Oh, what fun! Acyclovir IV shortage...

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Omegadramon

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Substitute to ganciclovir until tolerate po (lol, no)? Use foscarnet?

enlighten me.
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So Z, what would be that one drug that you would absolutely hate to see go on a significant shortage, for a relatively long period of time. Maybe due to lack of substitution options, financial impact, effect on patient care. Which would you go with?

And Pri, I'd be interested to see which you'd pick too..
 
SpirivaSunrise said:
So Z, what would be that one drug that you would absolutely hate to see go on a significant shortage, for a relatively long period of time. Maybe due to lack of substitution options, financial impact, effect on patient care. Which would you go with?
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I'm gonna guess linezolid or azithromycin :D.
 
SpirivaSunrise said:
So Z, what would be that one drug that you would absolutely hate to see go on a significant shortage, for a relatively long period of time. Maybe due to lack of substitution options, financial impact, effect on patient care. Which would you go with?

And Pri, I'd be interested to see which you'd pick too..
Click to expand...

If in community: Azthromycin
Hospital: Vancomycin and/or Zosyn

In both setting? Then must be Vicodin
 
meister said:
Nah just go with valacyclovir, make GSK happy.
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That is about the time I call the medical student/intern and let them know that valacyclovir is not available parenterally, so let's try something else. Then they mumble something about what their Attending told them (their answer to just about everything) and I tell them I don't care, and unless their Attending pisses IV valacyclovir, the patient isn't getting it.

Though, not quite as bad when I have to call the orthopedic surgery resident to let him know hydrocodone does not come IV, or the ID Fellow to inform him/her that the dose of linezolid is not 6.0 mg (of course, despite what their Attending told them).
 
SpirivaSunrise said:
So Z, what would be that one drug that you would absolutely hate to see go on a significant shortage, for a relatively long period of time. Maybe due to lack of substitution options, financial impact, effect on patient care. Which would you go with?

And Pri, I'd be interested to see which you'd pick too..
Click to expand...

Effect on patient care/lack of substitution: off the top of my head would say oxaliplatin due to the impact it would have on colorectal cancer patients. May change my mind later though, it's 5:41 AM.
 
rxforlife2004 said:
If in community: Azthromycin
Hospital: Vancomycin and/or Zosyn

In both setting? Then must be Vicodin
Click to expand...

I thought about putting Vanco off limits for the question, but it's a legit selection, so I didn't. Wanted to see if you all would come up with some unexpected choices.

Anyways...it's an interesting discussion! ;)
 
Pretty specific to where I practice, but a shortage of Norvir would be devastating. (with the assumption this includes both formulations)

On the other hand, if we took the initiative, it would make for one heck of a case study (for before, during and after shortage results).
 
SpirivaSunrise said:
So Z, what would be that one drug that you would absolutely hate to see go on a significant shortage, for a relatively long period of time. Maybe due to lack of substitution options, financial impact, effect on patient care. Which would you go with?

And Pri, I'd be interested to see which you'd pick too..
Click to expand...

Well, it isn't one drug, but if all the insulins go on shortage, that would be a pain in the ass.
 
Priapism321 said:
That is about the time I call the medical student/intern and let them know that valacyclovir is not available parenterally, so let's try something else. Then they mumble something about what their Attending told them (their answer to just about everything) and I tell them I don't care, and unless their Attending pisses IV valacyclovir, the patient isn't getting it.

Though, not quite as bad when I have to call the orthopedic surgery resident to let him know hydrocodone does not come IV, or the ID Fellow to inform him/her that the dose of linezolid is not 6.0 mg (of course, despite what their Attending told them).
Click to expand...

Hey man everyone's sleep deprived, plus I'm just a med student who knows nothing and is just doing what his intern said! Although in all fairness they could at least check epocrates.
 
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meister said:
Hey man everyone's sleep deprived, plus I'm just a med student who knows nothing and is just doing what his intern said! Although in all fairness they could at least check epocrates.
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Yeah I love it when I page a resident and they tell me...well thats what epocrates said.....and i say...well its not right
 
meister said:
What sort of stuff does epocrates get wrong? Do MDs ever call the pharmacy and consult for a dose or suggestions beforehand?
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A lot of things when dealing with one individual's particular situation. And yes, the MD's call a lot. However, where I work now, I just write the orders, much more efficient in my opinion.
 
meister said:
They send you a diagnosis and you look at the chart and initiate therapy according to protocol?
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Yeah as part of my practice they do. They call me and tell me whats going and ask if I can take a look and give them a suggestion or take care of it. As far as what epocrates and other drug databases get wrong is that they give suggestions and people take them as thats the only way to do it. They dont take into account the individual patient. For exacmple, take Zosyn. If you look it up they give you 1,000 different dosing guidelines for dif. indications and renal function. Resdents/students may underdose just based on renal function. I come by and jack up the dose base on the size of the patient and how sick they are...
 
Epocrates, etc also have typos once in awhile.

UptoDate sometimes gives funky intervals for zosyn renal dosing.
 
meister said:
They send you a diagnosis and you look at the chart and initiate therapy according to protocol?
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If by "send me a diagnosis" you mean converse with me on rounds and by "protocol" you mean they ask me what I want to do with the patient, then yeah.
 
There's currently a backorder on Metoprolol XL. We're down to one bottle of 100 25mg tablet, and two bottles of 50mg tablets.
 
We're out of metoprolol xl
 
Glycerin said:
Maybe this deserves its own thread, but since pip/tazo was mentioned...

How many of you have seen 4 hour on/4 hour off pip/tazo infusions? Thoughts?
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Yeah there are some thoughts/data that it maximizes the pharmacokinetic/pharmacodynamic properties of the drug. I will let you look it up...:D The problem is that nurses bi*&^ because it ties up a line for 12 hours.
 
bigpharmD said:
I will let you look it up...:D
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Already did. ;) Read an article today, in fact, using that method in P. aeruginosa pneumonia. I didn't really care for the dose, and since it was in critically ill patients, I'm not sure if renal adjustments were taken into account. I'd like to see more trials comparing various concentrations to see if the outcome remains the same. I was just curious to see if you all had seen it in practice.
 
I rotated at one hospital that was doing that.

My hospital tends to do continuous infusions.
 
SpirivaSunrise said:
So Z, what would be that one drug that you would absolutely hate to see go on a significant shortage, for a relatively long period of time. Maybe due to lack of substitution options, financial impact, effect on patient care. Which would you go with?

And Pri, I'd be interested to see which you'd pick too..
Click to expand...


Aspirin. Without it... we may see a lot more Myocardial Infarction.
 
Glycerin said:
Maybe this deserves its own thread, but since pip/tazo was mentioned...

How many of you have seen 4 hour on/4 hour off pip/tazo infusions? Thoughts?
Click to expand...


This was popularized by Nicolau at Hartford with Merrem 500mg Q6h...3 to 4 hour infusion. Carbapenem and Beta-lactams are time dependent bacteriocidal agent. Therefore we need to make sure serum concentration is above MIC... prolonged infusion allows for it. With Zosyn, many institutions do it. You can get a similar level with 13.5grams continuous infusion vs. 4.5gram q6h. That's 25% less drug to attain similar concentration. Saves money.
 
Glycerin said:
Already did. ;) Read an article today, in fact, using that method in P. aeruginosa pneumonia. I didn't really care for the dose, and since it was in critically ill patients, I'm not sure if renal adjustments were taken into account. I'd like to see more trials comparing various concentrations to see if the outcome remains the same. I was just curious to see if you all had seen it in practice.
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How dare you question if I've seen it. If I haven't seen it, it probably doesn't exist.:smuggrin:
 
rxforlife2004 said:
If in community: Azthromycin
Hospital: Vancomycin and/or Zosyn

In both setting? Then must be Vicodin
Click to expand...


Shortage of Azithromycin, we can use clarithromycin.
Shortage of Vanco, we can use Zyvox.
Shortage of Zosyn, we can use Merrem, Imipenem, or Doripenem.

Shortage of Vicodin... use percocet or Oxycodone/Apap.
 
Always thought it would be a cool casual-type interview question...maybe for future residents. I'd preface it by saying there's no real right or wrong answer, and I'd like to hear them think aloud.

i.e. Maybe drug A? No, we could substitute it with B or C. How about drug D? No, E would be a fine alternative, etc., etc.
 
Priapism321 said:
If by "send me a diagnosis" you mean converse with me on rounds and by "protocol" you mean they ask me what I want to do with the patient, then yeah.
Click to expand...
They let you go on rounds? Wow, the nerve, they should keep you guys locked up in the basement where you belong.
 
ItsOverZyvox said:
This was popularized by Nicolau at Hartford with Merrem 500mg Q6h...3 to 4 hour infusion. Carbapenem and Beta-lactams are time dependent bacteriocidal agent. Therefore we need to make sure serum concentration is above MIC... prolonged infusion allows for it. With Zosyn, many institutions do it. You can get a similar level with 13.5grams continuous infusion vs. 4.5gram q6h. That's 25% less drug to attain similar concentration. Saves money.
Click to expand...

we usually do 18gm/24hr. is that not how it's usually done?
 
njac said:
we usually do 18gm/24hr. is that not how it's usually done?
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Can be used , but 13.5 grams will take care of most Pseudomonal isolates. With an MIC of 32 mcg/mL, an 18 gram continuous infusion may be warranted, but then again, may not even be adequate based on the absurdity of the sensitivity breakpoint.
 
Sparda29 said:
So are we, we have nothing but brand name left, the pharmacist was calling up the MDs looking for substitutes.
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Both generic companies making generic metoprolol XL had some kind of quality control issues at their plants and aren't making anything for now, so it's out for everyone, and will be for a while, probably... We were already out in mid-January.
 
njac said:
we usually do 18gm/24hr. is that not how it's usually done?
Click to expand...

No.... why bother with that....just give 4.5g q6h if you're going to do that...
 
So with metoprolol XL out of the picture for who knows how long, do you think physicians will be switching chronic CHFers over to tartrate (even though it isn't indicated) or to carvedilol?
 
SpirivaSunrise said:
Grrr....kick myself for not giving my answer in the original post. ;)

Swore you were going to pick an ABX. I figured most would pick something in their specialty.
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Antibiotic is all about "Me Too" therefore if we lose one, we have alternatives.... Abx is not my specialty...
 
Hels2007 said:
Both generic companies making generic metoprolol XL had some kind of quality control issues at their plants and aren't making anything for now, so it's out for everyone, and will be for a while, probably... We were already out in mid-January.
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Actually, Ethex is the primary supplier and the one who has the quality control issues. Par is the other major supplier. They are ramping up production it is just taking awhile.
 
No propofol for a long period of time would suck immensely. Also IV multivitamins...not having enough of that can be pretty troublesome.
 
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