Drug Shortages and Discontinuations

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Drug shortages can occur for a variety of reasons and may include, but are not limited to, shortages of raw materials, quality control issues which lead to voluntary withdrawal and longer production times for some products, and competition among drug manufacturers. For more details see the Multi-Stakeholder Toolkit (last revised 2017).

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. Confirm that the drug is shorted. For certain drugs, manufacturers are required by law to report anticipated and actual drug shortages and discontinuations. These reports are available and searchable at www.drugshortages.ca.

  2. 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.

  3. 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 the 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 prescriber, start at appropriate dose, titrate to desired effect (especially if narrow therapeutic index), and monitor for therapeutic 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 the Health Canada Drug Product Database for other dosage forms that may be available and proceed as above.
    • As necessary, consult SPDP regarding coverage for substituted product.

  4. 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.
    • RxFiles Charts (available at SHIRP)
    • CPS (available at SHIRP)

  5. If there is not a therapeutic equivalent, check treatment guidelines and recommend a drug from another pharmacologic class. Monitor and titrate to desired effect.
  6. Compound products when no commercial agents are available.

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.

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 & Discontinuations

 
Drug Availability / Alternatives
Acenocoumarol

Sintrom® 1mg and 4mg tablets have been discontinued.

Acenocoumarol is approximately twice as potent as warfarin.  See CPS (subscription). Available through SHIRP      

Acetaminophen Pediatric

Pediatric doses of acetaminophen have been on shortage with intermittent availability in various dosage forms (e.g., liquid, chewable and suppositories)


Options to Address the Shortage

  • discourage panic-buying by reassuring the public that other products are available to meet their needs and consider limiting quantities sold
  • recommend alternative brands (e.g., Tempra) or dosage forms (e.g., chewables, tablets). Counsel on the appropriate dose as the product may not provide an appropriate dose on the label
  • repackage larger stock bottles of acetaminophen. All sales of repackaged acetaminophen must be patient-specific to be exempt from DEL requirements.   In addition to the labelling requirements for patient-specific medication (e.g. prescriptions, see section 13 of Part J), the repackaged acetaminophen must also include:
    • Patient-specific directions for use (i.e., weight-adjusted dose)
    • Lot#
    • Drug Expiry Date
    Pharmacies must not:
    • repackage acetaminophen in bulk, and/or
    • make them available for patient self-selection.
  • use compounded acetaminophen if no commercial product is available, which can be prescribed by pharmacists during this shortage.
    • See medSask's Acetaminophen Shortage page for background, prescribing (including PAR) and dispensing information as well as information for the general public
    • Medisca supplies formulae using tablets and powder
Last updated: Nov 30/22
Adefovir

Adefovir 10mg tablets are shorting with estimated availability of Nov/23

For alternatives see RxFiles Hepatitis B Drug Therapy. RxFiles is available through SHIRP 

Last updated: Nov 28/22

Amoxicillin oral suspension

All brands/strengths of amoxicillin suspension and chewable amoxicillin tablets are shorting.  Earliest availability: early Jan/23.

Alternatives:

  • Viral infections are common and antibiotic therapy is inappropriate to treat these infections. Before selecting an alternative for amoxicillin, ensure antibiotic therapy is necessary. Infections for which antibiotics are inappropriate include bronchitis, viral pharyngitis, COVID-19, and others. RxFiles has prescriptions for viral infections for children and adults, which validate their symptoms, explain why antibiotics are inappropriate, and provide management strategies. 

  • For therapeutic alternatives see medSask/CPhA shortage document (updated Nov 2022)
  • Medisca supplies a compounding formula using capsules
  • See our tips on how to administer adult formulations or opened capsule contents to children
Last updated: Nov 29/22
Amoxicillin/clavulanic acid oral suspension

Amoxi-clav suspension is on short although some strengths sporatically available. Estimated availability: end of Nov/22

Medisca supplies a compounding formula

For alternative antibiotic options see indication in Bugs & Drugs

Last updated: Nov 28/22

Atropine ophthalmic drops

All brands of atropine 1% ophthalmic drops are shorting. Estimated availability mid Jan/23

Alternatives:

  • Other mydriatic eye drops are available: cyclopentolate, tropicamide, phenylephrine
  • For excess respiratory secretions see RxFiles:Palliative Care Symptom Management (subscription). RxFiles is available through SHIRP

Last updated: Nov 30/22

Auralgan Otic Drops (antipyrine 5.4% & benzocaine 1.4%)

Auralgan Otic drops have been discontinued by the manufacturer.

Possible alternative: Polysporin® Plus Pain Relief Ear Drops. These contain lidocaine 50 mg/mL & polymyxin B sulfate 10 000 IU/mL.

Last updated: Jul 27/22

Azithromycin oral suspension

All brands of azithromycin suspension are shorting. Earliest availabiiity: mid Dec/22

  • Medisca provides compounding formulae
  • For alternative antibiotic options see indication in Bugs & Drugs
  • no evidence that the tablets can't be crushed
  • See our tips for administration of adult tablets (whole or crushed) to children

Last updated: Nov 29/22

Betamethasone sodium phosphate enema

Betnesol® enema has been discontinued

Alternative:

  • Entocort®  (budesonide) enema
Budesonide nebules

All brands and strengths of budesonide for nebulization are shorting.  Earliest estimated availability: mid Dec/22

Alternatives:

Last updated Nov 28/22
Buprenorphine Implant

Probuphine® 80mg implant is to be discontinued when current inventory has been depleted -  anticipated to be May 2023.

Information from manufacturer: The reason for discontinuation is due to the inability to successfully acquire continued supply and is unrelated to any safety concerns.

Last updated: Oct 7/22

Bupropion

XL formulations shorted - some brands sporadically available.

Convert to different formulations using same total daily dose (up to the maximum recommended dose for a given dosage form), but adjust frequency as indicated:

12-hour sustained release (SR) = once or twice daily depending on dose; twice daily for doses >150mg/day 

24-hour extended release (XL) = once daily

  • For patients taking 150 mg daily, consider reducing the daily dose to 100 mg SR once daily, switching to 150 mg SR once daily, or switching to 150 mg XL once daily, depending on product availability.

See PDF for more details of switching and potential therapeutic alternatives. 

Drug Availability
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.

Cefprozil oral suspension

All brands/strengths shorting although some products sporatically available. . Earliest estimated availability: end of Dec/22

Alternatives:

  • 250 & 500mg tablets available 
  • no evidence that the tablets can't be crushed
  • See our tips for administration of adult tablets (whole or crushed) to children
  • Medisca supplies a formula for an oral suspension
  • For alternative antibiotic options see indication in Bugs & Drugs
Last updated: Nov 28/22
Cefuroxime oral suspension

Ceftin® suspension is shorting. Estimated availability: Apr/23

Alternatives:

  • 250mg & 500mg tablets are still available
  • crushing not recommended due to extremely bitter taste, however, crushed tablets have been found to be compatible with apple, grape & orange juice as well as chocolate milk
  • see our tips for administration of adult tablets (whole & crushed) to children
  • For alternative antibiotic options see indication in Bugs & Drugs
Last updated: Dec 6/22
Ciclesonide nasal spray

Omnaris® is on short. Estimated availability: Dec 5/22

For alternatives see RxFiles (subscription) Intranasal Corticosteroids. RxFiles is available through SHIRP

Last updated Nov 21/22

Ciclopirox topical cream

Loprox® Cream and Lotion are shorting. Estimated availability: mid Dec/22

For alternatives see RxFiles(subscription) Antifungal Treatment Chart.  RxFiles is available through SHIRP.

Last updated: Nov 28/22
Clarithromycin oral suspension

Biaxin® suspension now available

All brands/strengths of clarithromycin suspension are shorting.  Earliest availability: end of Dec/22

Medisca supplies a compounding formula

For alternative antibiotic options see indication in Bugs & Drugs

Last updated: Nov 28/22

Clomiphene

Clomid® and Serophene® - discontinued

Alternatives:
Compounded by compounding pharmacy or pharmacological alternatives - see PDF

Codeine oral tablets,immediate release

Codeine 15 & 30mg and Lenoltec #2 tablets are shorting. Estimated availability: mid-Dec/22

Alternatives:

  • Codeine 5mg/ml syrup
  • Acetaminophen/Caffeine/Codeine 8mg tablets
  • Acetaminophen/Codeine 30mg tablets 
Last updated: Nov 28/22
Codeine oral tablets, controlled release

Codeine Contin® 50mg & 200mg tablets shorting. Estimated availability: mid Dec/22

Alternatives:

  • Codeine Contin® 100 & 150mg tablets 
  • Morphine, hydromorphone and oxycodone come in long-acting formulations.  For opioid equivalencies and information on switching see Opioid Manager
Last updated: Nov 28/22

Codeine (combination) syrup

All combination codeine/cough/cold medication products (eg Calmylin, Cotridin) are shorting.  The earliest availability is for Damylin with codeine syrup (codeine/diphenhydramine/ammonium) -  end of Dec/22 

Alternatives:

  • Supply each active component separately. Codeine 5mg/ml Syrup is available
Last updated: Nov 28/22
Colestipol

Colestid® granules are shorted. No date given for availability. 

Alternatives: 

Last updated: Sep 30/22

Contraceptives (Oral)

For discontinued products refer to SK Formulary, for similar ingredients or RxFiles Oral Hormonal Contraception: Supplementary Tables, for similar hormonal activity.

Corticosteroids - Ophthalmic

Many ophthalmic corticosteroid products are currently unavailable - see specific listings.  As of Nov 21/22 these products are in stock:

  • Lotemax® (loteprednol 0.5%)  drops, gel and ointment
  • Alrex® (loteprednol 0.2%) drops
  • Minims prednisolone 0.5% drops - 20 x 0.5ml
  • Maxidex® (dexamethasone 0.1%) ointment

Approximate equivalencies:

  • Low-mid potency -  prednisolone 0.12%, prednisolone 0.5%
  • Mid-high potency - fluorometholone 0.1%, dexamethasone 0.1%, loteprednol 0.2%
  • Higher potency -  loteprednol 0.5% gel,oint, prednisolone 1% , difluprednate

Note that some antibiotic/corticosteroid combination products are available.

For more information on ophthalmic corticosteroid products and alternatives, see CPS - Dry Eye Table 7: Ophthalmic Anti-inflammatories for Red Eye and Cataract Surgery Postoperative Care. CPS is available through SHIRP.

Updated Nov 21/22

Co-trimoxazole (sulfamethoxazole/trimethoprim) oral 

The AA brand of the DS, regular and pediatric tablets are available
Suspension - no date for availability. 
See PDF for management options 

Drug Availability
Difluprednate

Durezol® ophthalmic drops are shorted - indeterminate availability. No other brands are manufactured.

For alternatives see CPS (subscription): Dry Eye Table 7: Ophthalmic Anti-inflammatories for Red Eye. CPS is available through SHIRP.

also, see Corticosteroids - Ophthalmic above for more information

Last updated: Nov 4/22

Dimenhydrinate 

All children's formulations have been shorting (liquid, chewable tablets, suppositories). Earliest availability: mid-late Dec/22

Alternatives:

  • Adult tablets are scored and can be split into halves and quarters
    • Dosing:
      • Children 2-6 yrs: 15-25mg po every 6 to 8 hours prn
      • Children 6-12 yrs: 25-50mg po every 6 to 8 hours prn
  • Liquid and suppositories can be compounded - no formula available
  • See our tips for administration of adult tablets (whole or crushed) to children
  • Diphenhydramine liquid:
    • Dimenhydrinate consists of 2 drugs: diphenhydramine and 8-chlorotheophylline and must be metabolized to its active ingredient, diphenhydramine.
    • Although not recommended for use in children < 6 yrs of age, diphenhydramine could be considered in consultation with physician.
    • Dosing for motion sickness prophylaxis: 
      • Children - 0.5 to 1 mg/kg/dose po every 6 hour. Usual dose - 12.5 to 25 mg/dose; maximum dose: 25 mg/dose
  • Optimize non-pharmacologic measures.  For details on these and for other alternative pharmacological treatments see CPS - Nausea and Vomiting. CPS is available through SHIRP.
Last updated Nov 23/22
Dipyridamole/ASA 200/25mg capsule

Taro-Dipyridamole/ASA 200/25mg capsules are shorting. Estimated availability Feb/23

For alternatives see PDF

Last updated Dec 5/22

Dorzolamide ophthalmic drops

Trusopt® regular drops are now in stock

All brands of regular dorzolamide 2% ophthalmic drops are shorting. Earliest estimated availability: mid Dec/22

Trusopt® Preservative Free 2% drops also shorting with availability of Mar/23

Alternatives:

  • combination dorzolamide/timolol drops (regular and PF) remain available
  • also, see Glaucoma Agents, Topical below for therapeutic alternatives
Last updated: Dec 5/22
Drug Availability
Erythromycin base oral tab/cap

AA-Erythro 250mg has been discontinued

Eryc 333 mg is shorting with indeterminate availability.

Alternatives:

  • compounded product - no formula available
  • see Bugs & Drugs for therapeutic alternatives
Last updated: Nov 21/22
Estrogens (conjugated) /bazedoxifene acetate

Duavive® - Currently on backorder. Indeterminate availability.

Indication: Treatment of vasomotor symptoms associated with menopause.

Alternatives: Estrogen + progestin

Last updated Aug 29/22

Estradiol transdermal patch

Climara® 25 patches are shorted. Estimated availability: Dec 22/22

Oesclim® 25 patches are shorted. No restock date given.

Alternatives:

  • Estradot® 25 is available however, they are NOT considered interchangeable with Climara® or Oesclim® 
  • Climara® and Oesclim® 50 mcg patches are still in stock
  • Cutting transdermal patches is not recommended.  However, all patches mentioned here are matrix patches and if NO OTHER OPTIONS, there is limited data indicating cutting matrix patches is safe
Last updated: Dec 5/22
Exenatide Injection

Byetta® 1.2 & 2.4 ml prefilled pens and Bydureon® injection have been discontinued by the manufacturer. No other forms or brands of exenatide are available.

For GLP-1 receptor agonist alternatives see CPS (subscription): Diabetes Mellitus. CPS is available through SHIRP.

Fluorometholone ophthalmic drops

All brands of fluorometholone 0.1% drops are shorting. Estimated restock date: Jan/23

For alternatives see CPS (subscription): Dry Eye Table 7: Ophthalmic Anti-inflammatories for Red Eye. CPS is available through SHIRP.

also, see Corticosteroids - Ophthalmic, above, for more information

Last updated: Nov 15/22

Fluphenazine decanoate injection

Oral dosage forms available.

Both brand name (Modecate®) and generic products have been discontinued.
See PDF for alternative antipsychotic depot injectables.

Fluzone® High-Dose Quadrivalent

See Influenza High-Dose vaccine, below

Formula, Infant

Some specialty infant formulas have been shorted due to temporary closure of Abbott Nutrition’s U.S. based facility earlier this year. Health Canada has issued an interim policy which allows for importation and sale of infant formula from other countries. Supply has stabilized and the shortage has largely subsided. However, supply is still limited and imported product remains an important strategy.

CPhA has comprehensive information available at: Information for Pharmacy Professionals.

Types of Formulas
  • Regular infant formulas contain intact proteins or partially hydrolyzed proteins (for babies with intolerances and gastrointestinal discomfort). There is currently no shortage of regular infant formula in Canada. These types of formula are still found on shelves in retail stores and pharmacies.
  • Hypoallergenic infant formulas contain extensively hydrolyzed proteins (for mild allergies) or are amino acid-based (for severe or multiple allergies). These are the formulas affected by the shortage. 
Labelling and Placement 
  • As of late October 2022, some extensively hydrolyzed formulas may be returned to pharmacy shelves, at the discretion of the manufacturer.
    • Only products with bilingual labels may return to pharmacy shelves. Products without bilingual labelling will continue to need to be kept behind the pharmacy counter.  
  • Amino acid-based formulas need to continue to stay behind the pharmacy counter as per usual practice.
  • Reserve product kept behind the pharmacy counter for infants with a clear medical indication and order only upon request. Pharmacies can consider including signage on the shelves to redirect families to the pharmacy counter for ordering hypoallergenic formula. Hospital stocks should not be used as they need to be protected for babies that were hospitalized because they found no other options.
  • Pharmacies need to provide additional labelling information when the imported products are sold. Labelling information is available in Appendix A of the Health Canada interim policy or in some of the product information sheets below.
  • See list of distributors of Canadian supply of extensively hydrolyzed products and amino acid-based products as well as ordering imported supply.
 Resources
Last Updated

26 Oct 2022

Glaucoma Agents, Topical

  • Intermittent shortages of various topical products for primary open-angle glaucoma have been occurring in Canada.
  • RxFiles (Topical Ophthalmics for Primary Open Angle Glaucoma), CPS (Glaucoma), and other resources are available through SHIRP to help determine best therapeutic alternatives if the patient’s current agent is not available.
  • While several different products are available, options are limited for patients who are sensitive to the preservative benzalkonium chloride (BAK).
    • For those who are sensitive to BAK:
      • If BAK can be tolerated at all:
        • consider use of a product with a lower concentration  
        • when > 1 agent is required, use a combination product when available to reduce overall exposure to BAK
      • When possible, choose a preservative-free product (few exist) or a product with an alternate preservative.
      • This table lists the agents available in Canada and indicates the preservative contained in each.

Gramicidin 0.025 mg/mL/polymyxin B sulfate 10 000 units/mL (Optimyxin)

Optimyxin eye and ear drops shorted. Estimated availability: mid Jan/23

Alternatives: Polysporin® drops 

Last updated: Nov 21/22


Drug Availability
Haloperidol tablets

All strengths of haloperidol tablets are shorted.  Estimated availability: mid-March/23 

Alternatives:

  • For alternative antipsychotic options see CPS (Schizophrenia and Related Psychotic Disorders) and
    RxFiles  (Schizophrenia: Antipsychotics). CPS and RxFiles are subscription resources available through SHIRP.
Last updated: Nov 15/22
Haloperidol LA injection

Haloperidol LA Inj 100mg/ml is on allocation.  

Contact Sandoz at 1-800-361-3062 for more information.

See PDF for alternative antipsychotic depot injectables.

Last updated: Sep 21/22

Hepatitis A/B Pediatric Vaccine - Twinrix® Jr 

Twinrix® Jr shorting. Estimated availability: end of December/22

Alternatives:

  • Adult strength Twinrix® remains in stock. For ages 1-15 years, there is an alternative dosing recommendation using the adult Twinrix®two doses of Twinrix® (720/20)/1 mL - the first administered at the elected date and the second between six and twelve months after the first dose.
  • Check for previous doses of HA and/or HB received (e.g. school immunization programs [HB], previous travel [HA and/or HB], residents of northern SK or reserves [HA]).
  • Pediatric formulations of vaccine supplying HA & HB separately are available
  • This document discusses delayed doses, use of alternate product, and more.
Last updated Dec 6/22
Hydrocortisone enema

Cortenema® has been discontinued.

Alternative: 

  • Entocort®  (budesonide) enema
Hydrocortisone sodium succinate (Solu-Cortef®)

A shortage has been reported of the Solu-Cortef® 250 mg vial size. Estimated availability date is Jan 9/23. Other vial sizes are availble. 

Conservation strategies and information regarding treatment and prevention of acute adrenal insufficiency are available in this document. (French)

Hydrocortisone 1%/ Pramoxine 1% rectal foam (Proctofoam-HC®)

Proctofoam-HC® is being shorted - no availability date given.

Alternatives:

Last updated: Aug 5/22
Hydroxyzine capsules

AA & Teva brands of hydroxyzine 10mg capsules are on long-term short. Estimated availability date: Feb/23.

Atarax® syrup is also shorting with indeterminate availability.

Alternatives:

  • The 25mg & 50mg capsules remain available.
Last updated: Nov 30/22
Ibuprofen, pediatric

Pediatric formulations of ibuprofen have been on shortage with intermittent availability.

See medSask's Acetaminophen and Ibuprofen Shortage page for background, prescribing (including PAR) and dispensing information - as well as information for the general public.

For compounding formulae see Medisca's Potential Shortage Support page.

Last updated: Nov 30/22

Indacaterol Breezhaler®

Onbrez® Breezhaler® has been discontinued by the manufacturer. There are no other products containing indacaterol alone.

Alternatives:

  • There are inhalation products containing indacaterol in combination:
    • Atectura® Breezhaler® - indacaterol & mometasone
    • Ultibro® Breezhaler® - indacaterol & glycopyrronium
    • Enerzair® Breezhaler® - indacaterol, mometasone & glycopyrronium
  • for LABA alternatives, see RxFiles COPD Drug Comparison chart. RxFiles is available through SHIRP
Infant Formula

See "Formula, Infant"

Influenza High-Dose vaccine (Fluzone® High-Dose Quadrivalent)

Some wholesalers have been showing shortages of Fluzone® High-Dose Quadrivalent vaccine.

Communication from the DPEB Immunizations Team Nov 10/22:

Supply of funded High Dose Fluzone has been depleted at some distribution centers. An additional order has been placed with the manufacturer and is expected to be available for pharmacy order next week.

Pharmacies are permitted to arrange for supply to be transferred to other pharmacies, ensuring the cold chain is maintained and transfer details (i.e. vaccine type, # of doses, pharmacy sending and pharmacy receiving inventory) are emailed to dpebimmunizations@health.gov.sk.ca.

Patients requesting High Dose Fluzone may be referred to another pharmacy that has supply or a public health clinic. Afluria is also a viable options for patients age 65+ that would like to receive influenza vaccine when High Dose Fluzone is not available.

If you have any questions please contact dpebimmunizations@health.gov.sk.ca.

Last updated: Nov 15/22

Iron dextran injection

Dexiron has been discontinued

For alternatives see PDF

Drug Availability
Levofloxacin tablet

All strengths of levofloxacin tablets are shorting. Estimated availability: End of Dec/22

For therapeutic alternatives see Bugs & Drugs

Last updated: Nov 21/22
Linezolid oral suspension

Zyvoxam® 100mg/5ml oral suspension is shorting with estimated availability: end of Dec/22

Alternatives:

  • A 600mg tablet is available and can be used to compound a suspension. See formula here
  • Alternate antibiotic options can be found at Bugs & Drugs
Last updated: Nov 30/22
Methocarbamol

A number of "Robax" products are shorted:

Robaxin® 500mg - no date given

Robaxacet® 8  - estimated availability end of Dec/22

Alternatives:

  • Other Robax products are available e.g., Robaxin® 750mg; Robaxacet®; Robaxacet® Extra Strength; Robax® Platinum; Robaxisal® C 1/4 & C 1/2
  • For other muscle relaxants see RxFiles (subscription) LOW BACK PAIN – PHARMACOLOGICAL TREATMENT. RxFiles is available through SHIRP.
Last updated: Nov 21/22
Methotrimeprazine Injection

Nozinan 25mg/ml Injection is shorted - estimated return to stock: Dec 15/22

Alternatives:

  • Tablets are available in all strengths
  • Injectable alternatives: See PDF
Last updated: Aug 31/22
Methylphenidate, Long Acting

Biphentin®, Foquest®, generic methylphenidate ER- intermittent shortages of some strengths.

Alternatives:

  • Some strengths of the formulations may be available.
  • Concerta® is available but is NOT interchangeable with the generic methylphenidate ER.
  • Note that Biphentin®, Foquest® and Concerta® are not interchangeable.

Ritalin® SR and Sandoz-methylphenidate SR tablets have been discontinued.  Apo-methylphenidate SR 20mg is still marketed. 

Last updated: Oct 14/22

Minoxidil tablets

Loniten® 2.5mg & 10 mg tablets are shorted with indeterminate availability.

No other brands manufactured.

Alternative:

  • minoxidil powder is stocked by McKesson therefore potential for compounding
Last updated: Oct 7/22
Nitrofurantoin macrocrystal 50mg capsules

Teva-nitrofurantoin macrocrystal 50mg capsules are shorting with no return to stock date. No other brands manufactured.

Alternatives:

  • Teva-nitrofurantoin macrocrystal 100mg capsules available.
  • PMS-nitrofurantoin BID (generic for Macrobid®) available.  This is a nitrofurantoin monohydrate/macrocrystals mixture which provides release of nitrofurantoin over a longer period of time and is dosed twice daily.
  • AA-nitrofurantoin 50mg and 100mg tablets. 
    • Nitrofurantoin macrocrystals are a larger crystal form of nitrofurantoin. The absorption of the macrocrystals is slower and its excretion somewhat less when compared to regular nitrofurantoin.
    • The 50mg tablets can be used in place of the macrocrystal 50mg capsules (particularly for UTI prophylaxis) but monitor for loss of efficacy or treatment failure. The same dosing schedule is used.
Last updated: Nov 30/22
Ofloxacin ophthalmic drops

Ocuflox® ophthalmic drops are shorting - indeterminate availability.  No other brands manufactured.

Alternatives:

  • See CPS (subscription) Conjunctivitis for ophthalmic antibiotics. CPS is available through SHIRP.
Last updated: Sep 23/22
Olanzapine IM 10mg

Zyprexa® IntraMuscular injection 10mg/vial is shorting although may be sporatically available. Estimated shortage resolution: end of Jan/23. Call Lilly Customer Response Centre at 1-888-545-5972 for more information.

For therapeutic alternatives see RxFiles (subscription) - Antipsychotics: Oral & Short-Acting Injections. RxFiles is available through SHIRP.

Last updated: Nov 16/22

Oseltamivir

Sporatic availability of all strengths of oseltamivir.

Alternatives:

  • Relenza® (zanamir) is indicated for the treatment and prophylaxis of uncomplicated influenza.
    • Treatment ≥7 years of age: 2 inhalations (10 mg) BID x 5 days
    • Prophylaxis ≥7 years of age: 2 inhalations (10 mg) daily for 7-10 days
    • Note that Relenza® is not indicated for children < 7 years of age 
    • No renal dosing adjustment necessary
Last updated: Nov 30/22
Oxybutynin XL tablets

Ditropan XL® 5mg & 10mg tablets have been discontinued. 

There are no other brands of long-acting oxybutynin tablets.

Alternatives:

  • generic 2.5mg & 5mg immediate release tablets and 1mg/ml syrup
  • Oxytrol® transdermal system
Last updated: Sep 16/22

Drug Availability
Phenytoin Chewable tablets

Dilantin® Infatabs 50mg are shorting. Estimated availability: end of Dec/22

Alternatives

  • The 125mg/5ml suspension is in stock
  • The 30mg and 100mg capsules are available.
  • **Note that the Infatabs and suspension contain phenytoin free acid. Phenytoin capsules contain phenytoin sodium.**
    • Therefore, each 50 mg Dilantin® Infatab contains 50 mg phenytoin; each 5 ml of oral 125 suspension contains 125 mg phenytoin but each 100 mg phenytoin capsule contains  only 92 mg phenytoin and each 30 mg phenytoin capsule contains 27.4 mg phenytoin. 
    • The capsules are extended release and may be dosed anywhere from one to four times daily; the Infatabs and oral suspensions need to be dosed three times daily in adults and may be dosed two to three times daily in children. Once daily dosing is not appropriate for the Infatabs or suspension.
Last updated Dec 5/22
Pneumococcal conjugate vaccine -13 (Prevnar 13™)

October 3, 2022 Update: Pfizer has now made Prevnar-13 pre-filled syringes available to pharmacy wholesalers.  Availability may be limited. 

Previously, communication from Pfizer suggested that Prevnar-13™ would only be available to government agencies (eg Public Health) for administration and that community pharmacies would only have access to the newly approved Prevnar 20™ although there is no guidance from NACI, Health Canada or SHA on use.  See the product monograph for indications and dosage. 

For CDC recommendations on Prevnar 20™ use see Pneumococcal Vaccine Recommendations | CDC

Last updated: Oct 7/22

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+:

  •    Jamp K-8 (NPN 80013005) 600 mg long acting tablet;
  •    Sandoz K-8 (NPN 02247834) 600mg 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+:
  • Jamp Potassium Cl ER 600mg capsules (NPN 80062704)
  • Micro-K® Extencaps (NPN 02042304)

       Note: These capsules contain 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.

Alternative liquid providing 1.33mEq/ml KCl+:

  • Odan-Potassium Chloride (NPN 80046782 )
  • Jamp KCl liquid (NPN 80024835)
    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+:
  • Sandoz K-20 (NPN 02242261)
  • Odan K-20 (NPN 80004415)
  • JAMP K-20 (NPN 80013007)
Prednicarbate 0.1% ointment

Dermatop® 0.1% ointment is shorted - indeterminate availability.

Alternatives: the 0.1% cream is still available

Last updated: Oct 7/22

Prednisolone ophthalmic drops

All brands of the 1% ophthalmic drops are shorting. Earliest return to stock: end of Nov/22

Alternatives:

  • Minims prednisolone 0.5% drops 20 X 0.5 ml remain available.
  • also, see Corticosteroids - Ophthalmic above for more information
Updated Nov 4/22
Prochlorperazine injectable

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

Last updated: Sep 21/22

Proctofoam-HC® see Hydrocortisone 1%/ Pramoxine 1% rectal foam
Promethazine injectable Injectable formulation has been discontinued by manufacturer
Alternate forms: 50 mg oral tablets available. For information call 1-866-926-7653
Bulk chemical listed in Medisca catalogue.
Therapeutic alternatives: See PDF.
Propranolol immediate release tablet

Propranolol 10, 20 & 40mg tablets shorting with estimated availability: beginning of Dec/22

Alternatives:

  • The 80mg tablets are still in stock.  They are film-coated and splitting is possible.
  • For therapeutic alternatives, see the medSask/CPhA Inderal®-LA shortage document
Last updated: Nov 15/22
Propranolol long-acting capsule

All strengths of Inderal®-LA have been discontinued by the manufacturer. 

No alternative brands available in Canada.

Consider switching to immediate release propranolol, another beta blocker, or another therapeutic option. See RxFiles or CPS for appropriate alternatives. Both subscription only but available through SHIRP.

See the medSask/CPhA Inderal®-LA shortage document for guidance on how to switch to immediate-release propranolol, other beta-blockers, or therapeutic alternatives.

Last updated: Jul 22/22

Pyrantel pamoate suspension

Jamp Pharma Pyrantel Pamoate suspension 50mg/ml is shorted.  Estimated availability: end of Nov/22
Combantrin® suspension has been discontinued.

Alternatives:
  • Combantrin® 125 mg tablets available. Jamp brand 125mg tablets available.
  • For patients unable to swallow tablets, the tablet can be crushed and mixed with a soft food immediately before administering.
  • Vermox® (mebendazole) 100mg by prescription is available.
  • Albendazole is available only through Health Canada’s Special Access Program (SAP).
Last updated Nov 15/22
Drug Availability
Quinagolide

Quinagolide (Norprolac®) has been discontinued.

For alternatives see PDF

Quinine

All strengths and brands of quinine capsules are shorting. Estimated return to stock:end of Dec/22.

Alternatives:

Last updated: Nov 30/22

Ranitidine injectable Currently not available through McKesson. Under allocation. Contact Sandoz at 1-800-361-3062.

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 
Oral: Pantoprazole 40 mg ~ Lansoprazole 30 mg ~ Omeprazole 20 mg ~ Esomeprazole 40 mg ~ Rabeprazole 20 mg
Nasogastric administration: lansoprazole, esomeprazole.
Ranitidine oral solution

Indeterminate availabilty.
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

Some generics intermittently available.

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.

Ropinirole tablets

No brands of ropinirole 0.25, 1 & 5 mg tablets are currently available. Earliest estimated resupply date: Feb/23.

Ran-ropinirole 2 mg tablets are available.

See PDF (last updated Jan 2020) for therapeutic alternatives.

Last updated Nov 30/22

Scopolamine transdermal patch

Transderm V transdermal patches have been discontinued by the manufacturer. An alternative options PDF will follow.

Sodium citrate/​sodium lauryl sulfoacetate/​sorbitol/​glycerin/​sorbic acid enema

Microlax® enemas (12 pack) are discontinued. The manufacturer has a 4 pack available for hospital orders. There is no micro enema alternative. 

Fleet® (regular, kids and mineral oil) and Lax-a-Nema® enemas are available. 

Spironolactone tablets

Some Teva 25mg tabs are available

Spironolactone 25 & 100 mg tablets are shorting with estimated availability of Dec 12/22

Therapeutic Alternatives

NOTE: RxFiles and CPS have information regarding a lot of the condtions for which spironolactone is used. Applicable charts and chapters have been suggested below. Both are subscription resources that can be accessed in SK through SHIRP

Consider use of spironolactone/HCTZ when appropriate such as:

  • the individual is on both agents separately
  • addition of HCTZ may be beneficial for additive BP lowering and/or edema – be cautious if other diuretics are on board

Like spironolactone, eplerenone is a mineralocorticoid receptor antagonist (MRA) that, in most cases, is a substitute for spironolactone. However, eplerenone is not full formulary (SK Drug Plan, NIHB) and is 20x the cost of spironolactone, making it unrealistic for many individuals.

In some conditions (primary aldosteronism, stable heart failure), short-term (e.g. a few weeks) interruption of MRA therapy may be manageable without substituting another agent. In these cases, first consider reducing the dose (e.g. from 1 tablet to ½ tablet) as supply permits.

Heart Failure with Reduced Ejection Fraction (HF-rEF)

  • MRAs are among standard therapies of HFrEF because they reduce hospitalization and death
  • optimize other standard therapies (beta blocker; ACEi/ARB/ARNI; SGLT2i)
  • remind/educate individuals about lifestyle interventions (e.g. sodium, fluid, alcohol intake, physical activity in stable individuals)
  • consider eplerenone if feasible (target dose 50 mg daily)
  • if MRA therapy not possible:
    • monitor symptoms of congestion and add/increase diuretic as needed
      • individuals with advanced or decompensated heart failure may need close monitoring to watch for new or worsening HF symptoms
    • monitor BP, though MRAs do not have large effect on BP
    • monitor potassium if individual at risk of hypokalemia
    • repeat bloodwork when MRA is restarted

 Resources

Hypertension

If spironolactone is used only for hypertension (no heart failure or edematous component), the individual has most likely failed several other treatments (resistant hypertension). Management strategies:
  • ensure adherence of other antihypertensives
  • consider eplerenone if feasible
  • other alternatives include amiloride, bisoprolol
  • consult specialist if applicable

Resources

 Ascites

  • remind individuals to restrict sodium intake to < 2g/day
  • amiloride is an alternative
  • very limited data of eplerenone for ascites

 Resources

  • CPS: Chronic Liver Disease

Primary Aldosteronism

  • MRAs are the main treatment of primary aldosteronism
  • consider eplerenone if feasible
  • short-term (< 1 month) interruption of MRA therapy may be managed by use of other antihypertensives if BP increases

Hirsutism

 Last updated: Dec 5/22

Sulfacetamide/prednisolone ophthalmic

Blephamide® ophthalmic drops and ointment have been discontinued.  No other brands are available.

For alternatives see CPS (subscription): Red Eye.  CPS is available through SHIRP.

Sulfamethoxazole/trimethoprim

See Co-trimoxazole

Testosterone - injectable

Delatestryl® (Testosterone Enanthate) - available

Taro Testosterone Cypionate 100mg/ml - estimated availability: Dec 19/22

Depo Testosterone 100mg/ml - indeterminate availability

Oral and topical dosage forms currently available.

For alternatives: see PDF

Last updated: Nov 21/22

Travoprost 0.003% ophthalmic drops

Izba® 0.003% ophthalmic drops are shorting. Estimated availability: mid Dec/22

Alternatives:

  • travoprost 0.004% drops are available 
 Last updated: Nov 21/22
Trifluoperazine

AA-trifluoperazine 1mg & 2mg tablets are shorted. Indeterminate availability date.

AA-trifluoperazine 5, 10 & 20mg tablets are available

Updated: Nov 15/22

Trifluridine Viroptic® ophthalmic solution 1% has been discontinued.
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 antiviral treatment.

Reference: CPS (subscription) - Red EyeCPS is available through SHIRP.
Twinrix® Jr See Hepatitis A/B
Ulipristal 

Ulipristal 5mg(Fibristal) has been voluntarily withdrawn from the market in Canada due to risk of drug-induced liver injury.

See: https://healthycanadians.gc.ca/recall-alert-rappel-avis/hc-sc/2020/74063a-eng.php

Valproic Acid EC Capsules

PMS-Valproic Acid EC Capsules 500 mg are shorted. Estimated availability: Feb/23 

Alternatives:

  • Valproic acid 250 mg capsules - these are not enteric coated.
  • Divalproex sodium tablets – not interchangeable with valproic acid, but dosing is approximately the same. Switch to the same daily dosing schedule; once stabilized, it may be possible to reduce the frequency of doses (while maintaining the same total daily dose).
Last updated: Nov 15/22
Vigabatrin 500mg Sachet

Sabril® 500mg Sachet is shorting with no availability date.

Alternatives:

  • Sabril® 500mg tablets are available
  • No formula for an oral liquid was found. Contact a compounding pharmacy regarding possible compounding using the tablets.
  • For alternative antiepileptics see RxFiles: Seizures: Antiepileptics. RxFiles is available through SHIRP
Last updated: Aug 5/22