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Drug Shortages – A Global Issue
In this part of the world we are very fortunate. Rarely do we hear or experience shortages of any good or service we want or need. That’s why media reports of shortages of certain drugs, some of which are used by cancer patients, are so concerning.

“The sporadic shortage of certain drugs is not a new issue,” said Larry Broadfield, Manager of CCNS’s Systemic Therapy Program. “And, it is not unique to Nova Scotia. It is a global issue that pharmacists have been monitoring closely and effectively managing for some time.”

Good communication practices are also in place so physicians are aware of any shortages and can prescribe an equivalent alternative to ensure that patients continue to receive optimal care.

Larry explains that the raw materials for the drugs used in Canada can be sourced from anywhere in the world, but the production of drugs must meet manufacturing guidelines of the country where the drug will be used.

With the most recent drug shortage of Intravenous (IV) Ondansetron, the initial problem began when the Sandoz production plant in Montreal failed to meet manufacturing standards required by Health Canada. So production of the drug was halted while the company was addressing Health Canada concerns. Shortly after this, there was a fire at the plant which destroyed most of the inventory of the drug.

In the cancer world, Ondansetron is the anti-nausea drug of choice for most cancer patients receiving chemotherapy. Although available in oral form, it is often given in IV form for a variety of reasons such as for those who cannot swallow.
If there had been another supplier of the drug, the solution would have been to contact that supplier, but Sandoz is the only supplier. Single, rather than multiple, suppliers of a given drug is becoming a norm as a result of global efforts to reduce drug costs. As well, not every drug has multiple suppliers.

Dr. Stephen Couban, interim Head, Hematology for Capital Health said recurrent shortages of certain chemotherapy and supportive care drugs over the last couple of years is concerning.

“We are fortunate, though, to have very good national and international system of communication so we are aware of shortages and can plan to try and minimize the effects of the shortages on patients,” he said. “At the same time, we are working with the pharmaceutical industry to try and make these shortages less frequent in the future.”

Within Nova Scotia hospital drugs are centrally purchased, enabling better control over monitoring and distribution of those that are in short supply.

“Rather than releasing a drug that is in short supply until we run out, we are able to monitor supply closely, and recommend equivalent substitutions, where appropriate, to conserve the drug for patient for whom there is no equivalent alternative,” said Larry.

Although hospital drugs are centrally purchased, Nova Scotia’s physicians in district health authorities have the autonomy to make prescribing decisions for their patients based on the patient’s need and their own clinical judgement.

“As frontline health care workers, we are working very closely with our pharmacists and with Health Canada and our colleagues in Industry to try and reduce the effects of these shortages on patients,” said Dr. Couban.

In the event, however, of a drug shortage health professionals in district health authorities are able to rely on the Provincial Drug Distribution Program to monitor supply levels and provide recommendations regarding equivalent substitutions. This team consults with health professionals, as well as officials within the Department of Health and Wellness to develop a strategy to ensure that patients continue to receive high quality care in the event of a drug shortage.

In the case of Ondansetron, Cancer Care Nova Scotia was asked to consult with district health authorities about current usage of the drug and suggest an approach for managing the shortage while maintaining high quality patient care.

Following consultation it was agreed that because oral and oral dissolving tablet (ODT) forms are in good supply, in both hospitals and community pharmacies across the country, the recommended approach would be for physicians to automatically switch all patients who are able to tolerate oral medication to oral Ondansetron.

ODT Ondansetron is recommended for patients who have difficulty swallowing.
It is likely that Nova Scotia, Canada and indeed the rest of the world will continue to face sporadic drug shortages into the future. While not an ideal situation, cancer patients can rest assured that there are equivalent alternatives for most drugs. Clinical teams, including pharmacy staff and health administrators, have and will continue to closely monitor drug supply and bring the right people together when supply of a drug is low to provide recommendations to ensure cancer patients continue to receive high quality care.

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