Shortages affect availability of some drugs used in emergent cardiac care
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Key takeaways:
- There have been shortages of several cardiac drugs, including some used for emergencies, this year.
- Cardiologists should be aware of which drugs are in short supply and the potential alternatives.
Of the many drug shortages in the U.S. this year, several are used in cardiac emergencies, according to the American Society for Health-System Pharmacists.
Among the cardiac drugs in short supply are adenosine and lidocaine, which can be used to treat life-threatening arrhythmias, and dofetilide, which is used to treat atrial fibrillation and atrial flutter but must be initiated in the hospital and needs to be reinitiated in the hospital if patients are unable to get refills for use at home.
Healio spoke with Michael Ganio, PharmD, MS, BCPS, FASHP, senior director of pharmacy practice and quality at ASHP, to discuss what the affected drugs are used for, the consequences of not being able to obtain the drugs and the alternatives that physicians should be aware of.
Healio: Who uses adenosine?
Ganio: This is used in a couple of different areas. It can be used in cardiac stress tests and when patients have a specific type of arrhythmia when their heart is racing. It can slow down the heart and may stop it for a few seconds to reset its electrical activity. This can be used in life-threatening situations. Those are the primary uses in the cardiology world.
Healio: What is the nature of the shortage of adenosine?
Ganio: Some of the prefilled syringes, which are the most convenient for those emergent situations, have been in short supply. That means there could be a delay in getting the appropriate package size and concentration. The larger vials, the ones we might use in cardiac testing suites, are available, and smaller vials are available where you manually draw up the product. But the prefilled syringes seem to be problematic. Because those are ready to administer, they can be kept in crash carts or emergency kits.
Healio: What are the consequences if a patient cannot get this medication?
Ganio: There are other drugs that can be used in both situations. Adenosine is a drug of choice, which means it is the first option for a reason: side effects, cost and/or efficacy. If you are not using the drug of choice, you are going with another agent, which can mean different or worse side effects, less effectiveness or more expense.
Healio: What can cardiologists do if their patient is having trouble getting this medication?
Ganio: It is important to know that there may be shortages, and there are a lot of disciplines that are acutely aware of shortages, but sometimes, unless you are affected by shortages, you may not know this is a major issue. There are more than 300 drugs in shortage as of the end of March. Also, it is important to be careful with the alternatives. If the alternative is in a different form than what you are used to, such as a 4 mL vial instead of a 2 mL vial, you may be in the habit of drawing the entire vial when you should not be doing that with the alternative form. Be very aware that alternative dosage forms can mean you need to be doing something differently.
Healio: What is lidocaine used for?
Ganio: Lidocaine is included in the crash cart to treat a more life-threatening arrhythmia. It is a second-line treatment; amiodarone is usually the first-line treatment. However, lidocaine is available in prefilled syringes, which may make it the preferred choice in ambulances or in other emergency cases where time is critical. Finding the ampules of amiodarone and drawing them up may take time. If you are in a hurry, lidocaine may be a better option if the prefilled syringe is ready to go. Lidocaine can also be administered as an IV drip, and at one point that was in short supply, but currently it is just the small syringes that are.
Healio: Is amiodarone suggested if lidocaine is not available?
Ganio: Yes, depending on the patient’s clinical profile. There are always contraindications to any drug. In those cardiac arrest situations, depending on what rhythm the patient is in, like ventricular fibrillation, yes, amiodarone would be the alternative. However, these are the only two IV drugs used in these emergencies, so even as a second-line drug, this type of shortage can be concerning.
Healio: What is dofetilide used for?
Ganio: Dofetilide is primarily for patients with atrial fibrillation or atrial flutter. Patients have to be admitted in order to initiate treatment and need ECG monitoring to ensure they do not have any dangerous cardiac side effects. If enough doses are missed within 72 hours, the patient is supposed to be readmitted to resume therapy. There was a shortage of dofetilide, but the good news is, supply seems to have improved. It was a bit of a scare for some cardiologists, who were concerned that their patients would need to be readmitted, but in the last few months, we have not heard of shortages.
Healio: If dofetilide is unavailable, what are the alternatives?
Ganio: There are quite a few medications for AF. Cardiologists would have to work with the pharmacists to find something else, and then if the patient is switched back, they would have to go back to the hospital to be reinitiated.
Healio: What is being done to address the problem?
Ganio: There are over 300 ongoing drug shortages, so these examples are not unique, and it is having an impact on patient care in the U.S. The silver lining is, there has been a lot of attention on the problem. We have been in touch with a lot of Congressional offices and the FDA, and there seems to be much interest in addressing the problem.
For more information:
Michael Ganio, PharmD, MS, BCPS, FASHP, can be reached on Twitter at @mganio_ashp.
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