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:

  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 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.
  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.  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 available -  Apotex and Teva brands (all strengths available).
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
See PDF for alternatives
Alfacalcidol 2 mcg/ml

2mg/ml 0.5 ml and 1ml amps - currently 1ml amps available 

  • Alternatives for use in hypocalcemia and osteodystrophy in patients with CKD on dialysis: 
    injectable calcitriol (0.5 mcg IV three times weekly); dose of alfacalcidol:calcitriol roughly 2:1
  • oral alfacalcidol capsules or drops 0.25 mcg to 3 mcg daily
  • oral calcitriol capsules 0.5 to 1 mcg daily
Amantadine

Amantadine capsules 100MG - Available
Amantadine Syrup 50MG/5ML 500ML - Available
See PDF for alternatives
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
See PDF for alternatives
Amoxicillin suspension Amoxicillin powder for suspenion: Teva brand has the earliest restock date listed in McKesson as April 3, 2020
Amoxicillin-Clavulanate

Generics and name brand Clavulin - currently all strengths available.

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.
See PDF for alternatives
ASA/Butalbital/Caffeine/Codeine (Fiorinal®)

All strengths available. 

Dependence and withdrawal can be severe. Medication overuse headache may occur.        See PDF for details 
Atenolol

Available in all strengths. 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. 
Benazepril

AA Pharma 5mg, 10mg, 20mg have indeterminate availability

Refer to ACE Inhibitors (CPhA Monograph) for alternatives and dosage ranges in RxTx (eCPS)
Bupropion

Wellbutrin XL available.
Bupropion SR formulations are available.

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 - 150 mg 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 SR150 mg once daily. Because of the shorter duration of action of the SR formulation, consider asking switching to SR 100 mg PO BID.

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
In the event of shortage of SR and XL formulations, see PDF.

Drug Availability
Cabergoline

Dostinex available.                                                                                                        Apotex and Teva Cabergoline available Jan-March, 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. 

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

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.

All nasal spray calcitonin products have been withdrawn and discontinued from the market due to a small increased rate of cancer (up to 2.4 %). DINs became inactive October 1st, 2013.
Carbamazepine

200mg IR Teva brand available.                                                                                          Tegretol available March 25, 2020 according to McKesson.                          Currently no date for availability for Taro brand.                            

Chewable tablets currently available.
If converting from IR to CR formulation, the total daily dose would remain the same but administered twice daily. Dosage adjustments should be individualized based on clinical response and, if necessary, plasma carbamazepine levels.

When switching to suspension the total daily dose would remain the same but given in 3 to 4 divided doses. The suspension is absorbed somewhat faster that the tablet formulation.

References:
Tegretol product monograph.https://pdf.hres.ca/dpd_pm/00045114.PDF
Lexicomp
Cefixime

Available.
Therapeutic alternatives: ceftriaxone IM, azithromycin PO
See PDF for details.
Chlorpromazine injectable

Sandoz, the sole supplier, has discontinued marketing injectable chlorpromazine in Canada.
Alternate formulations: oral tablets 25mg, 50mg and 100mg are available.

Therapeutic alternatives: See PDF.
Chlorthalidone

AA Pharma 50mg (single ingredient) available.
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 switch to the combination product (Tenoretic, generics)
Hydrochlorothiazide at equivalent dose for hypertension or edema.
See PDF for alternatives
Cisatracurium besylate injectable

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 injectable

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

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
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.
Clioquinol/flumethasone Locacorten Vioform Otic drops available.                                                                  Topical cream - available.                                                                                          Fungal otitis externa often responds to cleansing and acidification.                          For acidification, a solution may be prepared by diluting white vinegar with equal parts isopropyl alcohol or water.                                                                   Reference:Otitis externa. RxTx -e-therapeutics.ca.
Clobazam

Frisium (Lundbeck) is discontinued. Lundbeck’s Medical Information at 866‑880‑4636 for questions or concerns.
Apotex and Teva brands are 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 and Serophene - discontinued

Alternatives:
Compounded by compounding pharmacy or pharmacological alternatives.
See PDF for alternatives

Co-trimoxazole (sulfamethoxazole/

trimethoprim) oral 

Both DS and regular strength tablets available from either Teva or Apotex
Suspensions - no date for availability. FOR INFORMATION CALL 800-268-4127

Options:
Use other methods of administration.
Alternatives: A different antibiotic with a similar spectrum of activity.

Co-trimoxazole injectable

Septra IV currently 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.

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 - 200mg indeterminate availability according to McKesson
Cyclomen - 50mg currently available
See PDF for alternatives.                                         
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  Available

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
Dexamethasone

Maxidex 0.1% ophthalmic suspension currently unavailable. 

Maxidex 0.1% ophthlamic ointment currently available.

Dexamethasone 0.1% ophthlamic solution (DIN2023865) available, but not currently on SK Formulary.
Digoxin

Pendopharm 0.0625mg estimated end date March 1, 2020. (McKesson estimates March 20)                                                                                                                    Pendopharm 0.125mg estimated end date February 21, 2020.                                      Pendopharm solution estimated end date, March 28,2020 according to McKesson.      Pendopharm 0.25mg tablets in the process of being discontinued.                                 Sandoz injectable 0.25mg (10 x 2ml) available.       

See PDF for management strategies. 
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 - Available February 13, 2020 according to McKesson
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 listed as D/C
Auvi-Q 0.3 mg - currently listed as D/C
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:
  • 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 tablets https://www.e-therapeutics.ca/search
Reference:
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 February 26, 2020.   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.
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?
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 indeterminate availability according to McKesson.
Twinrix Jr. (360/10) 0.5ml prefilled syringe available February 6, 2020 according to McKesson.
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
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.
Locacorten Vioform See clioquinol/flumethasone
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.

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.
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.
Metformin

Currently product is available.

Some lots of Apotex and Ranbaxy have been recalled. See Health Canada advisory. 

In the event of shortage, see PDF for general information, resources to consult when treating patients with diabetes and options for treating patients with PCOS. 
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:
  • 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)Morphine sulfate if ischemic pain not adequately treated.
    • 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.
  • 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.
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):
  • 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.
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 currently available.                                          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 Currently not available through McKesson.                                       Contact Sandoz at 1-800-361-3062.
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
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.
Alternatives: See PDF for details
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.
Ropinirole

Ropinirole 0.25mg tablets Teva brand availalbe.

Higher strength tablets are not conducive to splitting. See PDF for management suggestions.  
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
Tamoxifen  Apotex brand 10mg and 20mg 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.