FDA Reports Critical Drug Shortages

Delays put EMTs on alert for dextrose, naloxone, epinephrine.

It’s the kind of thing most people take for granted: You’re suddenly taken seriously ill—a heart attack, dehydration, asthma, shock, perhaps even a heroin overdose—and in the ambulance or the emergency room, medical professionals immediately go to work, using the right drugs and medications for the job.

Imagine lying in the back of an ambulance, in cardiac arrest, or experiencing an episode of acute schizophrenia, or turning blue from a heroin OD—and the EMTs and nurses and other medical staff have only a precariously minimal supply of what you need. You might expect such a thing in wartime, or in parts of the developing world.  But drug shortages already plague health care, and may worsen as drug suppliers run the risk of cutting back production too aggressively on vital drugs used in emergency medical procedures.

At present, according to the Food and Drug Administration (FDA), shortages exist for the following drugs, among others:

Injectable Dextrose 50%: unanticipated increased demand. Full recovery by mid-September. Used in IV solutions.

Injectable ephedrine: manufacturing delays, increased demand. Full recovery by late August. Used as a brochodilator.

Injectable epinephrine: Unanticipated increased demand. Recovery by late September. Used in the treatment of cardiac arrest, shock and anaphylaxis.

Injectable haloperidol decanoate: On back order from major suppliers, estimated recovery by November.  Used for schizophrenia.

Injectable naloxone: manufacturing delays. Recovery by mid-September. Used for heroin overdose.

Writing for the New England Journal of Medicine online, Valerie Jensen and Bob A. Rappaport demonstrate that shortages of certain drugs in sterile injectable form have been increasing. Data from the Drug Shortage Program at the FDA show that, while 35% of the drugs experiencing supply shortages in 2008 were sterile injectables, that number rose to 46% in 2009.  “Reduction in the supply of these drugs can have dramatic effects on medical practice,” they write, “ultimately keeping patients from receiving the level of care they deserve and have come to expect.”

How do these shortages happen? For perspective, the authors lay out the case history of the injectable drug propofol, a fast-acting sedative commonly used to induce and maintain sedation or anesthesia. In 2009, three pharmaceutical manufacturers serviced the market for propofol—Hospira, Teva, and APP. In October of 2009, Hospira recalled “multiple batches of its propofol owing to the presence of particulate matter in the vials.” A few weeks later, Teva issued a recall on several lots of propofol due to “possible microbial contamination.” In June of 2010, Hospira had still not returned to the market, and Teva had chosen to exit the market for good. That left a single company as sole supplier of propofol for the entire U.S.—“an unrealistic expectation, given anesthesiologists’ reliance on the drug.”

Drug shortages can occur in other ways. Producers often abandon older drugs for newer, higher margin offerings. Free market policies can and do lead to supply shortages, particularly in the case of complex injectable products with long manufacturing lead times. Such drugs are most efficiently manufactured in amounts that leave little excess supply in inventory channels. As a result, “a sudden change in either the supply of or the demand for the drug can have catastrophic clinical consequences,” the authors write.

The FDA, say the authors, “cannot require a company to start or to continue manufacturing a drug or dictate how much of a drug must be manufactured…” The free market paradox is always part of medicine: competition drives down the price of drugs, making them more affordable and accessible to patients. But if prices go too low, manufacturers may choose to stop producing a given drug, thereby limiting competition and making the drug vulnerable to supply shortages.

However, the FDA does have the authority to temporarily allow the importation of drugs certified to be of similar formulation and quality, if there is a serious shortage. In the case of propofol, the FDA allowed the importation of a similar but unapproved drug, Fresenius Propoven 1%, which is used in other countries.

Shortages of sterile injectable drugs like propofol create special hazards. For example, they are commonly used in ambulances and emergency rooms for treating shock and heart attack. We are not talking about a shortage of cotton swabs here. In addition, the FDA warns of numerous adverse effects resulting from “multiple entries into single-use vials of the drug,” a common method of dealing with shortages. The authors cite a case in a Nevada endoscopy clinic, where the practice of obtaining multiple doses from a single-dose vial “led to an outbreak of hepatitis C infection, and approximately 40,000 patients were advised to be tested for potential infection of hepatitis B, hepatitis C, and HIV.”

Jensen, V., & Rappaport, B. (2010). The Reality of Drug Shortages -- The Case of the Injectable Agent Propofol New England Journal of Medicine DOI: 10.1056/NEJMp1005849

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