The outcry over anesthetic drug shortages started in 2009, when the American Society of Anesthesiologists (ASA) began hearing about shortages of the sedative Propofol. Anesthesiologists from around the country suddenly were having trouble obtaining the drug, considered the most popular anesthetic because it is ideally suited for ambulatory situations.
“It puts patients to sleep quickly and wears off quickly, so it’s great for situations where you want to send some patients home within a short period of time,” says Chad Itzkovich, MD, an anesthesiologist who works with New York Gastroenterology Associates in New York.
The impact of a Propofol shortage, as well as periodic shortages of other anesthetic drugs, has ranged from inconvenient to problematic. Arnold Berry, MD, MPH, vice president for scientific affairs for the ASA, says that there have been times when facilities have considered postponing cases because they didn’t have the drugs they needed.
“It hasn’t been widespread, but it’s a serious consideration,” Berry says. “Sometimes, we’re using drugs that wouldn’t be our first choice.”
Reasons for the Shortage
Berry explains that the drugs used by anesthesiologists are sterile, injectable medications that are injected directly into a patient’s blood stream. As such, they are required to be the purest of all medications, which in turn makes them among the most difficult to produce. But, he adds, there are many other factors that influence the shortage of anesthetic drugs, including manufacturing issues, such as difficulty obtaining the necessary raw materials, which often come from developing countries; increasingly stringent manufacturing standards; and distribution issues. Those factors, combined with a low profit margin on some anesthetics, including Propofol, led Israel’s Teval Pharmaceutical Industries and Hospira Inc. of Lake Forest, Ill., to halt production and recall some batches of the sedative due to quality-control issues.
Working in collaboration with the U.S. Food and Drug Administration, importation of hundreds of thousands of doses of a Propofol-like drug from Europe eased some of the shortage issues, but not for everyone.
“What happens is the hospitals, the very large surgical centers, they stockpile the stuff,” Itzkovich of New York Gastroenterology says. “They have tons of Propofol, so when you get to the smaller surgical centers and the doctor offices, which have no pull because they don’t have big supply contracts, they’re not only paying more for all the meds, they have an unreliable supply.”
The result, Itzkovich says, has been a change, to some degree, in the way anesthesiologists practice, including rationing the use of Propofol. This includes using other medications, such as Fentanyl or Versed, together with Propofol to achieve desired results. But there has also been a negative impact on anesthesiologists’ revenue.
“There’s a direct effect from the increased cost of the Propofol, but I can’t say that’s overly large. In addition to that, it’s the indirect effect in that we can take care of fewer patients safely in a day,” he says. “Where Propofol wears off quickly, other drugs do not, and that results in longer recovery times. Physicians need to understand that the patient’s experience might not be quiet as good as before.”
Other Anesthetics in Short Supply
Berry says that while Propofol was the first anesthetic drug shortage brought to the ASA’s attention, there have been other drug shortages as well. For example, Succinylcholine, which is a drug used specifically by anesthesiologists to produce muscle paralysis, allows anesthesiologists to intubate a patient and safely care for the individual by controlling the airway. There have also been shortages of Epinephrin, which is one of the commonly used vaso-active agents, which is a critical drug for resuscitation and for severe allergic reaction.
The growing concern, Berry says, is that the problem of anesthetic drug shortages is not going away any time soon. “The American Society of Health System Pharmacists helps keep track of drug shortages,” he says. “And according to [the Society’s] information, 2010 was the year with the greatest number of drugs in short supply since they’ve kept track. And 2011 is shaping up to be just as bad.”