Drug Shortages

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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:

  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
Alfacalcidol 2 mcg/ml

2mcg/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
Amoxicillin suspension

Amoxicillin powder for suspenion:

Currently available in 250mg/5ml strength (various brands).

Amoxicillin 125mg/5ml available in July 2020 according to McKesson.

See PDF for alternatives to amoxicillin suspension
Amoxicillin-Clavulanate

Generics and name brand Clavulin - currently not all strengths available. 

Therapeutic alternatives:
macrolides, clindamycin (but not if need Gram neg coverage), fluroquinolones, cefixime, cefuroxime.

Beta-blocker Ophthalmic Drops

Timolol XE (timolol 0.5%) currently available.

Other single ingredient timolol eye drops have availability listed as September - October, 2020.

Betoptic® S (betaxolol) indeterminate availability.

Betagan® (levobunolol) and generics discontinued.

Combination products: timolol/dorzolamide, timolol/brimonidine,timolol brinzolamide, timolol latanoprost, timolol/travoprost currently available.

See RxTx (subscription) Glaucoma treatment algorithm for alternatives. RxTx is available through SHIRP.

Betaxolol

Betoptic® S (betaxolol) indeterminate availability.

Combination products: timolol/dorzolamide, timolol/brimonidine,timolol brinzolamide, timolol latanoprost, timolol/travoprost currently available.

See RxTx (subscription) Glaucoma treatment algorithm for alternatives. RxTx is available through SHIRP.

Bromocriptine

5mg capsules available.

2.5mg tablets available mid-July 2020 according to McKesson.

Refer to cabergoline for possible alternatives. See PDF for details.

Drug Availability
Cabergoline

Dostinex available.                                                                                  Apotex available July 15, 2020                 

See PDF for details.

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.

Clomiphene

Clomid and Serophene - discontinued

Alternatives:
Compounded by compounding pharmacy or pharmacological alternatives.

Co-trimoxazole (sulfamethoxazole/trimethoprim) oral 

The AA brand of the DS, regular and pediatric strengths are available
Suspension - 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.

Drug Availability
Daunorubicin Cerubidine 20mg/4ml  Indeterminate availability
Dexamethasone

Dexamethasone oral tablets not currently available. 2mg and 0.5mg tablets available mid-June 16, 2020 according to McKesson. 

Dexamethasone Injection 4mg/ml and 10mg/ml currently available.

Dexamethasone Elixir 0.5mg/5ml currently available.

For information on allocated products call Sandoz 1-800-361-3062 or info.clients@sandoz.com

Dexamethasone injection can be given orally, either mixed with syrup or followed by juice or a popsicle. Clinical Resource, Giving Meds by Alternate Routes. Pharmacist’s Letter/Prescriber’s Letter. February 2020.

Maxidex 0.1% ophthalmic suspension and ointment currently available. 

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

Digoxin

Pendopharm 0.0625mg and 0.125mg tablets, as well as the 0.05mg/ml (115ml) solution currently available. 

Pendopharm 0.25mg tablets are discontinued.

Sandoz injectable 0.25mg (10 x 2ml) indeterminate availability. Under allocation call Sandoz -1 -800-361-3062 INFO.CLIENTS@SANDOZ.COM       

See PDF for management strategies. 

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.
Dipyridamole/ASA

Aggrenox discontinued.

Taro Dipyridamole/ASA 200mg/25mg available August 9, 2020 according to McKesson. 

See PDF for alternatives.       

Dobutamine The source of dobutamine in Canada is Sandoz:
Sandoz - 12.5mg/ml (10 x 20ml) available November 6, 2020.

Therapeutic alternatives:
Dopamine hydrochloride, norepinephrine bitartrate, milrinone. See PDF for details.
Drug Availability
Fentanyl injectable

Sandoz injectables currently under allocation. Contact Sandoz at 1-800-361-3062

Patches available in all strengths.
Procedural sedation -See PDF
Chronic pain - fentanyl patch - do NOT use in opioid naïve pts
Bulk powder - Currently unavailable.
See Switching Opioids

Fludarabine Indeterminate availability.   See PDF for management
Fluphenazine decanoate

Oral dosage forms available.

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

Fluticasone

Single and multi-ingredient products containing fluticasone may be intermittently unavailable.

See PDF for alternatives to fluticasone inhalers.

Furosemide injectable

Some brands are available. 
For questions on allocated quantities, Contact SANDOZ 1-800-361-3062.
Alternative Routes:

  • oral: 20 mg IV = 40 mg PO
  • administration through enteral feeding tube. It is reasonable to administer furosemide oral solution (can dilute with equal volume water if needed) through a feeding tube. Caution with doses > 140 mg daily (14 ml) which contain nearly 10 g sorbitol. 10 g sorbitol per day may cause flatulence and bloating; 20 g daily may cause diarrhea and cramping
Therapeutic Alternatives:
Ethacrynic acid: 50 mg/vial (close to $500 acquisition cost per vial)
Bumetanide: IV available through Special Access?
Glycopyrrolate injectable Sandoz products under allocation
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) Sandoz brand available under allocation.
Haloperidol LA 100mg/ml (5ml) available.
Alternative depot antipsychotic: aripiprazole, flupentixol, paliperidone, risperidone, zuclopenthixol
See PDF
Drug Availability
Lorazepam injectable 4mg/ml (10 x 1ml) under allocation. Contact Sandoz 1-800-361-3062
2mg/ml (10 x 1ml) discontinued. 
See PDF for details on treatment alternatives.
Losartan

Various brands have voluntarily recalled their product.

Check the Health Canada website for products affected. 

Should all brands of losartan and/or losartan-hydrochlorothiazide become shorted, see PDF for information about switching to a different ARB

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. 

Moxifloxacin injectable

Avelox I.V. -  To be discontinued for "business reasons".

Fresenius brand - Delay in shipping of the drug, under allocation. Call 1-877-821-7724

Oral moxifloxacin may be suitable. See PDF for alternatives

Naloxone 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. Kits may also be purchased from the following pharmacies.
Nifedipine extended-release

Adalat XL 20 mg and 60mg tablets not currently available.

Adalat XL 30mg and other brands currently available. 

See PDF for information regarding switching to a different calcium channel blocker.

Nystatin Oral suspensions available mid-June to mid-August 2020 according to McKesson.

Alternatives:
Refer to compounding pharmacy
Therapeutic alternatives: fluconazole, gentian violet, clotrimazole.
See PDF for alternatives
Opium and Belladonna Rectal Suppositories Indeterminate availability. For information 1-800-361-3062 
                                  
Therapeutic Alternatives:
Hyoscine (Buscopan) injectable, morphine suppositories, NSAID suppositories - See PDF for more details.

Drug Availability
Pantoprazole injectable

Powder for injection - indeterminate availability. Sandoz product under allocation. 1-800-361-3062 or info.clients@sandoz.com

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).

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)
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 indeterminate availability
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 1-866-926-7653
Bulk chemical listed in Medisca catalogue.
Therapeutic alternatives: See PDF.
Propylthiouracil  Discontinued
Therapeutic alternative: methimazole is the only alternative antithyroid drug in Canada.
Dose conversion imprecise. Usual maintenance doses in Graves' disease: 
Propylthiouracil: 100-150 mg PO daily in 2-3 divided doses
Methimazole: 5-15 mg PO once daily
Pyrantel pamoate suspension Jamp Pharma Pyrantel Pamoate suspension 50mg/ml available June 22, 2020. 
Combantrin suspension has been discontinued.
Combantrin 125 mg tablets available. Jamp brand 125mg 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. Under allocation.                                   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

Apotex brand available October 10,2020.
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.

Rocuronium Currently Sandoz under allocation. Other brands have no availability listed.
See Nondepolarizing Neuromuscular Blocking Agents for more information.
Salbutamol

Salbutamol 100ug inhalers: Various generic brands - Currently available

Salbutamol solutions for nebulization currently available from various manufacturers.

See PDF for alternatives.

Sodium phosphate effervescent tablets Phosphate-Novartis - discontinued
Jamp-Sodium Phosphate 500mg - available
See PDF for alternatives.
Succinylcholine

Teligent brand under allocation. Contact TeligentCanada_Customerservice@TELIGENT.COM

Alternatives: rocuronium - see Nondepolarizing Neuromuscular Blocking Agents.
Timolol ophthalmic

Timoptic® XE (timolol 0.5%) available May 8, 2020 according to McKesson.

Other single ingredient timolol eye drops have availability listed as October, 2020.

Combination products: timolol/dorzolamide, timolol/brimonidine,timolol brinzolamide, timolol latanoprost, timolol/travoprost currently available.

See RxTx (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.
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.
Verapamil oral

80mg and 120mg strengths, as well as Isoptin 180mg 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.