Pain & Symptom Management: RQHR Response - Injectable Drug Shortage

Transcription

1 Pain & Symptom Management: RQHR Response - Injectable Drug Shortage Carmen L. Johnson, MD CCFP, ABFP, AAHPM, AAPM, ABAM, ABRPM (Pain Medicine) Medical Director Palliative Care Services

2 Disclosures Speakers Bureau, Purdue Pharma Speakers Bureau, Pallium

3 Dedication Dr. Martha Santamaria Dr. Lawrence Librach

4 Learning Objectives Why sudden nationwide shortage of injectable meds? RQHR response to drug shortages Drugs affected, shortage severity Determinants in choosing alternate medications Medications we chose

5 Learning Objectives How did we do? Prescribing changes Any other lessons? Time savings Cost savings Future drug use

6 Headlines February 20, 2012 Sandoz Canada, a leading maker of injectable drugs, announced it has suspended or discontinued production of some drugs, prompting fears of a shortage of critical medications. CBC Online

7 Headlines Caught Health Care Professionals Off Guard Larissa Feldman s Montreal drugstore was among those left in the lurch by the sudden stoppage.... This morning, we ve tried to order some of these products.... [Much] to our surprise, there was none available, Feldman said. CBC Online

8 Headlines February 20, 2012 Significant reduction in output The company [Sandoz] said it was expecting a significant reduction in output and was halting production lines to upgrade operations after quality-control assessments by the [US] Food and Drug Administration warned the factory fell short of FDA standards. CBC News

9 Headlines March 4, 2012 To exacerbate supply concerns, a fire Sunday in the ceiling above the boiler room of Sandoz s Boucherville plant has halted production. CBC Online

10 Headlines March 6, 2012 Health Canada We ve seen an interruption of the supply, and principally of injectable medications for hospitals... Elective surgeries are being cancelled... and there s widespread concern. Dr. Robert Cushman. CBC News

11 Headlines Drugs affected: Painkillers Antibiotics Anaesthetics

12 Headlines March 6, 2012 Health Canada plans to fast-track new sources of certain medications... we do have arrangements with similar organizations like the [Food and Drug Administration] in the U.S. CBC News

13 Headlines Little Did The Canadian Public Know!...

14

15 Headlines Drug Shortage Crisis - United States The U.S. is experiencing a rapidly increasing frequency of drug shortages... Pharmacy and Therapeutics Pub Med Central National Institute of Health, November 2011

16 Headlines USA drug shortages Generic cancer drugs Heart medications Pain medications Morphine Hydromorphone

17 Shortages Reported Intravenous (IV) electrolytes Anaesthetic agents Furosemide Amino acids

18 Headlines March 6, 2012 In Canada, hospitals turn to sharing their supplies Myrella Roy,... Canadian Society of Hospital Pharmacists, says, hospitals typically have a few weeks of inventory on hand... So, when they are notified that a particular drug or number of drugs may be in short supply, they can only fall back on a few weeks worth of inventory. Canadian Press

19 Headlines Week of March 5, 2012 Officials with Alberta Health Services asked doctors to conserve injectable medications. Cancer patients received oral anti-nausea medications instead of injections. CBC News

20 Headlines March 13, 2012 DRUG SHORTAGES COULD MEAN 1890 s STYLE SURGERY! CBC News

21 Headlines Canadians will face medicine from the 1890s or no surgery at all if a shortage of injectable drugs continues, the head of the Canadian Medical Association says. No anaesthesia, no antibiotics. CBC News

22 Headlines March 13, 2012 Canceled or postponed elective surgeries reported in Quebec. CBC News

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24 Impact on Symptom Management Injectable drugs: Mainly patients end of life difficulty swallowing Hospital Community, hospice, home care program

25 Major Drug Categories Painkillers Anti-nausea Anti-seizure Sedation Secretion control

26

27 RQHR Emergency Meeting February 2012 Pharmacy newsletter weekly or biweekly Drugs shorted and their alternates Newsletters continuing today Categories: grey depleted red less than 2 weeks yellow use judiciously

28 Drugs Affected Pain morphine, hydromorphone Nausea gravol, ondansetron, haloperidol (esp. community) Seizures midazolam, phenobarb, dexamethasone

29 Drugs Affected Sedation midazolam, haloperidol, methotrimeprazine (community) Secretions glycopyrrolate, atropine, hyoscine

30 Mar. 15/12 Apr. 19/13 (56 wks) Drug - Nausea # of Weeks Short dimenhydrinate 56 ondansetron 30 Both on shortage list same week 12 wks

31 Mar. 15/12 Apr. 19/13 (56 wks) Drug - Pain # of Weeks Short fentanyl 34 morphine 17 hydromorphone 15 ketorolac 13 fentanyl & morphine on list same week 1 wk fentanyl & hydromorphone on list same week 1 wk morphine & hydromorphone on list same week 6 wks

32 Mar. 15/12 Apr. 19/13 (56 wks) Drug - Secretion # of Weeks Short atropine 4 glycopyrrolate 18 hyoscine 3 atropine & glycopyrrolate on list same week 1 wk atropine/glycopyrrolate/hyoscine on list same week 0 wks

33 Mar. 15/12 Apr. 19/13 (56 wks) Drug - Sedation # of Weeks Short midazolam 26 propofol 5 ketamine 29 midazolam & propofol on list same week 3 wks

34 Mar. 15/12 Apr. 19/13 (56 wks) Drug - Seizures # of Weeks Short midazolam 26 phenytoin 14 midazolam & phenytoin on list same week 9 wks

35 Mar. 15/12 Apr. 19/13 (56 wks) Drug - # of Weeks Short dexamethasone 1

36 Mar. 15/12 Apr. 19/13 (56 wks) Drug - haloperidol # of Weeks Short community only

37 Determinants Alternative Meds Safety, efficiency Bioavailability (buccal, rectal, transdermal) Onset duration of action

38 Determinants Alternative Meds Duration of effect Dosage frequency Comfort rectal meds gel caps

39 PAIN/DYSPNEA Analgesics MS Contin matrix rectal ok M-Esselon time release beads Hydromorph Contin time release beads Oxyneo - matrix, not for rectal use

40 PAIN/DYSPNEA Rectal Admin MS Contin IR morphine IR hydromorphone IR oxycodone

41 PAIN/DYSPNEA Methadone Suspension/Tabs Very lipophilic Complete absorption 30 min vomiting patients Buccally or rectally

42 PAIN/DYSPNEA Methadone Suspension/Tabs Immediate & long term analgesic effects Immediate 4-6 hr analgesia Repeated dosing longer action analgesic Dose times daily

43 PAIN/DYSPNEA Methadone Suspension/Tabs cont d Long half life Reservoir in fat tissue If buccal volume problematic dose more frequently - smaller amounts increase concentration switch rectal route

44 PAIN/DYSPNEA Methadone Sub-Q Injection Chronic shortage From UK, Health Canada RQHR: pharmacy manpower shortage to mix methadone for sub-q use

45 PAIN/DYSPNEA Fentanyl Transdermal Patches Difficult to titrate Not useful on cachectic patients Several hours therapeutic

46 PAIN Dexamethasone Good pain reliever, esp. bone Neuropathic model of pain Reduces inflammatory markers Modulates ph Reduces noxious pain transmission

47 PAIN Dexamethasone Inflammation/edema brain Reduces seizure risk Anti-emetic, appetite stimulant No info on rectal use

48 PAIN NSAIDs Diclofenac supp mg TID Indomethacin supp mg BID Naproxen supp 500mg BID Ketoprofen supp mg BID No decrease seizure risk brain edema

49 GASTRITIS Omeprazole Can be given PR

50 AGITATION/DELERIUM Antipsychotics 1 st - sub-q important - nursing safety Benzodiazepines 2 nd - can increase agitation

51 AGITATION/DELERIUM Anti-Psychotics Haloperidol sub-q - PCU supply - hospital priority - unavailable community - no info PR Prochlorperazine 10mg supp Chlorpromazine sub-q

52 AGITATION Anti-Psychotics cont d Methotrimeprazine sub-q - not always available Methotrimeprazine 10mg PO unavailable - 25mg available

53 AGITATION Benzodiazepines used rarely Can increase agitation/falls Midazolam sub-q for emergencies Ativan SL or PR or sub-q

54 SECRETIONS Anti-cholinergic Usually atropine, glycopyrrolate Glycopyrrolate shorted - doesn t cross BBB - better for delirium All others can exacerbate delirium Atropine cardiac resuscitation

55 SECRETIONS Anti-cholinergic cont d Amitryptiline PR 25-50mg Q4H PRN Meclizine 25mg PR Q4H PRN compounded Scopolamine patch 1.5mg Q3 days Hyoscine 10mg S/Q Q2H PRN

56 NAUSEA/VOMITING Anti-dopaminergic Prochlorperazine 10 supp Q6H PRN Promethazine mg supp Q8H Haloperidol 0.5 mg 1 mg po q4h prn Could use haloperidol sub-q on PCU

57 NAUSEA/VOMITING Anti-cholinergics nausea with movement Scopolamine patch 1.5mg Q3 days Meclizine compounded

58 NAUSEA/VOMITING 5HT3 antagonists Ondansetron PO EDS frequent dosing - short ½ life Mirtazapine PO wafer Q HS once a day dosing sleep, pain (5HT2) appetite stimulant, mood

59 SEIZURES Barbituates Phenobarbitol sub-q not available community Phenobarbitol sub-q limited hospital

60 SEIZURES Anti-convulsants Carbamazapine 100mg PR Q8H Sodium channel blocker Valproic acid 500mg PR Q8H Gabaergic, sodium, calcium channel blocker Both need frequent dosing

61 SEIZURES Benzodiazapines Midazolam: reserved acute seizure short half life requires frequent dosing $$

62 SEIZURES Benzodiazapines Ativan 2mg sub-q or PR Q6H Ativan SL not effective swallowed Clonazepam 2mg PR Q8H - usually BID - long half life

63

64 HOW DID WE DO? No formal data Perceptions

65 HOW DID WE DO? Pain control adequate Nausea/vomiting - better Secretion adequate

66 HOW DID WE DO? Reduction complaints reduced over sedation Less confusion

67 HOW DID WE DO? Methadone: Very well tolerated Very effective for dyspnea/pain

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69 Palliative Care Unit Statistics (3A) March 2011 February 2013 Prescribing changes S/Q opioid usage

70 CHANGES IN PRESCRIBING

71 CHANGES IN PRESCRIBING

72 CHANGES IN PRESCRIBING

73 CHANGES IN PRESCRIBING Methadone Changes in Prescribing Orders Methadone Scheduled Methadone prn 7 16

74 CHANGES IN PRESCRIBING Hydromorphone Total Oral Mg Used 80,000 60,000 40,000 20,000 0 HM SR HM IR Total HM ,703 16,086 30, ,656 47,384 70,040

75 CHANGES IN PRESCRIBING Morphine Total Oral Mg Used 15,000 10,000 5,000 0 Morphine SR Morphine IR Total Morphine ,940 4,790 12, ,950 5,730 13,680

76 CHANGES IN PRESCRIBING Oxycodone Total Oral Mg Used 1,500 1, Oxycodone SR Oxycodone IR Total Oxycodone ,055 1,

77 CHANGES IN PRESCRIBING Methadone Total Oral Mg Used 250, , , ,000 50, Methadone 85, ,701

78 CHANGES IN PRESCRIBING Total S/Q Medications Used 100,000 50,000 0 Morphine S/Q Hydromorphone S/Q ,905 76, ,340 72,846

79

80 WHAT OTHER LESSONS? Time savings? Cost savings?

81 NURSING MED ADMIN TIMES Looked at drug admin times Different drugs/routes

82 NURSING MED ADMIN TIMES Analgesics Sub-Q Line Insertion/Priming gather supplies, initiate sub-q line min:sec (most have sub-q line PRN meds) 8:00s hydromorphone sub-q med 3:45s x6 22:30s day buccal methadone 2:15s x3 6:45s day Time saved/pt 15:45s day

83 NURSING MED ADMIN TIMES Analgesics cont d Buccal methadone vs hydromorphone sub-q 5 patients x 15:45s day = 1:18:45s day

84 NURSING MED ADMIN TIMES Analgesics cont d min:sec hydromorphone sub-q med 3:45s x6 22:30s day rectal methadone (ped feed tube) 3:30s rectal methadone TID 3:30s x3 10:30s day Time saved/pt 12:00s day

85 NURSING MED ADMIN TIMES Analgesics cont d min:sec hydromorphone sub-q med 3:45s x6 22:30s day rectal methadone BID 3:30s x2 7:00s day Time saved/pt 15:30s day

86 NURSING MED ADMIN TIMES Analgesics cont d Rectal methadone vs hydromorphone sub-q 5 patients x 12:00s - 15:30s = 1 hour 1:17:30s

87 NURSING MED ADMIN TIMES Anti-emetics ondansetron sub-q 3:45 x3 11:15s sub-q line insertion/priming 8 min Nursing time used: 19 min 15 sec 1st day mirtazapine RD daily 2:15s

88 NURSING MED ADMIN TIMES Anti-Seizure midazolam sub-q Q4H 3 min 18 min/day clonazepam gel tab PR BID 6 min 12 min/day clonazepam long half-life midazolam short half-life, break through seizures

89 COST SAVINGS Analgesics Morphine Injection Hydromorphone Injection Methadone Oral Solution 10mg/ml = 43 cents 2mg/ml = 55 cents 10mg/ml = 37 cents/ml 15mg/ml = 44 cents 10mg/ml = $ mg/ml = $ mg/ml = $6.68

90 COST SAVINGS Analgesics MS Contin Hydromorph Contin Methadone Tablets 15mg = $.104 3mg = $ mg = 17 cents 30mg = $ mg = $ mg = 57 cents 60mg = $.26 6mg = $ mg = 90 cents 100mg = $ mg = $ mg = $ mg = $ mg = $ mg = $3.9355

91 COST SAVINGS Analgesics Fentanyl Patches 12 = $ $ = $ $ = $ $ = $ $ = $ $8.45 (generic vs. brand)

92 COST SAVINGS Analgesics Morphine IR Hydromorph IR Oxycodone IR 5mg = 14 cents 1mg = 15 cents 5mg = 9 cents 10mg = 19 cents 2mg = 22 cents 10mg = 15 cents 20mg = 34 cents 4mg = 22cents 20mg = 15 cents 30mg = 44 cents 8mg = 52 cents

93 COST SAVINGS Benzodiazepines Clonazepam Tablet Midazolam Injection.25mg = 7 cents 1mg/ml x 2ml = $.78 - $1.56.5mg = 7 cents 1mg/ml x 5ml = $ $3.90 2mg = 13 cents 5mg/ml x 1ml = $.41 $1.94 5mg/ml x 2ml = $2.65 Gel caps and lubricants very low - not a factor 5mg/ml x 10ml = $8.82

94 COST SAVINGS Anti-emetics Mirtazapine RD 15mg $ Ondansetron Inj 4mg/2mL $0.68/vial Ondansetron Inj 8mg/4mL $1.25/vial Haloperidol 5mg/ml $1.10ml Methotrimeprazine 25mg/ml $3.25ml

95 COST SAVINGS Secretions Hyoscine butyl bromide 20mg/ml $4.34/ml Scopolamine patch 1.5mg $3.96 Amitryptiline 25mg $0.13 Amitryptiline 50mg $0.25

96 COST SAVINGS Secretions Atropine 0.6mg/ml $0.825/ml Glycopyrrolate 0.2 mg/ml Glycopyrrolate 0.2mg/ml $7.46/2ml $53.80/20ml

97 FUTURE Cost Saving and Time Saving Benefits 1) Methadone as 1st line agent for dyspnea/pain 2) Clonazepam 3) Mirtazapine

98 LEARNING OBJECTIVES Have Learned: Why sudden nationwide shortage of injectable meds RQHR response to drug shortages Drugs affected, shortage severity Determinants in choosing alternate medications Medications we chose

99 LEARNING OBJECTIVES Have Learned: How did we do? Prescribing changes Any other lessons? - time savings, cost savings Future drug use

100

101 THANK YOU TO: Dr. Martha Santamaria Antonio Pedro University Hospital Dr. Lawrence Librach University of Toronto Bev Cross, RN, Nurse Educator, RQHR Dr. Alana Kilmury, Palliative Care Physician RQHR

102 THANK YOU TO: RQHR Pharmacy team Regina Palliative Care Team Members Kathleen Richlen-Tilden, PhD Terrilynn Lowes, Marcia Sehn, Admin Assistants

103 REFERENCES CBC News Online Pub Med Central, US National Library of Medicine, National Institutes of Health, Pharmacy and Therapeutics. Vol. 36(11); Nov 2011; PMC Twycross R, Wilcock A (eds). Palliative Care Formulary, 4 th Ed., Palliativedrugs.com Ltd, United Kingdom, 2012

104 REFERENCES Pereira JL, Associates. The Pallium Palliative Pocketbook: a peer-reviewed, referenced resource. 1 st Ed., The Pallium Project, Edmonton, Canada, 2008 Walsh D, et al. Palliative Medicine, 1 st Ed., Saunders Elsevier, Philadelphia, 2009 Stahl SM, Stahl s Essential Psychopharmacology, 3 rd Ed., Cambridge University Press, New York, 2008

105 REFERENCES Kim S, Shin I, Kim J, Kim Y, Kim K, Kim Ki, Yang S, Yoon J: Effectiveness of mirtazapine for nausea and insomnia in cancer patients with depression. Psychiatry and Clinical Neurosciences 2008; 62: Chang F, Ho S, Sheen M: Efficacy of mirtazapine in preventing intrathecal morphine-induced nausea and vomiting after orthopaedic surgery. Anaesthesia 2010; 65: Teixeira F, Novaretti T, Pilon B, Pereira P, Breda, M: Mirtazapine (Remeron TM ) as treatment for non-mechanical vomiting after gastric bypass. Obesity Surgery 2005; 15:

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