Cause For Concern

The Hospitalist. 2011 July;2011(07):

July 1, 2011 | The Hospitalist

Smaller Inventories Can Leave a Pharmacy Strapped, But Unavoidably So

Although the rising problem of drug shortages can be traced mainly to quality issues at manufacturers and a dwindling number of drugmakers, especially makers of generics, part of the issue sits a little closer to home for hospitalists: The pharmacies where they get their drugs just aren’t as well-stocked as they once were.

Like other sectors of American industry, hospital pharmacies now tend to keep only about as much as they expect they will actually use, with maybe a small buffer. It’s a concept known as the “just in time” philosophy of inventory.

Such a system cuts down on storage costs and waste, experts say. But it also leaves less in stock when a drug shortage hits.

“Hospitals aren’t keeping the large stocks of drugs like they’ve done in the past because the stockpiling, if you will, of inventories of drugs is just not as commonplace today as it probably was in the past,” says Diane Ginsburg, ASHP president.

And the system is not likely to change.

Nor should it, says Joseph Li, MD, SFHM, a former pharmacist who is director of the hospital medicine program at Beth Israel Deaconess Medical Center and associate professor of medicine at Harvard Medical School in Boston.

“You never want to overstock, because many medications are very expensive and certainly they all have expiration dates,” says Dr. Li, SHM president. “So you certainly want to use all the medications that you purchase.”

Keeping too much of a drug on hand can itself lead to shortages at other places, Ginsburg says.

“You can only hedge so much and predict so much,” she explains. “You want to keep medications on hand to be able to meet your patients’ needs. .. But stockpiling definitely can contribute to the shortage problem, and that’s just not good practice.”—TC

“In the past couple of years, it’s just been exponential,” says Diane Ginsburg, president of the American Society of Health-System Pharmacists and clinical professor and assistant dean for student affairs at the University of Texas’ College of Pharmacy in Austin.

According to the FDA, 77% of the shortages in 2010 involved sterile injectable drugs.

“There are fewer and fewer firms making these older sterile injectables, and they are often discontinued for newer, more profitable agents,” FDA spokeswoman Yolanda Fultz-Morris said in an email. “When one firm has a delay or a manufacturing problem, it is extremely difficult for the remaining firms to quickly increase production.”

The biggest cause for the shortages in those drugs has been product quality issues, namely microbial contamination and newly identified impurities, according to the FDA. From January to October of 2010, 42% of drug shortages were due to quality problems.

Eighteen percent were due to product discontinuation by the manufacturer and another 18% were due to delays and capacity problems. Nine percent were due to difficulties getting raw materials, and 4% of the sterile injectable shortages were due to increased demand because there was a shortage of another injectable medication. In other words, one shortage led directly to another.

Kevin Schweers, a spokesman for the National Community Pharmacists Association, says generic drugs, especially Schedule II substances, have been in short supply. But there can be problems even when one generic is available to replace another generic.

An example, he says, is when a “new generic substituted in place of the old one is made by a different manufacturer and may come in a different color or shape. That can leave patients”—including those just released from hospitals—“wondering and asking the pharmacist why their medication is different or if a mistake was made.”