Demand for medications needed for patients who were intubated or put on a ventilator led to some shortages. The CARES Act has some provisions that may help deal with long-standing causes of the drug shortages that plague U.S. healthcare.
Although drug shortages are hardly a new problem for American healthcare, the COVID-19 outbreak has worsened them and put a spotlight on some festering problems that lead to imbalance between supply and demand for some important medications. The American Society of Health-Systems Pharmacists (ASHP) has close to 200 on its drug shortage list, while the FDA’s count is closer to 150. The two lists vary slightly with the FDA determining when demand exceeds supply, while ASHP’s list is based on manufacturers reporting and confirming shortages on a national scale. Tetracycline, an oral antibiotic, was listed as unavailable as of March, while the FDA reported that physicians were scrambling to find alternatives to cancer drugs, doxorubicin and methotrexate, according to ASHP.
COVID-19 has triggered a spike in demand for the sedatives, analgesics and neuromuscular medications used for patients on ventilators or who are intubated. The drugs in high demand include metoprolol, propofol, doxycycline hyclate injection, albuterol sulfate inhalers, cisatracurium, lidocaine, epinephrine and morphine. Demand for emergency syringes filled with sodium bicarbonate, sodium chloride and dextrose has also surged. In mid-March, ASHP listed five drugs associated with ventilator use were officially in short supply: norepinephrine, fentanyl injection, hydromorphone injection, rocuronium and vecuronium.
“The pandemic might not be causing the shortages, but it is exacerbating them,” says William A. Haseltine, Ph.D., a former Harvard Medical School professor and chairman and president of ACCESS Health International, a global health think tank based in New York. Haseltine says that drug shortages can be traced back to an underestimation of the number of COVID-19 patients who would be put on ventilators or intubated, drugs being used off-label for a variety of conditions and a shortage of the ingredients used to make many pharmaceuticals or, as they are called in drug manufacturing, active pharmaceutical ingredients (APIs).
“We need to reevaluate stockpiles to ensure there is a strategic reserve as we did during SARS and MERS, become less dependent on China and India and create long-range plans for long-term needs,” says Haseltine.
No Single Source of Information
Using its members’ purchase data, Vizient, a healthcare services company in Irving, Texas, calculated fill rates and the supply and demand of 13 drugs used in some aspect of COVID-19 treatment.
The demand for six sedatives and anesthetics used for patients who were intubated or put on ventilators increased by 140% from January to April. The fill rate — the percentage of customer demand that is met by immediate stock availability — dropped 50% for April. The demand for three analgesics from January to April increased 45%, while the fill rate dropped 72% in April; however, demand dropped 35% between the two work weeks.
The demand for four neuromuscular blockers increased 309% between January and April, while fill rates dropped 42% for April.
Although demand for drugs used to treat severe cases of COVID-19 has subsided some, there is still not enough supply, says Dan Kistner, Pharm.D., group senior vice president, pharmacy solutions for Vizient. He attributes drug shortages to problems with product quality and small surpluses of ingredients or products.But the entire situation is cloudy because there’s no single source of information and alack of transparency makes it difficult to know to how much of a product is available and where it is being manufactured, says Kistner.
Premier Inc., a group purchasing organization in Charlotte, North Carolina, that provides a variety of other services, has a program, ProvideGx, that works with generic drug manufacturers to address drug shortages. The program has provided healthcare providers with access to 150 drugs recently designated as shortage medications and is targeting 50 more in the upcoming months, according to the company. Acyclovir, ribavirin, fentanyl, propofol and midazolam are among the drugs that the program is tracking. Ribavirin, for example showed a 200% increase in demand with only a 50% fill rate. In February, ProvideGx partnered with Pfizer to supply to drugs in short supply, including Corvert (ibutilide fumarate injection), used to treat atrial fibrillation, and vincristine sulfate injection, a cancer chemotherapy.
Patrick Sudol, senior director of ProvideGx, says that having just one API manufacturer and production requirements that require specialized equipment can lead to shortages. “We need forecasting to determine how much of a certain drug would be needed and to build a better supply chain,” notes Paula Gurz, senior director of pharmacy for Premier. She says most of the shortages are older drugs with regional supply lines. Because prices are low, suppliers are often scarce, Gurz explains. “Ideally we’d like to have three suppliers so if one exits the marketplace, there are still two
Mari Edlin is a freelance journalist in Sonoma, California.