drug shortages

Monday, January 14, 2013

For the true fan, the injury report is a must read when it comes out before the big game. Whether there is detailed information of an injury or illness like in the NFL reports or the ambiguous lower body injury that populates the NHL releases, knowing who is hurt and if they will play has become big news. A player who is not available affects the coach’s game plan and the duties assigned to other players. Injuries that occur during the game are that much more challenging, requiring adjustments on the fly. It doesn’t make news, but the same thing happens in medicine and the medication shortages are changing the way medicine is being practice in the US.

The Federal Drug Administration lists more than 120 medications that are in short supply or unavailable and that has or will shortly change the game that will affect millions. The potential damage can be mild inconvenience. The shortage of sterile injectable sodium bicarbonate that is mixed in with lidocaine, the local anesthetic that is injected to numb lacerations, means that those injections will burn a little more. Or the consequences of a drug shortage can change the way medicine is practiced. Intravenous nitroglycerin is used to dilate arteries that supply the heart muscle, increasing blood flow should those arteries become narrow and cause chest pain or angina. Nitroglycerin also dilates arteries in the rest of the body, decreasing blood pressure and is one of the front line drugs for malignant hypertension (blood pressure out of control) and aortic dissection (tearing of the main artery that leads from the heart).

The latest shortages can be blamed on Hurricane Sandy and the damage it caused to pharmaceutical manufacturing plants. Doxycycline, a form of tetracycline, is a commonly used antibiotic to treat a variety of infections from pneumonia and bronchitis to Lyme disease and sexually transmitted diseases. That antibiotic is no longer easily found and alternative antibiotics need to be prescribed. At least doctors and patients can have leisurely discussions about different alternatives that may or may not be as effective, and may or may not be prone to side effects and allergies, but a big gun in the physician playbook is on the injured, cannot play list.

The antibiotic shortage is an inconvenience when another pill is available, but what about shortages of intravenous medications that make a difference in people’s care. IV pain medications are in short supply, including Fentanyl, Dilaudid and Ketorolac (Toradol) an injectable anti-inflammatory, all made the FDA list this week. Furosemide (Lasix) injectable, a diuretic that makes a patient urinate, is hard to find and it is one of the mainstays in the treatment of congestive heart failure, along with nitroglycerin. Valium and its cousin Versed, used to sedated patients, are another tough find, as is the sedative/anesthetic Propofol of Michael Jackson fame. Propofol is the go to drug in the ER, OR and ICU but its use is slowly being restricted as supplies dwindle.

Pharmacists have an important role trying to keep their shelves filled with the medications commonly used in their hospital. Should a wholesaler be unable to provide adequate supplies, they need to check their rolodex for alternative sources, often using their connections to call on other hospitals that may have abundance. It’s important for the pharmacist to be proactive and ahead of the game. Once a major shortage occurs, the price for the remaining stockpile can soar. And sometimes, cost is not important. Intravenous fat emulsion is in short supply but is critical in the care of patients whose bowel has stopped working or those who cannot absorb enough nutrients to meet the needs of their body. Total parenteral nutrition (TPN) is used to “feed” these patients though intravenous lines until their intestine starts working again, a situation that can take week, months or longer.

Injury reports are usually in tiny print buried deep in the sports section, but for those who are interested, the information is there. The same is true for drug shortages. The information is there is you know where to look,but for most people, there is blind faith that their hospital or pharmacy has ample supply of the medications that they need. That isn’t always the case and pharmacists and doctors need to be aware that a backup player may need to be ready if their first choice for treatment isn’t ready to play.


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medication shortages

Monday, November 5, 2012

There is a fragile line between success and failure in sports. Often it comes down to what team can survive injuries to key players and the game plan is adjusted. The fan expects that there is always another player who can come in, but sometimes the bench is empty. It may not be the star player that cannot be replaced, but instead it may be the specialized skill of a long snapper or the place kicker who changes the complexion of the game. In medicine, the patient can be placed at a major disadvantage if a needed medication isn’t available. In this land of plenty, medication shortages are becoming routine and rationing medical care wasn’t supposed to refer to whether a hospital f=pharmacy was well stocked.

There is a pipeline that delivers medication from the pharmaceutical company’s manufacturing plant to the pharmacist in the hospital. Like building a care or a computer, there are many steps involved in delivering the components, but instead of motherboard sand steering wheels, there are chemicals and reagents that need to arrive in just in time to make the final drug. Sometimes, there are scheduled downtimes and hospitals can stockpile medications to meet their needs and sometimes, there just isn’t enough to go around and no idea when the next shipment will arrive.

The memo said that intravenous nitroglycerin is in very short supply and won’t be available for routine use. Nitro dilates blood vessels and is one of the staples for treating angina and other symptoms caused by narrowing of arteries to the heart muscle. By dilating those blood vessels, increase blood flow can restore oxygen supply and prevent muscle damage. It’s also a great drug for controlling very high blood pressure because it works quickly and if the blood pressure drops too low, turning off the IV infusion makes the effects of the drug go away. IV nitro is a great way to treat patients but a nat8oinawide shortage makes us go to the bench for alternatives. In the chest pain patient, it may be morphine, oxygen and nitroglycerin tablets dissolved under the tongue (but be wary; it’s a big dose of nitro and can the blood pressure can fall quickly). Still it’s an alternative standard of care that worked well before the intravenous nitro was introduced 30 years ago.

Propofol is a great anesthetic if used in a controlled setting, like the operating room or ER, but it’s running out as well. While it got a bad rap with the unfortunate death of Michael Jackson, the drug works wonders in sedating patients for short painful procedures, like reducing joint dislocations or shocking a heart rhythm back to normal. It works quickly and wears off quickly so that patients tend to wake up quickly. The alternatives are narcotics and sedatives that work well but the patient needs a longer time to wake up. That means more manpower planning because the time a nurse will be at the bedside may be measured in hours and not minutes.

There are dozens of other drugs that running into shortages and are on the FDA list. From cancer medications to antibiotics and medicines to treat seizures, doctors and pharmacists are planning ahead looking at second line alternatives to treat the variety of illnesses that can arrive at the hospital’s door. It may be an inconvenience like the shortage of sodium bicarbonate that is used to buffer lidocaine and make it burn less when used to anesthetize a cut before suturing, or it can be a big deal. Certain antibiotics used to treat very resistant bacteria are in short supply and the alternatives are less than attractive.

In an American hospital, the shelves have always been full. A medical team responds to losing a player, whether a role player or a star, will be very similar to the football coach looking down the bench and finding a replacement. It may not be the same and it may not be the best, but the game plan has to be adjusted to have the best chance of winning. Somehow, though, it seems that the medical stakes are a bit higher.

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