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Critical Drug Shortages Can Be Better Managed by Sharing of Information

The COVID-19 pandemic is making the shortage of critical medications even worse, according to a study which suggests how pharmacists specifically and healthcare systems in general can work together to mitigate it. The article also includes advice on what drug substitutions to use in which circumstances. Here is more information.

ANN ARBOR, MI – The ongoing shortages of critical medications is being made much worse by the COVID-19 pandemic, according to a new journal article that discusses how the potential scarcities might be managed.

The report in the Annals of the American Thoracic Society discusses the need to develop ethically sound policies to deal with low supplies of commonly used medications, which are becoming more acute with so many resources directed toward COVID-19 treatment.

https://www.atsjournals.org/doi/abs/10.1513/AnnalsATS.202004-362VP

"It is critical that these conversations occur now due to current shortages, as well as the necessary lead time to plan for future shortages," said Andrew G. Shuman, MD, co-chief of the Clinical Ethics Service, Center for Bioethics and Social Sciences in Medicine, University of Michigan Medical School. "Drug shortages have been a national emergency for years and are currently exacerbated due to COVID-19. Issues related to supply chain and anticipated increased ICU needs over the course of the pandemic are worsening the problem."

Co-author, Yoram Unguru, MD, MS, MA, a physician-ethicist at The Herman and Walter Samuelson Children's Hospital at Sinai and Johns Hopkins Berman Institute of Bioethics, added, "As of today the American Society of Health-system Pharmacists (ASHP) reports 213 drugs shortages in the United States. It is not just patients with COVID-19 who are affected. One example of a current drug with a critically short supply is Erwinia asparaginase, a life-saving chemotherapeutic agent for both children and adults with cancer."

The most severely affected medical specialties are oncology, critical care and infectious disease, according to the article. The authors urge regional communication among hospitals to help determine how local drug supply chains are affected. "Sharing information is an important first step," the suggest. "The second and more difficult step involves actual sharing of medications among hospitals and health systems."

Barriers to doing this can be great, however, requiring cooperation among competing health systems, concerns about potential liability and legal regulations that affect the transfer of drugs.

"Tantamount to this effort is facilitating communication between pharmacists -- those tasked with maintaining supplies, as well as those embedded within clinical teams -- in order to inform the clinical team how supply may impact care delivery,” pointed out co-author Erin Fox, PharmD, director of drug information and support services for Utah Health. “Pandemic-era strategies for conservation of commonly used critical care agents at risk of shortages should be noted, recognizing that these shortages are often regional and unpredictable, and intensive care protocols and strategies are highly individualized."

The report suggests that, even where the ventilator supply was sufficient, the critical shortage of sedatives, paralytics and/or opioids might have been associated with inadvertent extubation.

Based on the Society of Critical Care Medicine's Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU, the authors make the following recommends for conserving commonly used critical care agents:

• With analgesia, the report lists fentanyl as first line, hydromorphone as second line and morphine as third line, adding, "Consider adjunctive acetaminophen, gabapentin and oxycontin."
• For sedation, dexmedetomidine or propofol are listed as first line with the authors noting, "Consider adding ketamine." Second line is lorazepam, with midazolam as third line. "Do not use dexmedetomidine alone for deeper sedation," the report advises.
• For neuromuscular blockade, cisatracurium is listed as first line, vecuronium as second line and rocuronium as third line, with this recommendation: “Ensure appropriate sedation and pain control before initiating.”

“COVID-19 has upended an already-vulnerable medication supply chain and risks engendering devastating shortages of life-saving drugs, regardless of whether patients suffer from this virus,” the authors conclude. “Clinicians and the institutions for which they work will need to communicate at local, regional, and national levels to appropriately respond. Whenever feasible, they will need to use best available evidence to conserve existing supplies and they will need to plan for contingencies such as how to prioritize patients in the event of critical shortages. Only with clear lines of communication and a proactive, collaborative approach can we weather this impending storm. “

The authors also caution about future problems, such as drug hoarding, explaining, "Once effective treatments and/or vaccines for COVID-19 are available, prioritizing nascent supplies will present a formidable challenge.”