Dealing with Drug Shortages
First off – Before you read further, don’t panic…there are many ways within every practice to work around drug shortages. We just need to be cognizant of potential challenges and prepared to step outside our comfort zone a bit.
Why are drugs in shortage?
- Current Covid-19 situation has demonstrated there are many drugs we share with our human counterparts that are currently in high demand maintenance of Covid-19 patients on ventilators and overall for treatment of these patients in hospital.
- Even if not shared (for example, Propofol 28 is veterinary specific), the raw materials may be shared – it is a great unknown as to any impact at this time.
- In some cases, raw materials for drugs are imported and in short supply. Moreover, many of these drugs (for example, the pure mu opioid agonists) were already in short supply prior to the Coronavirus pandemic due to manufacturing challenges.
- Ongoing DEA quota reductions that were in place prior to this crisis have further limited availability of pure mu agonist opioids and while the DEA has increased quotas somewhat, they still impact availability of drugs.
What drugs might be difficult to obtain right now?
- Opioids, especially pure mu agonists – however, butorphanol and buprenorphine are currently available
- Benzodiazepines – especially midazolam
- Propofol – but fortunately not Propofol 28 (yet?)
- Dexmedetomidine – it is possible if veterinary production or raw material is diverted to human product that is in short supply currently
- Ketamine – possible if it becomes a substitute for other short supply drugs but currently not an issue
- Vasopressors and inotropes – dopamine, dobutamine, norepinephrine, epinephrine, phenylephrine, may all become more challenging to obtain
- Corticosteroids – especially injectable formulations
- Neuromuscular blocking agents – already in short supply due to heavy use
- Bronchodilators – albuterol and others
- Antibiotics – azithromycin is the main drug of concern here
- Fluids – saline and possibly others
Solutions you can deploy right now to preserve and prioritize your drug use?
- Whenever possible reserve the pure mu agonist opioids for analgesia and do not use them for sedation
- Butorphanol works well as a sedation adjunct in place of hydromorphone for example.
- Use local and regional techniques as much as possible – we should be doing this anyway as it is best practice for our patients. There are many techniques that are easy to implement.
- Medetomidine – this remains an approved and available as a small animal drug
- Propofol 28 is still available and is only approved for veterinary use. Consensus is that it is entirely safe to use in cats but should not be used as a CRI in cats (or dogs).
- Alfaxalone is only approved for veterinary use. If you have not used alfaxalone, now is the time to use it in some less challenging (healthier) patients and become comfortable with how it differs from propofol. Note – it is a controlled drug and it is more expensive.
- Ketamine remains available for now and is a very useful adjunct analgesic and induction drug in many patients.