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COVID-19 ICU Drug Shortages Redressed, But Only in Part

Syringes and vials containing anesthesia drugs

Syringes and vials containing anesthesia drugs

As the federal government took steps to ease shortages of some critical sedatives and other drugs used in the ICU, pharmacy and anesthesiology groups say more needs to be done.

On Tuesday, the Drug Enforcement Administration loosened restrictions on controlled substances needed for the ICU treatment of COVID-19, increasing by 15% the allowed production volumes of fentanyl, morphine, hydromorphone, codeine, ephedrine, pseudoephedrine, and certain intermediates for their production. The agency also boosted the amount of ketamine, diazepam, midazolam, lorazepam, and phenobarbital that can be imported.

More action is being sought, though.

The American Society of Anesthesiologists (ASA), for example, is calling for the FDA to work with manufacturers to extend expiration dates of critical products.

The ASA threw the spotlight most urgently on the ICU sedative propofol. "With the increased demand for this drug and the number of COVID-19 positive patients needing ventilators, we can only anticipate that this will soon be in shortage," the group said in an open letter to the FDA.

The society also listed neuromuscular-blocking drugs it anticipated could be in shortage (atracurium, cisatracurium, rocuronium, vecuronium, and succinylcholine), pointed to an increased need for resuscitative drugs (dopamine, dobutamine, epinephrine, norepinephrine, phenylephrine, ephedrine, and atropine), and asked the FDA to monitor reversal agents (neostigmine, glycopyrrolate, and sugammadex).

"We're trying to be creative with other drugs we might have on hand, but obviously it's not ideal," said ASA President Mary Dale Peterson, MD.

For example, pharmacists are filling the gaps in hard-hit areas like New York and Detroit by strategies including using longer-acting drugs like methadone or putting drugs normally taken orally through a nasogastric tube instead, she noted.

Manufacturers she's spoken with have ramped up production, including for large vials of propofol, which will help, albeit likely to take weeks to impact hospitals' supply, she told MedPage Today.

The European Commission has extended assurances to the generic drug industry that it can coordinate amongst itself to battle shortages of critical hospital drugs without fearing antitrust accusations.

The FDA needs to develop an essential medicines strategy, with creating a list of essential medicines as the first step and then stockpiling those medications, argued G. Caleb Alexander, MD, of the Johns Hopkins Bloomberg School of Public Health in Baltimore, and Dima Qato, PharmD, MPH, PhD, of the University of Illinois at Chicago College of Pharmacy, in a viewpoint in JAMA.

A group of anesthesiologists, pharmacists, and others (again) called on states to give up their lethal-injection drug stockpiles to hospitals.

"Many of the medicines needed during this critical time are the same drugs used in lethal injection executions," specifically midazolam, vecuronium bromide, rocuronium bromide, and fentanyl, wrote Joel Zivot, MD, of Emory University in Atlanta, and colleagues in the open letter.

"Based on publicly available information from a handful of states, stockpiled execution drug supplies could be used to treat over a hundred COVID‐19 patients," they noted. "When one factors in the drugs held by states that refuse to release details of their supplies, it is likely many times that number of patients could benefit from their release. All told, these supplies could be used to save the lives of potentially hundreds of patients suffering from COVID‐19 and potentially thousands of patients in other ICU settings."

Not to be ignored are the potential equipment shortages, such as in the special filters needed to convert anesthesia gas machines to ICU ventilators, and even disposable laryngoscope blades, Peterson added.

"If I take the optimistic view, we're seeing in some of our harder hit areas that they are sort of at their peak, starting to get past their peak of new patients coming in with COVID-19," she said. "I'm hoping right now we may be experiencing the worst of it."

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Monday, 01 June 2020

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