Drug Shortages and Discontinuations
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Drug shortages can occur for a variety of reasons.The factors currently affecting drug supply are shortages of raw materials, quality control issues which lead to voluntary withdrawal and longer production times for some products and competition among drug manufacturers. The problem is expected to ease somewhat with renewed production in some cases and takeover of supply by another company in others. For more details see the environmental scan on Drug Supply Disruptions posted on the CADTH website.
In the meantime, healthcare providers are responsible for ensuring patients continue to receive appropriate drug therapy. A general protocol to follow in handling drug shortages is offered below:
- Ensure there is a valid indication for the drug. Review the patient’s drug and medical history. For a checklist of criteria to consider, check the CPhA Drug Shortages Guide pg 4 - 6.
- Substitution of a different brand of the same drug (molecule):
- Check the Saskatchewan Prescription Drug Plan (SPDP) Formulary for interchangeable brands of the same drug; then check for availability of these brands. (Call wholesalers, manufacturers)
- If none are available, is there a non-interchangeable brand of the same drug in the same dosage form? Obtain authorization for substitution from prescriber, start at same dose or a reduced dose and titrate to desired effect (especially important if drug has a narrow therapeutic index) and monitor for beneficial and adverse effects. Follow-up with the patient in 24 – 48 hours, as indicated by kinetic and pharmacologic characteristics of the drug.
- If no Formulary drug in the same dosage form is available, check Health Canada Drug Product Database for other brands that may be available and proceed as above.
- If none available, is there a different dosage form of the same drug? Obtain authorization for substitution from doctor, start at appropriate dose and titrate to desired effect (especially if narrow therapeutic index) and monitor for beneficial and adverse effects. Follow-up with the patient in 24 – 48 hours as indicated by kinetic and pharmacologic characteristics of the drug.
- If no Formulary drug is available, check Health Canada Drug Product Database for other dosage forms that may be available and proceed as above.
- If none available, is there a different dosage form of the same drug? Obtain authorization for substitution from prescriber, start at appropriate dose and titrate to desired effect (especially if narrow therapeutic index) and monitor for beneficial and adverse effects. Follow-up with the patient in 24 – 48 hours as indicated by kinetic and pharmacologic characteristics of the drug.
- As necessary, consult SPDP regarding coverage for substituted brand.
- If no other forms of the same molecule are available, substitution of another drug in the same therapeutic class can be considered. Check the references below for dose equivalence data. This information is not always available. Even when a therapeutically equivalent dose is administered, patients may react differently. Pharmacists should follow-up with the patient frequently until the patient is stabilized on the new medication.
- Rx Files Charts - www.rxfiles.ca
- e-therapeutics + (available at SHIRP)
- Handbook of Clinical Drug Data , 2010, 11th edition - hardcopy text
- If there is not a therapeutic equivalent, check treatment guidelines and recommend a drug from another pharmacologic class. Monitor and titrate to desired effect.
- e-therapeutics+
- RxFiles
- Others, e.g. Healthcare Network Clinical Guidelines, National Guideline Clearinghouse, etc.
- Compounding capsules or tablets in the desired doses when other strengths of drug are available or from bulk powders may be another option, especially in instances where there is not a readily available or acceptable substitute.
In order to provide greater information to health care practitioners and the general public, Canada’s Research Based Pharmaceutical Companies (Rx&D) and the Canadian Generic Pharmaceutical Association (CGPA) began collecting information on behalf of their individual member companies on current and impending drug shortages in the fall of 2011. Rx&D has now turned over its database architecture (i.e. the former Rx&D Drug Shortages Database) and opened its use to non-Rx&D members (i.e. all market authorization holders) who are authorized to sell medicines in Canada, and who may need to use the site to report a drug shortage. Information is being provided on a voluntary basis. It does not necessarily include all pharmaceutical companies in Canada, and therefore there may be gaps in the data. The new database is called Drug Shortages Database Canada:
medSask is not responsible for the content of this database, and does not assume any liability that may arise from any use of or reliance on the information contained therein. The information in the database has been provided by drug manufacturers, and is presented here for reference purposes only. There is no warranty, representation or guarantee with respect to the accuracy, timeliness or completeness of this information. medSask accepts no responsibility for any errors or omissions, and expressly disclaims any such responsibility.
medSask cannot accept phone, email, fax, or other inquiries about the content of this information. Inquiries regarding specific drug shortages should be directed to the appropriate drug manufacturer as identified. Questions about alternatives for shorted drugs and drug plan coverage for alternatives may be directed to the appropriate provincial drug information service.
The following tables provide suggestions for handling shortages of specific drugs. This information is intended for use by healthcare providers for general informational purposes only. It remains the responsibility of the healthcare provider to use professional judgment in evaluating this information in light of any relevant clinical or situational data. This information is provided without warranty of any kind and medSask and the University of Saskatchewan assume no responsibility and/or legal liability whatsoever for any errors, omissions or inaccuracies contained therein.
Fluticasone propionate oral inhaler
Salbutamol oral inhaler
Amoxicillin oral suspension
Dipyridamole/ASA oral capsule
Hydrocortisone 10 mg tablet; French version
Specific Drug Shortages & Discontinuations
To check current availability status of Sandoz parenteral drugs go to the Sandoz website.
| Drug | Availability / Alternatives |
| 5-AMINOSALICYLIC ACID (MESALAMINE) |
400mg Asacol® has been discontinued. Teva 400mg 5-ASA tablet (DIN 02171929) currently available. Not interchangeable with Asacol® as per the SK Formulary. For more information: https://www.rxfiles.ca/RxFiles/uploads/documents/members/Cht-IBD-UC-Crohns .pdf and eCPS - Inflammatory bowel disease. Both subscription only but available through SHIRP |
| Acenocoumarol |
Sintrom® 1mg and 4mg tablets have been discontinued. Acenocoumarol is approximately twice as potent as warfarin. See eCPS (subscription). Available through SHIRP |
| Auralgan Otic Drops (antipyrine 5.4% & benzocaine 1.4%) |
Estimated availability: Feb 11/22 Possible alternative: Polysporin Plus Pain Relief Ear Drops. These contain lidocaine 50 mg/mL & polymyxin B sulfate 10 000 IU/mL. |
| Beclomethasone dipropionate 0.025% cream |
Propaderm® cream is shorted. Estimated availability: Mar 3/22. Alternatives: Corticosteroid creams with similar potencies can be found in the RxFiles - Topical Corticosteroid Comparison Chart. Available through SHIRP |
| Beta-blocker Ophthalmic Drops |
Timoptic® XE (timolol 0.5% - Elvium brand) available. Timolol ophthalmic solution 0.5% currently available. See DPEBB Bulletin #739: Effective July 22,2020 Health Canada has approved the import of Pharma-Stulln Timolol 0.5% ophthalmic solution. It will be temporarily listed as a full Formulary benefit and not interchangeable with other timolol ophthalmic solutions. Betoptic® S (betaxolol) available. Betagan® (levobunolol) and generics discontinued. Combination products: timolol/dorzolamide, timolol/brimonidine,timolol brinzolamide, timolol latanoprost, timolol/travoprost currently available. See eCPS (subscription) Glaucoma treatment algorithm for alternatives. eCPS is available through SHIRP. |
| Buprenorphine extended-release injection (Sublocade®) |
Health Canada has approved importation of US-labelled product. See manufacturer's risk communication here. See Bulletin #745 (October 1, 2020) from DPEBB regarding temporary SK Formulary inclusion of Buprenorphine extended-release injection. |
| Drug | Availability |
| Calcitonin, Salmon, synthetic |
Calcimar® 200U/ml (2ml) INJECTION available |
| Carbamazepine oral suspension |
Taro-carbamazepine suspension shorted - estimated availability date - Feb 6/22 Tegretol® suspension shorted - estimated availability date - Feb 21/22 Alternatives:
|
| Ciprofloxacin XL |
Cipro XL 500mg & 1000mg are shorted - indeterminate availability Alternative:
|
| Clomiphene |
Clomid® and Serophene® - discontinued |
|
Codeine 10mg/5ml; pseudoephedrine 30mg/5ml; triprolidine 2mg/5ml |
Cotridin Syrup is shorted with indeterminate availability. Alternatives:
|
| Colestipol |
Colestid® granules and tablets are shorted with indeterminate availability date. Alternatives: The bile acid sequestrants cholestyramine and colesevelam are available in both powder and tablet form. See RxFiles Lipid Lowering Therapy: Drug Comparison Chart (subscription) for dosing details. RxFiles is available through SHIRP |
| Contraceptives (Oral) |
For discontinued products refer to SK Formulary, for similar ingredients or RxFiles Oral Hormonal Contraception: Supplementary Tables, for similar hormonal activity. |
|
Co-trimoxazole (sulfamethoxazole/trimethoprim) oral |
The AA brand of the DS, regular and pediatric strengths are available |
| Drug | Availability |
| Enoxaparin |
Lovenox® HP 100mg, 120mg and 150mg prefilled syringes and the 100mg/ml vial are available. All other Lovenox® products are on allocation. For more information contact Sanofi Customer Service: 1-800-265-7927 or lavalcs@sanofi.com Alternatives: Most strengths can be found in the biosimilar enoxaparin products: Inclunox®, Noromby™ or Redesca® . Please note that the SK Drug Plan does not consider the biosimilar products interchangeable with Lovenox®. See DPEBB bulletin |
| Erythromycin Base |
AA-Erythro 250mg - currently on backorder. Estimated availability: Mar 10/22 Alternatives: Eryc® 333mg; can be compounded |
| Estrogens (conjugated) /bazedoxifene acetate |
Duavive® - Currently on backorder. Indeterminate availability. Indication: Treatment of vasomotor symptoms associated with menopause. Alternatives: Estrogen + progestin |
| Fluphenazine decanoate injection |
Oral dosage forms available. Both brand name (Modecate®) and generic products have been discontinued. |
|
gramicidin 0.025 mg/mL/polymyxin B sulfate 10 000 units/mL |
Optimyxin eye/ear drops shorted. Estimated availability: Apr 11/22 Alternatives: Polysporin drops are available |
| Drug | Availability |
| Hydrocortisone tablets |
Hydrocortisone (Cortef™) 10mg and 20mg are available. See Pfizer's communication to pharmacies, dated 17 Dec 2020. French version is here. 5 mg tablets are accessible through the Special Access Programme. See PDF for conservation strategies and information related to use in adrenal insufficiency. French version here. |
| Hydrocortisone 2.5% cream |
Sandoz Hydrocortisone 2.5% cream is shorted - estimated availability: Feb 19/22. No other brands are available. Alternatives: Can be compounded |
| Hydrocortisone enema |
Cortenema® has been discontinued. Alternatives: Other corticosteroid enemas are available:
|
| Hydromorphone Oral Suspension |
Dilaudid® Oral Suspension has been discontinued. PMS-Hydromorphone oral suspension is now available. Alternatives:
|
| Irbesartan |
As of May, 2021, several manufacturers are recalling various lots of irbesartan and irbesartan-HCTZ. See Health Canada for more information and a list of affected products. Recalls of further lots/manufacturers may ensue. Should irbesartan become unavailable, refer to Angiotensin II Receptor Blocker Comparison. This document is being updated to reflect the current situation. |
| Iron dextran injection |
Dexiron has been discontinued For alternatives see PDF |
| Drug | Availability |
| Losartan |
As of May, 2021, some manufacturers have recalled various lots of losartan. See Health Canada for more information and a list of affected products. Recalls of further lots/manufacturers may ensue. Should all brands of losartan become unavailable, see Angiotensin Receptor Antagonist (ARB) comparison chart for information about switching to a different ARB. This document is being updated to reflect the current situation. |
| Medroxyprogesterone acetate injectable suspension 150 mg/mL (Depo-Provera®) |
Depo-Provera® 150mg/ml is shorted - estimated availability date: Jun 1, 2023 Health Canada has approved importation of US-labelled product. Note the US-labelled product is only indicated for contraception and is available in a prefilled syringe. See Pfizer information here. Regarding interchangeability: If the prescription directs the dispensing of Depo Provera®, a new prescription would be required in order to dispense the US-labelled medroxyprogesterone acetate (Depo-Provera CI) 150mg/mL pre-filled syringes. See the DPEBB Bulletin for more information. |
| Morphine HP 50mg/ml |
Sandoz Morphine HP 50mg/ml 50 ml is shorted due to a manufacturing disruption. Approximate availability date is Apr 10/2022 At this time, the 10 ml size is still available |
| Morphine - Slow Release |
Kadian® 20mg, 50mg & 100mg are available Alternatives: Pain management: See Opioid Manager OAT: See the British Columbia Centre on Substance Abuse directive |
| Morphine suppositories |
Statex suppositories have been discontinued. Some stock may still be available. Alternatives:
|
| Naloxone | Omega, Sandoz and Teligent brands 0.4mg/ml 10 x 1ml available NALOXONE KIT WITH 2 VIALS - available through McKesson Contact Poison Control for emergency information in the event naloxone is unavailable. Naloxone Kits are available to Saskatchewan residents without a prescription. Residents may access free health region funded naloxone kits at the following locations. |
|
Neomycin/methylprednisolone acne lotion |
Neo-Medrol® acne lotion has been discontinued Alternatives:
|
| Nifedipine extended-release |
XR 30mg and XR 60mg Mylan brand currently available. Adalat® XL 30mg available. XL 20mg indeterminate availability. See PDF for information regarding switching to a different calcium channel blocker. |
| Ofloxacin |
Ocuflox® 0.3% ophthalmic drops are shorted. Estimated availability: Sep 30/22 Alternatives: See RxFiles: Anti-Infectives for Common Infections: Conjunctivitis. Available through SHIRP |
| Opium and Belladonna Rectal Suppositories | Discontinued by manufacturer. For information:1-800-361-3062 Therapeutic Alternatives: Hyoscine (Buscopan) injectable, morphine suppositories, NSAID suppositories - See PDF for more details. |
| Oxcarbazepine |
Apo-oxcarbazepine 150, 300 & 600 mg tablets are shorted with estimated availability of Apr 10/22 Alternatives:
|
| Drug | Availability |
| Phenelzine |
23 Nov 2020 01 Oct 2020 23 Sep 2020 24 Jun 2020 |
| Potassium Chloride (Slow-K®) |
Slow-K® (NPN 80040226) 600 mg KCl (8 mEq K+) slow release matrix tablets have been discontinued.
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+:
|
| Potassium citrate tablet |
Urocit®-K 5 mEq tablets are shorted. Estimated availability: Feb 2/22 Alternatives: 10mEq tablets are available. K-citra oral solution is also available |
| Prednisolone Sodium Phosphate 0.5% ophthalmic solution |
Minims-Prednisolone 0.5% is on backorder with no availability date Alternatives: Several brands of the 1% prednisolone acetate ophthalmic drops are available; Pred Mild® (prednisolone acetate) 0.12% drops are available *Note: The acetate suspension has greater bioavailability than the sodium phosphate solution |
| 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. |
| Progesterone - micronized |
All generic brands of micronized progesterone capsules are currently shorted with availability dates ranging from Jan 21 to Feb 11/2022. *Jan 14 - PMS brand now available* McKesson still has Prometrium 100mg capsules in stock. |
| Promethazine oral | Histantil 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 available. For information call 1-866-926-7653 Bulk chemical listed in Medisca catalogue. Therapeutic alternatives: See PDF. |
| Propylthiouracil |
Discontinued distribution in Canada by Paladin. Australian product by Phebra has been authorized by Health Canada and is available at McKesson. See Bulletin #738 (July 15, 2020) from DPEBB regarding temporary SK Formulary inclusion of Phebra brand PTU 50 mg. Therapeutic alternative: methimazole is the only alternative antithyroid drug in Canada. |
| Pyrantel pamoate suspension |
Jamp Pharma Pyrantel Pamoate suspension 50mg/ml is shorted. Estimated availability: Jan 7/2023 Alternatives: Albendazole is available only through Health Canada’s Special Access Program (SAP). |
| Drug | Availability |
| Quinagolide |
Quinagolide (Norprolac®) has been discontinued. For alternatives see PDF |
| 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. |
| 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. |
|
Silodosin |
Rapaflo® capsules have been discontinued. No other brand is available. Alternatives: Other medications in the alpha1-adrenergic receptor antagonist family are available - alfuzosin, doxazosin, tamsulosin and terazosin. See eCPS (subscription) Lower Urinary Tract Symptoms and Benign Prostatic Hyperplasia for details. eCPS is available through SHIRP. |
| Sodium phosphate effervescent tablets | Phosphate-Novartis - discontinued Jamp-Sodium Phosphate 500mg - available See PDF for alternatives. |
|
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 and Lax-a-Nema are now available. The pediatric forms of both have been discontinued. |
|
Sulfamethoxazole/trimethoprim
|
See Co-trimoxazole |
|
Sumatriptan nasal spray
|
Imitrex® Nasal Sprays 5mg and 20mg are shorted - Estimated availability: Feb 13/22 No other brands are available. Other forms of sumatriptan are still available. |
|
Tazarotene
|
Tazorac® 0.05% Gel has been discontinued Alternatives:
|
| Testosterone |
Delatestryl (Testosterone Enanthate) - available Taro Testosterone Cypionate 100mg/ml - available Depo Testosterone 100mg/ml - indeterminate availability Oral and topical dosage forms currently available. For alternatives: see PDF |
| Timolol ophthalmic |
Timoptic® XE (timolol 0.5% - Elvium brand) available. Timolol ophthalmic solution 0.5% 10ml currently available. See DPEBB Bulletin #739: Effective July 22,2020 Health Canada has approved the import of Pharma-Stulln Timolol 0.5% ophthalmic solution. It will be temporarily listed as a full Formulary benefit and not interchangeable with other timolol ophthalmic solutions. Combination products: timolol/dorzolamide, timolol/brimonidine,timolol brinzolamide, timolol latanoprost, timolol/travoprost currently available. See eCPS (subscription) Glaucoma treatment algorithm for alternatives. RxTx is available through SHIRP. |
| Tirofiban 0.05mg/ml | Aggrastat® - MANUFACTURER CANNOT SUPPLY FOR INFORMATION CALL 610-833-6050. |
| Trifluoperazine |
AA-trifluoperazine 1mg & 2mg tablets have been discontinued AA-trifluoperazine 5, 10 & 20mg tablets are available |
| Trifluridine | Viroptic® ophthalmic solution 1% - indeterminate availability. For information call 800-361-4261. 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: eCPS - Red Eye. eCPS is available through SHIRP. |
| 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 |
| Valsartan |
As of May, 2021, some manufacturers have recalled various lots of valsartan. See Health Canada for more information and a list of affected products. Recalls of further lots/manufacturers may ensue. Should all brands of valsartan become unavailable, see ARB comparison chart for information about switching to a different ARB. This document is being updated to reflect the current situation. |
| Voriconazole |
Vfend® oral suspension is shorted with estimated availability of Feb 11, 2022 Voriconazole 50 and 200mg tablets are available. Trissel's Stability of Compounded Formulations - 6th Ed. has details on a compounded suspension for veterinary use. Trissel's is available through SHIRP. |