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|Newsletters: Tips for Dealing with Drug Shortages|
Tips for Dealing with Drug Shortages
Joseph Nadeau, Pharmacist, Mayo Clinic Home Parenteral Nutrition Program
Shortages continue to be a concern for home parenteral nutrition (HPN) consumers and health care providers. In January 2013, there were 121 drugs listed as being "short” on the FDA Web site. Information on shortages is provided voluntarily. As the FDA Web site states, "Manufacturers are not required to report information, such as reasons for shortages or the expected duration of shortages.”
In the past year, virtually every component of a normal HPN solution has been in short supply, except for water. Current drugs listed as short include amino acid solutions, dextrose, and fat emulsion (lipids). While we are out of many things, I will comment specifically only about some of the issues that have been a challenge lately.
Fat Emulsions—Making up the Calories
Several home care companies have begun conserving fat emulsion (lipids), which forces prescribers to examine how calories are delivered and to get creative. There are only three sources of calories in PN: dextrose, protein, and fat. If there is less of one, it may mean more of another. For example, to make up for dropping 50 grams of fat per week (one unit of 20%, 250 ml), it would be necessary to add an extra 20 grams of dextrose per day. It is up to the doctor who prescribes your HPN to determine how to adjust your solution if it is necessary, so it is essential for you to have a good relationship with him or her. You are always urged to discuss issues like this with your physician.
Multivitamins—How You Take Them Matters
Many home care companies continue to conserve IV adult multivitamins. The method of conservation may have a big effect on some consumers. For example, HPN consumers who are taking warfarin (such as Coumadin) for anticoagulation may have noticed widely varying results when they get their INR (a measure of "bleeding time”) checked. Home care providers who are using vitamins three times per week as a conservation measure are adding to this variability, because the dose of vitamin K is now only being provided three times per week, instead of the typical seven times per week, and vitamin K directly affects the INR.
It may be more beneficial to give 5 ml of the vitamins six times per week rather than 10 ml three times per week, in order to provide a consistent level of vitamin K. In the end, the dose of vitamins per week is the same, but the INR levels should become more consistent. If you notice inconsistencies in your INR, you should discuss it with the home care company providing the vitamins as well as the doctor who prescribes your warfarin and the doctor who prescribes your HPN to arrive at a safe and mutually acceptable solution.
Vitamin levels should be checked regularly and, as always, any concerns should be discussed with your doctor. During this time of IV multivitamin conservation, oral vitamins certainly are being used to help supplement. Depending on your diagnosis, and whether your problem is motility related or if you have short bowel syndrome or another issue, oral vitamin choices can be tailored to the diagnosis to achieve better vitamin levels.
For example, short bowel consumers might benefit from water-soluble forms of the fat-soluble vitamins to provide consistent doses of vitamins A, D, E, and K. This is based on diagnosis and anatomy, where if fat is not getting absorbed properly then also fat-soluble vitamins are not being absorbed properly. The water-soluble trait of these specialized vitamins helps them be absorbed by a different method. AquADEKs® is an example of this type of vitamins.
Consumers with motility problems may not be missing potions of their gut and can use different vitamins to get the desired effect. Chewable vitamins like Flintstones™ Complete may be a perfect choice for them.
In any case, discussion with your local health care provider is the way to get started. Your health care provider should have knowledge of your diagnosis and anatomy and can steer you to the best solution.
Trace Elements—Selenium Is Essential
Trace elements continue to be in short supply. Providers and consumers need to be aware that blood levels of these elements need to be checked regularly and adjusted when needed. SELENIUM IS A REQUIRED TRACE ELEMENT IN HUMANS. Selenium should always be a concern for home care providers. There can be dire consequences, such as cardiac problems, if levels drop too low and go unchecked, yet certain trace element packages do not contain selenium.If IV selenium is not available, you should discuss oral supplementation with your prescribing physician when appropriate.
At this point, there is no indication that drug shortages related to HPN are resolving. Health care providers have been challenged on a daily basis by these shortages. Consumers are encouraged to discuss any concerns with their doctor as well as with the company providing their HPN.
In addition, you should contact your local political representatives to voice your concerns. Please share your concerns with the Oley Foundation, as well, and any experiences you have had with drug shortages. It is helpful to have those stories available in one place, when legislators or journalists are looking for that type of information.
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Oley exhibit at A.S.P.E.N.'s Clinical Nutrition Week
Oley Regional Conference