CURRENT DRUG SHORTAGES (through February 9th, 2012)

CURRENT DRUG SHORTAGES (through February 9th, 2012) CRITICAL SHORTAGES CURRENT & ONGOING SHORTAGES Therapeutic class new shortages other/ongoing shortages Adenosine analgesic Ketamine inj Alfentanil inj Aminocaproic Acid Oxymorphone Bupivacaine Ascorbic Acid Inj Bupivacaine w/epi Atropine Buprenorphine inj Black widow spider antivenin Choline mg trisalicylate Bleomycin Hydromorphone Carpuject Syringes Butorphanol Nalbuphine inj Carboplatin Naloxone inj Cisplatin Oxycodone IR tabs and caps Cytarabine Ropivacaine inj Daunorubicin Sufentanil inj Diazepam inj Doxorubicin liposomal anti inflammatory Dexamethasone sod phos inj Doxorubicin Ibuprofen inj Etomidate inj Indomethacin inj Etoposide Inj Metaxalone tab Fentanyl inj Fluorouracil Foscarnet inj Furosemide inj anticonvulsants Phenytoin inj Fosphenytoin inj Hydromorphone PCA Valproate inj Idarubicin Leucovorin antimicrobials Aztreonam inj Acyclovir (Tabs, Caps, and Inj) Levoleucovorin antivirals Ceftazidime inj Amikacin inj Lorazepam inj antifungals Ciprofloxacin IR tabs Ampicillin sulbactam Ketorolac tromethamine inj Neomycin oral soln Azithromycin inj Magnesium sulfate Pentamidine isethionate Capreomycin Mannitol injection Telavancin inj Cefaclor Susp MESNA Injection Cefotaxime inj Metoclopramide inj Cefpodoxime Metoprolol inj Clarithromycin IR Tabs Morphine inj Ciprofloxacin Inj Ondansetron Inj Doxycycline Hyclate Inj Paclitaxel Fluconazole Inj Prochlorperazine Ganciclovir Caps Ondansetron Inj Gentamicin

CRITICAL SHORTAGES Rocuronium Inj Sodium chloride 23.4% inj CURRENT DRUG SHORTAGES (through February 9th, 2012) CURRENT & ONGOING SHORTAGES Therapeutic class new shortages other/ongoing shortages Kanamycin Inj Levofloxacin inj Metronidazole (Inj caps and Tabs) Mitomycin Nitazoxanide tabs Nystatin Oral sus Primaquine phosphate Rifampin Inj SMX/TMP Inj Tetracycline caps Ticarcillin Clavulanate Tobramycin Solution Inj Vancomycin Inj antineoplastics Pentostatin inj Busulfan Vinblastine Dacarbazine Inj Denileukin diftitox inj Fludarabine Inj Idarubicin Inj Irinotecan inj Leuprolide acetate 14 day kit Mechlorethamine Inj Leuprolide acetate 14 day kit Mechlorethamine Inj Sodium thiosulfate inj Thiotepa inj Thyrotropin alfa antipsychotics Haloperidol Decanoate Inj Haloperidol Lactate Inj Lithium oral solution Thiothixene Caps Resolved cardiovascular Epinephrine inj Alprostadil Ammonium molybdate inj Methyldopate inj Amiodarone Inj

CRITICAL SHORTAGES CURRENT DRUG SHORTAGES (through February 9th, 2012) CURRENT & ONGOING SHORTAGES Therapeutic class new shortages other/ongoing shortages Diptheria and Tetanus Valsartan Argatroban Gold Sodium Thiomalate Inj Digoxin Inj Methylprednisolone tab Diltiazem inj Sodium Fluoride Oral Drops Dipyridamole Inj Sodium Phenylacetate and Sodium Benzoate Dopamine inj Esmolol inj Heparin sodium Inj Labetalol inj and tabs Lidocaine inj Lidocaine 2% Emergency Syringe Lidocaine w/epi inj Nicardipine Inj Norepinephrine Inj Procainamide hcl inj Reteplase Inj Ticlopidine Tabs Triamterene/HCTZ caps and tabs Vasopressin Inj endocrine gastrointestinal digestive Chorionic gonadotropin (human) Inj Levothyroxine inj Liotrix tablets Metformin Tabs Testosterone Cypionate IM Inj Famotidine inj Granisetron HCl Inj Lansoprazole orally disintegrating tabs Promethazine Inj supplements Cysteine inj Adult Multivitamins for Infusion electrolytes Sodium Acetate inj Calcitriol Inj Calcium Chloride Inj Calcium Gluconate Inj Copper inj

CRITICAL SHORTAGES CURRENT DRUG SHORTAGES (through February 9th, 2012) CURRENT & ONGOING SHORTAGES Therapeutic class new shortages other/ongoing shortages Cyanocobalamin inj MTE 5 Potassium Acetate Inj Potassium Phosphate Inj Sodium Bicarbonate 8.4% Inj Sodium Chloride 14.6% Inj Vitamin A Inj Zinc Chloride Inj Drugs No Longer Available miscellaneous Acetazolamide inj Acetylcysteine Acetaminophen/Dichloralphena zone/isometheptene Bumetanide inj Acetazolamide inj ADEK Chewable tabs Doxapram inj Alcohol Dehydrated Inj (Ethanol) Drotecogin alpha (Activated) inj Hyaluronidase Injection Aminophylline Emergency Drug Syringes Indigo carmine inj Ammonium Chloride Inj Epinephrine Metered Dose Inhaler Midazolam inj Amphetamine Mixed Salts ER capsules & IR tablets Ergonovine injection Oxytocin inj Aprepitant caps Flunisolide oral inhaler Protamine sulfate Atracurium inj Gatifloxacin 0.3% Ophthalmic solution Azathioprine inj Gemtuzumab Ozogamicin Injection Caffeine and Ergotamine Tartrate Heparin sodium (beef) inj Caffeine Citrate Injection and Oral Solution Inamrinone Inj Calcium acetate caps Ipecac syrup Chloroprocaine tabs Iron Polysaccharide Oral Liquid Chromium (Chromic Chloride) Injection Japanese encephalitis virus inactivated vaccine Cilostazol tablets Mebendazole tablets Cyclosporine inj

CRITICAL SHORTAGES Mephobarbital tablets Tetracaine topical soln Thiopental Inj Tinzaparin sodium injection TriHlBit Tripedia CURRENT DRUG SHORTAGES (through February 9th, 2012) CURRENT & ONGOING SHORTAGES Therapeutic class new shortages other/ongoing shortages vaccine Hepatitis A Vaccine Inactivated MMRV Live Vaccine Cocaine Topical Soln Deferoxamine Mesylate Inj Desmopressin Inj Dextroamphetamine tabs Diphenydramine hcl inj Droperidol inj Echothiphate Powder for Ophthalmic Solution Fat Emulsion Fluocinolone Acetonide intravitreal implant Glycopyrrolate Inj Indigo carmine inj Leflunomide Tabs Levothyroxine inj Methotrexate Inj Methoxsalen Capsules & Lotion Methylene blue inj Methylphenidate Tabs Milrinone Inj Naltrexone tabs Octreotide inj Pancuronium inj Papaverine Paregoric Liquid Phentolamine inj Rabies Immune globulin Ranitidine inj Rotigotine transdermal systems patch Scopolamine Transdermal Patch Selenium inj Sucralfate Oral Tertbutaline sulfate inj Trazodone Tabs Vecuronium Inj

Drug Shortages Affecting MHMH and Action Plans for Specific Shortages Drug Shortage information Action Plan Adenosine inj Pharmacy is unable to obtain the vials currently stocked on the emergency carts from our wholesaler. Prefilled syringes in 6 mg and 12 mg are currently available through our wholesaler. The Resuscitation Council has been notified and once stock reaches less than 100 across the system for shelf stock, the emergency cart stock will be decreased by 1/2 and pharmacy may begin stocking the cart with a combination of vials/prefilled syringes. A note will be placed on the cart if this occurs, and communication will be sent out to providers across the system. Amikacin Inj The shortage is due to a raw material shortage and manufacturing delays. The shortage duration is unknown. Aminocaproic Acid The shortage is due to one of the makers of the medication suspending production of the medication. The duration of the shortage is expected to last at least through mid-february 2012. Black Widow Antivenin Bleomycin Butorphanol inj Our current antidote supply has expired. The shortage is due to the low inventory of the manufacturer. The shortage duration is unknown. The antidote is available from the manufacturer in an emergency situation. The shortage is due to on manufacturer discontinuing the product in May 2011 and increased demand by other manufacturers. The duration of the shortage is expected to last through February 2012. System stock is being tracked. Currently, no supply is available. The shortage is due to multiple reasons including increased demand and suspension of manufacturing. The duration of the shortage may last anywhere from January to March 2012. Pharmacy inventory specialists will work directly with the wholesaler in the event that product is needed for emergency shipment. A memo was released to CV surgeons regarding the use of tranexamic acid in the event that stock becomes critically low. Current stock is stable but is being tracked on a weekly basis by pharmacy. Baptist Memphis has one vial with an expiration date of Feb 18. A memo was distributed to pharmacists describing the Emergency Supply Plan. Merck will supply 1 package/order on a case by case situation. It may take up to 24 hours to receive this shipment. A communication letter has been sent to oncologists/hematologists to notify them of the shortage. Alternatives: For Hodgkin's Lymphoma, omit bleomycin or use an alternative regimen. For testicular cancer, use the EP or VIP regimen. Memo/education released to OB (also posted on Methodist MD) for alternative, nalbuphine.

Daunorubicin Diazepam inj Doxorubicin Etomidate Furosemide Hydromorphone PCA Indigo Carmine The shortage is due to suspension of manufacturing and manufacturing issues. One manufacturer, Teva, has product available but is reviewing orders prior to releasing it to pharmacies. Currently, stock is unavailable due to manufacturing delay by the sole supplier of the medication. Expected release date is March of 2012. The shortage is due to manufacturing issues. The duration of the shortage is expected to be at least through 1Q12. Product is currently unavailable through Methodist's wholesaler due to manufacturing issues. Duration of the shortage is expected to be at least through March 2012. The shortage is due to increased demand and manufacturing delays. Duration of the shortage is expected to be at least through late-february to early-march 2012. Hydromorphone PCA is currently in limited supply through our wholesaler and supplier. In addition, the empty vials for hydromorphone PCA are also on shortage. The duration of the shortage is unknown at this time. The shortage is due to both manufacturers halting manufacturing of the product. One manufacturer has product on intermittent backorder and is releasing product as available. There is no estimated duration for the shortage. A communication letter has been sent to oncologists/hematologists to notify them of the shortage. Use alternative anthracycline or an alternative regimen for lymphomas, metastatic breast cancer, or sarcomas. Medication pulled from Omnicell except pediatric and ED Omnicells to conserve current stock. A communication letter has been sent to oncologists/hematologists to notify them of the shortage. Use alternative anthracycline or an alternative regimen for lymphomas, metastatic breast cancer, or sarcomas. Stock is being removed from anesthesia trays and placed on OR cardiac boxes for anesthesia use to conserve stock. Stock will remain on ICU and ED Omnicell but alternatives are encouraged where possible (see specific memo). Stock is being tracked on a weekly basis. Prescribers are encouraged to order po over IV where clinically appropriate. Stock is being tracked on a daily basis. Encourage use of morphine PCA where possible (see adult morphine PCA protocol for dosing). Prescribers have been notified of this shortage. Methylene blue may be an alternative in some situations.

Leucovorin inj Lorazepam Magnesium sulfate inj Mannitol Metoclopramide inj The shortage is due to increased demand and manufacturing issues. The expected duration of the shortage is through Feb 2012. Lorazepam injection is currently unavailable through our wholesaler due to increased demand and one manufacturer discontinuing production of the product. Projected length of the shortage through March-April 2012. Magnesium sulfate is on national shortage due to increased demand and manufacturing delays. The expected duration for the shortage ranges from February 2012 to March 2012 for the injectable presentations. The shortage is due to increased demand and manufacturing delays. Estimated resolution of the shortage is February 2012 to 1Q12. The shortage is due to manufacturing issues and regulatory issues with one manufacturer. The expected duration of the shortage is at least through mid- March 2012. P&T approved pharmacist interchange from leucovorin to levoleucovorin if needed. Leucovorin tablets are currently available and are not affected by the shortage. A communication letter has been sent to oncologists/hematologists to notify them of the shortage. Action plan has been approved by P&T. The first 2 steps of the action plan have been implemented: 1. Encourage po use wherever clinically possible. Additional restrictions as approved through P&T (restrict to seizure/status epilepticus) will only be implemented in the event that stock becomes critically low. 2. Remove from Omnicell with the exception of ED and ICU. All other doses are drawn up on demand from pharmacy. Action plan has been approved by P&T. Once system stock becomes less than 500 vials for the 2 ml presentation, the following action plan will be implemented: 1. conservation of magnesium sulfate in TPN solutions 2. Conservation of magnesium sulfate boluses via automatic interchange to oral supplementation for patients who meet certain criteria 3. standard IV bolus dosing of 4 grams to conserve stock and minimize waste for unused product returned to pharmacy 4. setting sufficient stock at all hospitals for pre-eclamptic/eclamptic patients (already done) and 5. potential removal from emergency carts. Action plan to be approved by P&T Committee. Prescribers are encouraged to use alternatives where possible. Pharmacy is utilizing premix bags to draw up into syringes to conserve current stock. If stock reaches less than 1000 grams across the system, restrictions to the following patient groups will be implemented: Use in kidney transplant recipients (limit of 12.5 grams per case) and liver transplant cases (limit of 25 grams per case) b. Use in craniotomy procedures c. Patients with severely elevated intracranial pressure with neurologic injuries, where concentrated sodium chloride is not an alternative P&T approved automatic conversion from IV to po in patients that meet certain criteria. Pharmacists were reminded that the oral disintegrating tablet is not included in the conversion plan as it is currently nonformulary and also on national shortage. Prescribers are encouraged to order po over IV where clinically appropriate. Medication will be pulled from all Omnicells to preserve current stock.

Midazolam Ondansetron injection Phentolamine mesylate Prochlorperazine inj Protamine Inj This product is on shortage due to increased demand and temporary manufacturing suspension by two makers of the product. The duration of this shortage is expected to last at least through February of 2012. The shortage is due to multiple reasons from manufacturers, including suspension of manufacturing, discontinuation of product, and increased demand. Estimated resolution of the shortage is mid-february 2012. The shortage is due to the sole supplier of the product temporarily suspending production and distribution of all drug products in November of 2011. The expected duration of the shortage is unknown. The shortage is due to the sole supplier of the product temporarily suspending production and distribution of all drug products in November of 2011. The expected duration of the shortage is unknown. The shortage is due to increased demand by the sole manufacturer. The product is currently on allocation, with no estimated duration of the shortage. A sedative plan has been approved by P&T for both adults and pediatrics as below. This will be implemented as stock becomes critically low: Adults midazolam is recommended to be reserved for procedural areas due to physician experience. Use propofol first for sedation in the ICU, with the option to add on benzodiazepine drips as needed. Ketamine and propofol are being suggested as options for intubation, but require physician administration. Pediatrics reserve midazolam for procedural areas and intubation kits, and restrict lorazepam to status epilepticus when supply becomes critically low. P&T approved automatic conversion from IV to po in patients that meet certain criteria. See antiemetic memo on Methodist MD. Prescribers are encouraged to utilize oral therapy where possible. There is a CPOE order alert for this shortage. Stock is depleted across the system. Nitroglycerin ointment may be an option with certain extravasations Stock is depleted. Alternatives should be used by prescribers (see memo on Methodist MD). There is a CPOE order alert for this shortage. An emergency use supply may be drop shipped. All physicians should be aware of this critical shortage. Inventory weekly.

Sulfamethozaxole/ trimethoprim Inj Vitamin K inj The shortage is due to recall and manufacturing issues by the sole supplier. 5 ml and 10 ml vials are available but the company is reviewing all orders. The 30 ml vials are on backorder with an estimated release date of 3Q12. Vitamin K injection is currently unavailable through our wholesaler, including ampules and the prefilled syringe utilized in pediatrics. Expected duration of the shortage is through February 2012. Product is available through emergency supply. Oral therapy and alternative agents may also be used based on clinical indication. The American Society of Health-System Pharmacists (ASHP) has provided a reference for alternative agents on their Drug Shortage webpage. Encourage po use wherever clinically possible. Stock is being monitored by the pharmacy department. Reference: ASHP s national current drug shortages list. www.ashp.org. Accessed on February 10, 2012.