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center126365Drugs – Shortages and Supply Issues 24th May 201900Drugs – Shortages and Supply Issues 24th May 2019The following advice is based on information available that the AGEM CSU Medicines Optimisation team (Norfolk) were aware of at the time of writing. *Please be aware the situation often changes on a daily basis and may depend on individual wholesaler supply to dispensaries / pharmacies. Pharmacies, dispensaries & patients should check supplies in their locality before requesting GPs to change prescriptions. Related Messages will also be added to Scriptswitch if relevant.Also NEW MIMs product shortages tracker available: Click for link ( via free registration)NEW (since 23.4.19, local stock checked 21.05.19*)Axsain cream (capsaicin 0.075%) cream – out of stock at all wholesalersExpected to be out of stock until Oct - Dec 2019 due to manufacturing issuesLicensed indications - post herpetic neuralgia, painful diabetic neuropathy (under expert supervision)No direct licensed equivalent?availableFor advice on alternative treatments see??NICE?CKS?- neuropathic pain? and Local Analgesics?Formulary?- see page 9Please note: Zacin cream (capsaicin 0.025%) is a different strength and only licensed for use in osteoarthritis.?Elleste solo MX 40mcg (estradiol) patches are out of stock at all wholesalersOther brands of estradiol patches are available but nearest equivalent dose is 50mcg?Evorel 50mcg patches are in stock at Phoenix & Alliance?Loprazolam 1mg tabs - out of stock at all wholesalers.1. Review ongoing need as per standard advice for hypnotics? HYPERLINK "" \o "PrescQIPP: appropriate & cost effective prescribing of short term hypnotics" \t "_blank" PrescQIPP: appropriate & cost effective prescribing of short term hypnotics2. Alternative similar short acting benzodiazepines equivalent to loprazolam 500mcg - 1mg dose:Temazepam 10mg -?available all wholesalersLormetazepam 500mcg - 1mg -?500mcg out of stock all wholesalers,?1mg in stock at Phoenix and?AAH?onlyZ-drug short acting: Zopiclone 3.75mg - 7.5mg -in stock at all wholesalersMontelukast 10mg tablets – generic in stock at Phoenix only, brand Singulair out of stockExpected date for more supplies of the generic end of May to Mid-June 2019Montelukast 5mg chewable tablets available at Phoenix & Alliance Questran (colestyramine) standard & lite out of stock again at all wholesalers.Due to changeover to new manufacturer - likely to be issues at least until August 2019However, Questran Lite may be available to Pharmacies/dispensaries with a valid Prescription from Alliance only -?PVS?Team on 0330 1028412See previous advice below from?UKMi?on alternatives:BUT please note Cholestagel (colesevelam) is also out of stock Colestipol (Colestid) is in stock at Alliance and?AAH?-?but see the link below - as different licensed indications Sulfate tabs 300mg – out of stock at all wholesalers, some stock expected end of May1. Consider if still needed -?standard recommendation, for cramp,? to interrupt treatment every 3 months to assess continued need (BNF),?also?reminder of dose-dependent QT-prolonging effects ?MHRA?20172. Quinine sulfate 200mg (?1.53) and quinine bisulfate 300mg (?1.59) - in stock at all wholesalers Quinine (anhydrous base) 100?mg = quinine bisulfate 169?mg; quinine sulfate 121?mg.Quinine bisulfate 300?mg tablets provide less quinine than 300?mg of the sulfateValsartan – all strengths, locally reported supply issues again40mg: caps?in stock at Phoenix and?AAH?only. Tabs out of stock all wholesalers80mg in stock Phoenix only. 160mg in stock Phoenix only. 360mg in stock at Phoenix & Alliance onlyIf completely?unavailable in your locality – consider changing to alternative ‘sartan?/A2RA’ See KM Bulletin ‘Which A2RA?’?Click here for link BACK IN STOCK (checked 21.05.19)Clomipramine ALL strengthsBack in stock at all wholesalersAiromir Autohaler (Salbutamol 100mcg/dose) 200 doseBack in stock at Phoenix & AllianceSevelamer Carbonate 800mgBack in stock at Phoenix & AllianceUPDATES on previous recent items (local stock checked 21.5.19)ProductCurrent availabilityBackgroundAdvice on alternativeAdalat products:All are Non-Formulary brands*Bayer is the sole supplier of these three formulations For 5mg & 10mg caps see update 5.3.19No other direct equivalentsFor LA 20mg, same daily doseNifedipine MR tablets 10mg ONE tablet TWICE a day but ensure the patient is advised verbally about the change. Now also difficult to obtainMR Tabs 10mg: Tensipine out of stock. Generically written may be available. Adipine in stock at Phoenix.MR Caps 10mg: Coracten available at Alliance only. For other strengths more cost effective brands are available e.g. Adipine tabs Tensipine tabs , Coracten caps – some of these are now subject to erratic supply with increased demandAdipine XL 30mg out of stock – Coracten XL in stock at Alliance only, Adipine XL in stock at PhoenixAdipine MR 20mg out of stock – Tensipine MR 20mg in stock AAH & Phoenix, Coracten 20mg MR caps in stock at AllianceAdipine XL 60mg out of stockCoracten XL in stock at Alliance only, Adipine XL in stock at PhoenixRemember – For hypertension & angina amlodipine is local formulary first line calcium channel blocker 5mg immediate release caps*Out of stock & and discontinued Feb19NEW – DH are working with other manufacturers and a new licensed UK source may be available by April – May19. Unlicensed special imported supplies are available10mg immediate release caps*Out of stock and discontinued Mar 19 LA20mg tabs*Out of stock until 2021LA30mg tabsOut of stock until 2021LA 60mg tabsOut of stock until 2021Retard 10mg tabsOut of stock and discontinued from Nov 18 Retard 20mg tabsDiscontinued from Nov 18Locally – PI# still in stock at Phoenix & AAHBetnesol (betamethasone 0.1%) eye ointmentNo longer available at wholesalersBrand was discontinued recently - Generic due to become available but not yet listed as available at local wholesalersNo other equivalent eye ointment – use betamethasone 0.1% eye/ear/nose drops (Vista-methasone is the most cost effective brand) – in stock all wholesalersBetnesol 0.1% brand out of stock at all wholesalersBumetanide 5mgOut of stock – expected end of July 19DH info: Mylan, the sole supplier of bumetanide 5mg tablets, have informed us they are not currently manufacturing stock of this strength. Supplies of the 1mg remain available Locally in stock at all wholesalersThere is a bumetanide 1mg/5ml liquid available from Chemidex however there is insufficient stock to cover an uplift in demand – NB very expensive ?198 / 150mlFurosemide 40mg available at all wholesalersCarbagen (carbamazepine) immediate release & MR – 200mg, 400mgNot available until mid-late 2019DH info: As carbamazepine is considered a Category 1 anti-epileptic medication, patients should normally be maintained on the same brand, however Mylan (the manufacturers of Carbagen) have informed DHSC that the above preparations of Carbagen tablet will be - unavailable until mid-late 2019.Novartis, the manufacturer of Tegretol which is the alternative brand of carbamazepine, tablets have confirmed that they are able to support additional demand during this time for all affected strengths and formulations.See support clinicians in prioritising and switching patients during this periodCilest (norgestimate and ethinyl estradiol)Non – formulary brand is being discontinued from July 2019 – already out of stock at AAHAlternative equivalent formulary brands Cilique & Lizinna, both in stock at all wholesalers (Hydrocortisone 10% rectal foam) – 14 doses ?9.33Out of stockMylan - Colifoam is manufactured outside the UK and they are still waiting for a shipment - No date yetLicensed indications: Ulcerative colitis, proctosigmoiditis and granular proctitisPlease check with patient’s consultant for most suitable alternative option.Alternative corticosteroid rectal foams available locallyBudenofalk (budesonide 2mg/dose – 14 doses ?57.11)Licensed for the treatment of active ulcerative colitis that is limited to the rectum and the sigmoid colonPrednisolone 20mg / dose – 14 doses ?187.00Licensed indications: Ulcerative colitis & proctitis.Elleste Duet Conti tablets (Estradiol 2mg, norethisterone acetate 1mg) ?17.02 3x28Out of stockWas expected Mid May 2019Alternative continuous combined oral therapy:Equivalent content :Estradiol 2mg/Norethisterone 1mgKliofem ?11.43 3 x 28 –in stock at sole supplier Alliance manufacturer states no supply issues but may go in and out of stock with increased demandDifferent progesterone: Estradiol 2mg / Medroxyprogesterone 5mg (less androgenic than norethisterone)Indivina 2mg/5mg ?20.58 3 x 28 –in stock at all wholesalersLower dose oestrogen content products are also available and may be suitable for older women, the higher oestrogen dose is usually needed to control symptoms in younger womenCKS?- Menopause HRTElleste Duet 1mg & 2mg (Estradiol 1mg or 2mg plus, estradiol 1mg or 2mg/norethisterone acetate 1mg) ?9.20 3x28Out of stockExpected Mid May 2019Alternative sequential combined oral therapy:Equivalent estradiol 1mg + estradiol 1mg/norethisterone 1mgNovofem ?11.43/84 available at Alliance onlyNo equivalent currently available for Elleste Duet 2mg Similar product which is available at all wholesalers but has a different progesteroneFemoston 1/10 or 2/10 (Estradiol 1mg or 2mg plus estradiol 1mg or 2mg/ dydrogesterone 10mg) ?16.17/ 84Dydrogesterone is less androgenic than norethisteroneElleste solo 1mg & 2mg (estradiol) tabs ?5.06/ 84out of stock at all wholesalers, stock now expected mid- May 2019Alternative brands Zumenon 1mg tabs ?6.89/ 84 – in stock all wholesalersZumenon 2mg tabs ?6.89/ 84 – in stock all wholesalersProgynova 1mg tabs ?7.30 / 84 – in stock all wholesalersProgynova 2mg tabs ?7.30 / 84 – in stock all wholesalersEpanutin 50mg Infatabs chewable (phenytoin)Out of stockDH info April 2019: Pfizer have informed DHSC of a temporary supply issue with Epanutin Infatabs from 1st May until September 2019 due to a delay in manufacturing. To help mitigate the shortage Pfizer has obtained approval from the MHRA to import stock of Dilantin (phenytoin) Infatabs from Canada.Canadian packs of Dilantin are considered as an unlicensed product in the UK. Epanutin 30 mg/5 ml Oral Suspension remains available, however, supplies are only available to meet normal market demand as such patients should not be switched to Epanutin Oral Suspension as this may precipitate a shortage of this presentation.See attached information from PfizerEpipen Auto-injector:150mcg (Junior)300mcg (Senior) Emerade150mcg300mcg500mcgJext 150mcg300mcgOut of stockIn stock AllianceIn stock PhoenixIn stock AAH & PhoenixIn stock Phoenix & AAHIn stock AllianceIn stock AllianceCheck with local Pharmacies/ DispensariesOngoing interruptions in the supply for all brands - further stock is due in the coming months so the situation should improve.For the latest updates and useful information see: 500mcg is an option for Adults > 60kg (500mcg dose for anaphylaxis recommended by Resuscitation Council UK advice-click for link) Further info is also available at Anaphylaxis Campaign websiteFemseven Conti Patches:?15.48 / 4 Estradiol 50mcg + levonorgestrel 7mcg per patchOne patch per weekOne Rx chargeBOTH discontinued from Dec 2018And out of stock at all wholesalersEvorel Conti ?13.00 / 8Estradiol 50mcg + norethisterone 170mcg (i.e. different progesterone) One patch every 3 to 4 daysOne Rx charge In stock at Phoenix onlyPost-menopausal women, with uterus, more than 6 months post-menopause (or 18 months since last period).Femseven SEQUI?13.18 / 4estradiol 50mcg alone patches, one per week for 2 weeks then estradiol 50mcg+ levonorgestrel 10mcg combined, one patch for week for 2 weeksmonthly bleedTwo Rx chargesEvorel SEQUI?11.09 / 8estradiol 50mcg alone patches, One patch every 3 to 4 days for 2 weeksthen estradiol 50mcg+ norethisterone 170mcg (i.e. different progesterone) combined, One patch every 3 to 4 days for 2 weeksmonthly bleedTwo Rx chargesIn stock at Phoenix & AAH, low stock at AllianceFemseven patches (estradiol) 50mcg, 75mcg, 100mcg Discontinued from Dec 2018Still in stock locallyEvorel or Estraderm patches (estradiol) 50mcg, 75mcg, 100mcg Availability depends on wholesaler & strengthLabetalol tabletsall strengths of both generic and brand (Trandate)Out of stock (See communication from NNUH)16.4.19 - DHSC have been informed there is a supply issue affecting all strengths of labetalol tablets until early to mid- May 2019.Labetalol is a non-selective beta-blocker with additional alpha blocking properties. It is licensed for the treatment of mild to severe hypertension, hypertension in pregnancy and angina pectoris with existing hypertension. Labetalol is primarily used for hypertension in pregnancy. Please see the following link for further advice ointment 3.5g & 5gNon-Formulary brandOut of stock No availability dateFormulary alternative options include:Xailin night eye ointment preservative free 5g (?2.51) 60 day shelf life post opening: in stock at Phoenix & Alliance and recommended by Royal College of Ophthalmology (RCOP) as an alternative. In stock at all wholesalersVitA-POS eye ointment preservative free 5g (?2.75) 6 month shelf life post opening. In stock at all wholesalersSee Local Dry Eye PathwayLevomepromazine 25mg/mlOut of stockWas expected back end of April 19DH info 16.4.19 - levomepromazine 25mg/ml - sanofi (Nozinan) - will be out of stock until the end of April. The only other UK supplier, Wockhardt, anticipate they will be out of stock this week due to the unexpected increase in demand; their next delivery has been delayed and further stock will not be available until the end of April.In the palliative care setting, it is widely used for terminal agitation and as a second line anti-emetic agent. Management options will need to be determined on a case by case basis, in consultation with the specialist palliative care teams. See the following link for further info: 290mcg (Constella)Out of stock at all wholesalers, expected back June 2019See?relevant pathway below for alternatives?Symptomatic treatment of moderate to severe Irritable Bowel Syndrome with Constipation (IBS-C) in adults TAG Double Green?(GPs can initiate and prescribe)?but only in line with local pathway?TAG Irritable Bowel Syndrome: constipation predominant (IBS-C) i.e. after treatment with at least two types of laxative during a 6 month period. OR?as last resort option as per the following constipation pathways:?NB Lubiprostone has recently been discontinued - pathways below to be updated HYPERLINK "" \o "TAG opioid induced constipation pathway" \t "_blank" TAG opioid induced constipation management pathway HYPERLINK "" \o "TAG chronic constipation in adults treatment pathway" \t "_blank" TAG chronic constipation in adults treatment pathwayLoestrin 20mcg (Ethinylestradiol 20 microgram / norethisterone acetate 1mg) ?2.70/63Loestrin 30mcgBoth 20mcg & 30mcg now out of stock No availability dateNo direct equivalents availableSimilar cost-effective alternatives:Containing low dose ethinylestradiol 20mcg or 30mcg but different, 3rd generation, progesterone (less side effect potential but slight increased VTE risk – see )Gedarel 20 or 30mcg / 150 (ethinylestradiol / desogestrel) in stock via all wholesalersMillinette 20 or 30mcg / 75 (ethinylestradiol / gestodene) in stock via all wholesalersHigher oestrogen dose increases risks related to circulatory diseaseMadopar (co-beneldopa)62.5mg caps in stock Alliance (low) (generic in stock Alliance)CR 125mg in stock at AAH & Alliance 250mg caps in stock Alliance (low)125mg caps in stock Alliance (low)125mg DISP in stock Alliance & AAH62.5mg disp in stock AllianceOngoing on/off issues with all Madopar plus:62.5mg disp, Roche update 12.2.19 is not expecting further stock until mid-end February. They have confirmed that good supplies of Madopar 100 mg/25 mg dispersible tablets remain available.See the memo link below regarding manipulation of 100/25mg dispersible to deliver 50/12.5mg dose until supplies of lower tablet strength resume pharmacies/dispensaries have any queries they can contact Roche Customer Service on the following number: 0800 731 5711Menadiol 10mg tablets -– not commonly used but some practices have patients on theseAlliance is the sole supplier; will be out of stock until around March 2019Still out of stock A National Shortage Alert, with information on alternative options, is available via are now supplying an unlicensed special which is the same formulation as the licensed product. Please find see information sheet in 20.3.19 issue which was drawn up about the special product. This product is available to order from AlcuraMethenamine (Hiprex) 1gStill out of stock at all local wholesalers, was expected back end of AprilManufacturer?may be able to supply individual Pharmacies and dispensaries on an emergency basis, via their usual wholesaler, by calling 0170 853100?or?0800 1218 267 (option 2)Only on local?formulary?as 3rd line?UTI?prophylaxis on consultant recommendation onlyNo equivalent alternative. Only used as prophylactic treatment so consider temporary stop until available or seek advice from consultant who recommended use.Metoprolol 50mg & 100mg tabs100mg out of stock all wholesalers50mg in stock at Phoenix & Alliance25.2.19 DH- Intermittent supply issues affecting metoprolol 50mg and 100mg as some manufacturers have recently discontinued these products and others are having supply difficulties. Supply is likely to be intermittent for a number of months. Suppliers of alternative beta blockers have been contacted to determine if they can meet any additional demand and currently, the manufacturers of carvedilol have indicated they would be unable to meet demand if patients were switched to this product. Manufacturers of bisoprolol, atenolol and propranolol have indicated they have capacity to support any additional demand on their productsSee the following for information on alternative agents and management options depending on indication Forte eye drops 1% (prednisolone)5ml in stock at Phoenix & Alliance10ml out of stock at all wholesalersReported supply issues – pack size may need amending( for 10ml – Pharmacy/ dispensary can supply 2 x 5ml)Stemetil 5mg/5ml syrup(prochlorperazine)Out of stock at all wholesalersSanofi have informed DHSC that there is very limited stock available of Stemetil oral syrup ?3.33/100ml, Stocks are likely to last until approximately late November 2018 with next delivery not due until the middle of 2019.Other presentations of Prochlorperazine which will continue to remain available are; 5mg Tablets (maleate)? 5mg ?0.66/28 in stock(see link below will disperse easily in 10ml water, in 5min – off-licence use)Buccal (maleate) 3mg ?49.79 / 50 in stockInjection (mesylate) 12.5mg ?5.23 / 10UKMI have prepared the following shortages memo, which provides potential advice on management options, this has now been published on the SPS website: 1mg & 5mg tabletsSupplies will not improve until some point in 2019 Manufacturing issues with the active ingredient, therefore long term issues affecting the tablets.Alternatives:Trifluoperazine solution SF 5mg/5ml: In stock at all wholesalers ?25.50 /150ml - most cost effective option for all doses - use oral syringe if low dose required.Trifluoperazine solution SF 1mg/5ml - in stock at Alliance only ?112.25 / 200mlNB: Unlicensed special supplies may be available but please check the cost compared to the above licensed solutions.If you require advice on stock shortages please contact your locality AGEM medicines optimisation team agem.medicines.norfolk@ The PSNC has also published a Dispensing and Supply Factsheet to provide information on medicines supply for patients and provide support to community pharmacies during this increasingly difficult period for pharmaceutical supply - Link# PI = Parallel ImportLabetolol NNUH communicationFrom: Communications (NNUHFT Shared) [mailto:communications@nnuh.nhs.uk] Sent: 25 April 2019 16:08To: Gp Link (NNUHFT Shared) <GPLink@nnuh.nhs.uk>Subject: National Labetolol shortageDear GP PracticeIn view of the current national shortage of labetalol please read the following guidance with regard to an alternative preparation.In practice (and in agreement with drug information, NNUH):Hypertension in pregnancyNICE guidelines state that where clinically appropriate, labetalol is recommended as the first line antihypertensive treatment for hypertension in pregnancy.? NICE guidelines recommend nifedipine or methyldopa as alternatives to labetalol for hypertension in pregnancy taking into account the side effect profiles:Nifedipine is second line choice after labetalol.2Use a modified release preparation of nifedipine, usually a twice daily (MR) preparation.If clinically appropriate, start nifedipine on a low dose: nifedipine 10mg MR twice a day, and if necessary increase to 20mg MR twice a day, then to 30mg MR twice a day and possibly up to 40mg MR twice a day.Third line treatment is methyldopa but it is less well tolerated with increased side effects such as sedation at higher doses.Methyldopa is contraindicated in depression.Nifedipine and methyldopa are not licensed specifically for hypertension in pregnancy.Expert opinion suggests that if switching from labetalol to nifedipine, labetalol 300mg tds is considered equivalent to nifedipine 20mg MR bd. Careful monitoring would be needed with escalation of dose depending on patient response, and it is important to bear in mind that non-response may represent worsening hypertension rather than a non-equivalent dose.If the woman is on labetalol < 300mg tds change over to nifedipine 10mg Modified Release (MR) bdIf the woman is on labetalol 300mg tds change over to nifedipine 20mg MR bdIf she is on higher doses of labetalol (in rare cases), refer to ANC for assessment (where doses ≤ 40mg MR bd can be prescribed but are likely to ?require hospital admission)Fran Harlow MBBS MRCOGLead for Maternal Medicine at NNUHClinical Skills Co-ordinator for Norwich Medical SchoolClinical Skills Lead for the Physician Associate program at NNUH ................
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