Pharmacy inventory specialists will work directly with the wholesaler in the event that product is needed for emergency shipment.

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1 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 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 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 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. 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.

2 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 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 and manufacturing delays. Duration of the shortage is expected to be at least through late-february to early-march 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. 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. 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.

3 Leucovorin inj Lorazepam Magnesium sulfate inj Mannitol Metoclopramide inj and manufacturing issues. The expected duration of the shortage is through Feb 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 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. 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 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.

4 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 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 The shortage is due to the sole supplier of the product temporarily suspending production and distribution of all drug products in November of 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 The expected duration of the shortage is unknown. 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.

5 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 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. Accessed on February 10, 2012.