From: Michele Durda
To: Gregg Knowles
Cc: Pharmacists
Sent: Friday, March 2, 2018 12:41:45 PM
Subject: Re: IV dilTIAZem shortage

Pharmacists,

Just as additional information to Gregg's discussion below.  We will be doing a pump drug library update on March 13 - at that time, we will be adding the new concentrated esmolol infusion and we will be adding the standard dilution esmolol concentration to the PCU-RCU library.  Until that time, the concentrated infusion would need to be programmed under "no drug selected" (on the Plum Pump), with the concentration and dosing units typed in.  Also, for esmolol infusions outside of the ICU, the nurse will need to go to an ICU library.  These issues with the pump library will be addressed after March 13.

Thanks,
Michele 

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From: Gregg Knowles
To: Pharmacists
Sent: Friday, March 2, 2018 11:42:01 AM
Subject: IV dilTIAZem shortage

To all,

As you are probably aware there is a shortage of IV dilTIAZem.  The reason for the shortage is similar to the reason for the narcotic shortage i.e.  Pfizer has purchased Hospira and is now finding quality issues in many formerly Hospira manufacturing facilities.  We currently have about a weeks supply of iv CardiZEM.  Pfizer has pulled their CardiZEM from wholesalers and is direct shipping to facilities on an allotment basis.  Our monthly allotment is about half a months worth of CardiZEM.  In an effort to spare CardiZEM, an email has been sent to cardiologist' informing them of the situation and asking they use other options when possible.  Alternatives include esmolol infusion, metoprolol ivp q6hr, oral CardiZEM.  In speaking to the cards I suspect we'll see mostly esmolol and metoprolol.  The dosing for esmolol is 500 mcg/kg ivp over 1 min followed by an infusion of 50 mcg/kg/min.  Max is 200 mcg/kg/min for rate control, 300 mcg/kg/min for other indications.  The restriction of esmolol only in icu's has been lifted.  Esmolol may be run on the floor (preferably a cardiac floor) but only at a fixed dose.  Titration is still allowed in the ICU, but any change of dose on the floor  will need a new order.  We have esmolol in a premixed infusion bag and bolus vials.  If a bolus is ordered, the vial will be sent up from central, the infusion bag comes from PSP.  Standard conc is 2500/250 (10mg/ml).  There is a double strength premix (2000/100) and we do carry it.  I do not see it in ICare so any orders to concentrate will have to be typed in for now.  I also do not see where a bolus dose goes into ICare so this may have to be a type in also.  IT is working on adding both so this may change.  Note the double strength is supposed to be added to the 'concentrated drips' VT.  With the short half-life we may not see the bolus ordered often.  

As for verification, the plan is to continue to dispense iv CardiZEM as long as we have it in stock.  Hopefully the docs will begin ordering enough alternatives that our allotment will suffice.  If we run out of dilt and it is ordered we will not be automatically converting orders over to an alternative.  Since it would involve a change in drug class we feel it prudent to call the md, inform them we have no dilt, rec an alternative, and go from there.  

Like the narcotic shortage, this could be a cloud over our head for all of 2018.  Pfizer is saying allotment may continue till March 2019.

Let me know if any questions/issues arise.  I'm sure they will.

Gregg K.
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Gregg Knowles, PharmD
Huntsville Hospital Pharmacy