% ophthalmic available 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. |
| Drug | Availability |
| Pantoprazole injectable | 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). |
| 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 available. Powder for suspension 125mg/5ml and 300mg/5ml discontinued. 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. See PDF for alternatives |
| Permethrin 5% cream and lotion | Kwellada-P Lotion 5% available. Nix 5% Cream available. Therapeutic alternatives (see PDF for details):
|
| Perphenazine | APO-Perphenazine 2, 4 and 8 mg tablets currently available. Therapeutic alternatives: See PDF. |
| Phentolamine mesylate injectable | Phentolamine mesylate 5mg/ml (10 x 1ml) SDZ available See PDF for information on therapeutic alternatives. |
| Phenytoin injectable | Sandoz and Sterimax brands 50mg/ml 2ml and 5ml sizes available. See PDF for alternatives |
| Phenytoin | All strengths of all oral dosage forms are available. Important - see PDF for instructions on switching. |
| 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) |
| Prednisolone Oral Solution |
Pediapred Oral solution 1mg/ml available October 19, 2019 according to McKesson. Prednisolone and prednisone are equivalent. That is, 5mg prednisolone is equivalent to 5mg prednisone, so an oral solution can be compounded using prednisone tablets. Be aware that many of the compounding recipes use a concentration of 5mg/ml whereas Pediapred is 5mg/5ml. |
| 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 oral | Histanil 50mg tablets available See PDF for injectable promethazine for alternatives |
| 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. |
| Propafenone | Generics available in both strengths 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. See PDF for alternatives |
| Propofol | Available Alternatives: Induction of anesthesia: See PDF for alternatives Procedural sedation: See PDF for alternatives |
| 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). |
| Drug | Availability |
| Ranitidine injectable | 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. |
| Ranitidine oral solution |
Generics available |
| Ranitidine tablets |
All strengths currently unavailable. Ranitidine, histamine H2-receptor antagonist (H2RA), contamination with N-nitrosodimethylamine (NDMA) has prompted a recall of both the 150mg and 300mg tablets. Testing methodology is being developed by Health Canada with ranitidine manufacturers to determine the extent of the problem, and whether additional H2RA products may be recalled. See PDF for alternatives. |
| Rocuronium | Currently available. See Nondepolarizing Neuromuscular Blocking Agents for more information. |
| Sodium Bicarbonate Injection 8.4% | Sodium Bicarbonate Syringe 8.4% 10 x 50ml available. Other sizes listed as under allocation. PRODUCT UNDER ALLOCATION. FOR QUESTIONS ON ALLOCATED QUANTITIES, PLEASE CONTACT PFIZER 1-800-267-2553 X4410 (Deborah King) allocation@pfizer.com Refer to PDF 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). |
| Sodium phosphate effervescent tablets | Phosphate-Novartis - discontinued Jamp-Sodium Phosphate 500mg - available See PDF for alternatives. |
| Sotalol | Both 80mg and 160mg available from various manufacturers. Alternatives depend on the indication for which sotalol is being used. See PDF for management suggestions. |
| Spironolactone | Available See PDF for alternatives. |
| Succinylcholine |
Teligent brand Available on December 24, 2019 according to McKesson. Alternatives: rocuronium - see Nondepolarizing Neuromuscular Blocking Agents. |
| Sulfasalazine | Available. See PDF for alternatives |
| Testosterone injectable | 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). |
| Thyroid (dessicated) | Thyroid 125mg - availability dates vary Thyroid 30mg - availability dates vary Thyroid 60mg - availability dates vary |
| Thyrotropin alpha | Thyrogen 0.9mg/ml Kit available. See PFD for management |
| Tirofiban 0.05mg/ml | Aggrastat - MANUFACTURER CANNOT SUPPLY FOR INFORMATION CALL 610-833-6050. |
| Trifluridine | Viroptic ophthalmic solution 1% For information call 800-361-4261.Indeterminate availability. 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 treatment can be tried. Reference: RxTx. https://www.e-therapeutics.ca/. CTC Red eye. |
| 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 PDF for information about switching to a different ARB. |
| Venlafaxine | Available. in the event of a shortage: If the 37.5mg strength is being used in addition to other strengths (e.g. for a total daily dose of 112.5 mg), consider increasing or decreasing to the next available dose (e.g. 75 mg or 150 mg) based on patient history with higher/lower doses regarding effectiveness and tolerability as well as current clinical situation. See PDF for more details or options should all strengths of venlafaxine become unavailable. |
| Verapamil oral | 80mg and 120mg strengths currently available. Other strengths - indeterminate availability. 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. See PDF. |
| Vitamin B 12 injectable | 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. See PDF for alternative dosage forms |
| Vitamin K injectable | 10mg/ml - 10x1ml, 1.0mg/0.5ml - 10 x 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 See PDF from Saskatchewan Health Authority. |