Tuesday, September 18, 2012
Vets face difficult drug shortages in Canada
The situation is worsening for Canadian veterinarians in desperate need of key drugs to treat their patients.
Veterinarians continue to remain in short supply of important drugs including morphine, fentanyl and Phenobarbital after production issues with generic drug manufacturer Sandoz, a subsidiary of Novartis.
A fire at a Sandoz production plant halted production of its 235 products, according to the Montreal Gazette. The fire, which broke out March 4, stopped production for about a week before limited production resumed March 12.
Making matters worse, in 2011 Sandoz began a major production upgrade at its Boucherville plant following warnings from the U.S. Food and Drug Administration (FDA) that it had discovered serious deficiencies in its production methods. The FDA warned the company that it would block its exports to the U.S. unless the deficiencies were corrected.
The upgrade caused a slowdown in production, which affected distribution of drugs to both human and animal doctors.
Suzanne Misisaszek, DVM, of Whitemud Creek Veterinary Clinic in Edmonton, Alberta, said she has had trouble finding the drugs she needs for her practice.
According to Misiaszek, the list of drugs in short supply includes glycopyrrolate, diazepam, midazolam, phenobarbital, meperidine, morphine, fentanyl and hydromorphone.
Misiaszek says that Sandoz has told her that no human drugs will be delivered to veterinary wholesalers before the end of 2012, as the priority is to supply human hospitals first.
For Misiaszek, the Canadian VMA and the American Veterinary Medical Association (AVMA) have been giving her practice the most guidance in how to approach the situation.
"This shortfall came without warning and our provincial and national VMAs have really stepped up to help with recommendations," Misiaszek said.
Misiaszek says her clinic has had to turn to alternatives for anesthesia in order to keep a reserve of anesthetics that are presently in short supply. Sometimes, compounded drugs are the only alternative, forcing veterinarians to spend more and pass on cost increases to clients.
"We are using alternative products for anesthesia in regular patients to ensure we have some of the shorted drugs for special cases," Misiaszek said. "An example of a shortfall concern is epileptic patients that use rectal valium as part of their rescue protocol. This is now unavailable without being compounded. This greatly increases the expense and decreases the shelf life of the product."
Sandoz announced that in mid-February, it introduced an allocation system based on 2011 demand which ensures that each customer receives a fair share of available medicines. Further improvements in output are expected which should increase allocation levels for all products in production to at least 100 percent of forecasted market needs by November 2012, the company announced. However, Sandoz has said it will maintain its allocation system through the first quarter of 2013, in order to avoid unnecessary stockpiling and potential backorders.
Sandoz said it had optimized production output at the plant while correcting its production practices, allowing the company to meet the vast majority of Canadian market needs for its entire injectable portfolio. In May, Sandoz Canada reported that it is now supplying more than 80 percent of market needs for its entire injectable portfolio, and more than 90 percent for the products currently in production.
"Sandoz Canada continues to make strong progress in its efforts to maintain a reliable supply of essential medicines following the temporary slow-down in production announced at its Boucherville plant earlier this year," Sandoz announced May 16, 2012.
Still, the situation is forcing veterinarians into a corner, Misiaszek says.
"We are now using more expensive drugs that we have less experience with," Misiaszek said.
Misiaszek said she is starting to use more alfaxalone, and relying more heavily on dexdomitor and using a butorphanol/buprenorphine combo instead of hydromorphone. Being in short supply of hydromorphone has led her clinic to revamp its anesthetic protocols entirely.
Misiaszek says she has also had a hard time treating seizuring patients without injectable phenobarb or valium. In such instances, she often ends up having to compound.
She recommends that veterinarians keep the shortfall drugs in stock for emergencies, using alternatives whenever possible.
"Try to be as familiar as possible with all products available to veterinarians - you never know when you will have to rely on them," Misiaszek said. "We tend to get stuck in our comfort zone."
However, cost to clients can often rise as a result of using alternative drugs.
Misiaszek also recommends webinars led by a boarded anesthesiologist that address alternative drug options.
Using an adverse event book for any new protocol instituted can also track how patients are doing on certain medication combinations, allowing practitioners to make adjustments in a timely manner, Misiaszek said.
Misiaszek says she has had to take staff time to revamp protocols, restructure ordering and pricing, and train staff on the new procedures.
Unfortunately, Misiaszek says she doesn’t see the shortage problem going away any time soon.
"This is a long term problem for us that will probably get worse as our ‘stock’ supply diminishes," she said. "I think that we will be able to cope with alternatives and compounded medications to ensure we have the proper drugs to treat our patients."
Looking long-term, however, Misiaszek says she hopes the drugs will be back in stock and that Health Canada will not source all of the drugs to only one supplier in the future.