Letters excretion of alpha-lipoic acid following oral administration in healthy volunteers. J Clin Pharmacol. 2003; 43:1257-67. 5. Ziegler D, Nowak H, Kempler P et al. Treatment of symptomatic diabetic polyneuropathy with the antioxidant alphalipoic acid: a meta-analysis. Diabet Med. 2004; 21:114-21. 6. Memorial Sloan Kettering Cancer Center. About herbs, botanicals and other products. www.mskcc.org/cancer-care/integrative-
medicine/about-herbs-botanicals-otherproducts (accessed 2014 May 2).
John B. Bossaer, Pharm.D., BCPS, BCOP, Assistant Professor Bill Gatton College of Pharmacy East Tennessee State University Johnson City, TN [email protected]
A potential unexpected consequence of drug shortages on long-term prescribing patterns
T
he number of reported drug shortages in the United States nearly tripled between 2005 and 2010, and recent deficits total as many as 280 different medications, including ondansetron, morphine, and 0.9% sodium chloride injection.1,2 While most of the discussion on drug shortages has focused on root causes or immediate delivery implications, a more subtle consequence may be seen in the long-term prescribing patterns. As a medical student, I observed physicians regularly prescribing second-, third-, and fourth-line therapies due to drug shortages. Arguments have been made that these medications are often more expensive than first-line agents, physicians are less adept at using them, and patient outcomes may suffer. While the medical community awaits an answer to the call for a more stable drug pipeline, physicians and patients are forced to adapt to this uncomfortable reality. Consider this example. During my rotation in an emergency department, the hospital had a shortage of prochlorperazine and metoclopramide, medications commonly used for acute migraine management at that institution. One emergency physician told me that this shortage had been ongoing for over two years at this facility and was concerned that his third-year residents had yet to experience managing a patient with appropriate first-line therapies. In the world of medicine and beyond, familiarity and repetition often dictate comfort. Trainees are expected to mod916
el behavior based on experience in the learning environment. Likewise, it has been suggested that physician decisionmaking is directly influenced by ease of recall and heuristic bias.3 Ask any physician about the patterns learned during the training process and the impact on practice, and you will likely find a connection between the two. Thus, residents may develop prescribing biases toward secondary and tertiary therapies, based on comfort and repetition of use in the training environment, due to shortages of first-line therapies. Oncologists, for example, face the challenge of determining cancer regimens, often dealing with inconsistent conversion factors, uncertain dosage adjustments, and the frequent lack of direct equivalents.4 Further, each regimen is associated with different patient responses, complications, and adverse effects. Imagine the scenario in which an oncology fellow is unable to use a standard regimen throughout the duration of training. This is a reality in which adverse effects and outcomes can be unfamiliar to the provider who has a lack of past management skills with a given drug. These same trainees will soon rise to the levels of mentor and attending physician and could effectively transfer prescribing habits longitudinally to future residents. These experiences have the potential to be translated to the remainder of any engaged medical team—nurses, advanced practitioners, and pharma-
Am J Health-Syst Pharm—Vol 72 Jun 1, 2015
The author has declared no potential conflicts of interest. DOI 10.2146/ajhp140295
cists, among others. What many view as an issue of immediate access and availability may have substantial and lasting consequences beyond the restoration of a stable medication pipeline. In the event that trainees are unable to assemble a body of experience with first-line therapies, education can facilitate student familiarity. The expanded use of simulation laboratories could help students by developing scenarios for generating comfort with first-line therapies. Further, evidence-based medicine must continue to be taught and reinforced, despite drug shortages. The issue of consequential downstream prescribing behaviors is one that should not only be considered but discussed and addressed within the breadth of ongoing drug shortages. 1. Devi S. US drug shortages could continue for years. Lancet. 2012; 379:990-1. 2. Food and Drug Administration. Current and resolved drug shortages and discontinuations reported to FDA. www. accessdata.fda.gov/scripts/drugshortages/ default.cfm#N (accessed 2014 Jul 15). 3. Thornton JG, Lilford RJ, Johnson N. Decision analysis in medicine. BMJ. 1992; 304: 1099-103. 4. Metzger ML, Billett A, Link MP. The impact of drug shortages on children with cancer—the example of mechlorethamine. N Engl J Med. 2012; 367:2461-3.
Aaron George, D.O., Family Medicine Resident Duke University Medical Center Durham, NC [email protected]
The author has declared no potential conflicts of interest. DOI 10.2146/ajhp140199
Copyright of American Journal of Health-System Pharmacy is the property of American Society of Health System Pharmacists and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
medicine/about-herbs-botanicals-otherproducts (accessed 2014 May 2).
John B. Bossaer, Pharm.D., BCPS, BCOP, Assistant Professor Bill Gatton College of Pharmacy East Tennessee State University Johnson City, TN [email protected]
A potential unexpected consequence of drug shortages on long-term prescribing patterns
T
he number of reported drug shortages in the United States nearly tripled between 2005 and 2010, and recent deficits total as many as 280 different medications, including ondansetron, morphine, and 0.9% sodium chloride injection.1,2 While most of the discussion on drug shortages has focused on root causes or immediate delivery implications, a more subtle consequence may be seen in the long-term prescribing patterns. As a medical student, I observed physicians regularly prescribing second-, third-, and fourth-line therapies due to drug shortages. Arguments have been made that these medications are often more expensive than first-line agents, physicians are less adept at using them, and patient outcomes may suffer. While the medical community awaits an answer to the call for a more stable drug pipeline, physicians and patients are forced to adapt to this uncomfortable reality. Consider this example. During my rotation in an emergency department, the hospital had a shortage of prochlorperazine and metoclopramide, medications commonly used for acute migraine management at that institution. One emergency physician told me that this shortage had been ongoing for over two years at this facility and was concerned that his third-year residents had yet to experience managing a patient with appropriate first-line therapies. In the world of medicine and beyond, familiarity and repetition often dictate comfort. Trainees are expected to mod916
el behavior based on experience in the learning environment. Likewise, it has been suggested that physician decisionmaking is directly influenced by ease of recall and heuristic bias.3 Ask any physician about the patterns learned during the training process and the impact on practice, and you will likely find a connection between the two. Thus, residents may develop prescribing biases toward secondary and tertiary therapies, based on comfort and repetition of use in the training environment, due to shortages of first-line therapies. Oncologists, for example, face the challenge of determining cancer regimens, often dealing with inconsistent conversion factors, uncertain dosage adjustments, and the frequent lack of direct equivalents.4 Further, each regimen is associated with different patient responses, complications, and adverse effects. Imagine the scenario in which an oncology fellow is unable to use a standard regimen throughout the duration of training. This is a reality in which adverse effects and outcomes can be unfamiliar to the provider who has a lack of past management skills with a given drug. These same trainees will soon rise to the levels of mentor and attending physician and could effectively transfer prescribing habits longitudinally to future residents. These experiences have the potential to be translated to the remainder of any engaged medical team—nurses, advanced practitioners, and pharma-
Am J Health-Syst Pharm—Vol 72 Jun 1, 2015
The author has declared no potential conflicts of interest. DOI 10.2146/ajhp140295
cists, among others. What many view as an issue of immediate access and availability may have substantial and lasting consequences beyond the restoration of a stable medication pipeline. In the event that trainees are unable to assemble a body of experience with first-line therapies, education can facilitate student familiarity. The expanded use of simulation laboratories could help students by developing scenarios for generating comfort with first-line therapies. Further, evidence-based medicine must continue to be taught and reinforced, despite drug shortages. The issue of consequential downstream prescribing behaviors is one that should not only be considered but discussed and addressed within the breadth of ongoing drug shortages. 1. Devi S. US drug shortages could continue for years. Lancet. 2012; 379:990-1. 2. Food and Drug Administration. Current and resolved drug shortages and discontinuations reported to FDA. www. accessdata.fda.gov/scripts/drugshortages/ default.cfm#N (accessed 2014 Jul 15). 3. Thornton JG, Lilford RJ, Johnson N. Decision analysis in medicine. BMJ. 1992; 304: 1099-103. 4. Metzger ML, Billett A, Link MP. The impact of drug shortages on children with cancer—the example of mechlorethamine. N Engl J Med. 2012; 367:2461-3.
Aaron George, D.O., Family Medicine Resident Duke University Medical Center Durham, NC [email protected]
The author has declared no potential conflicts of interest. DOI 10.2146/ajhp140199
Copyright of American Journal of Health-System Pharmacy is the property of American Society of Health System Pharmacists and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
