Sunday, January 22, 2012

Yes, we have no...Zofran?

Photo Credit

The issue of chemotherapy drug shortages has made the news a lot over the past 6 months or so, including an OpEd piece in the New York Times last August that pointed out that the situation is so bad that, in effect, cancer care is being rationed in the US.

How did this happen?

Well, the situation is quite complex, but much of what is going on was summarized beautifully by my colleague Michelle Hudspeth, Director of Pediatric Hematology/Oncology at Medical University of South Carolina (and graduate of our residency and fellowship programs), when she testified before Congress (her testimony is here).  Briefly, the problem can be traced, in part, to a rule by The Centers for Medicare and Medicaid Services (CMS) called the ASP + 6 Rule.  This rule limits what a private oncologist can charge for a chemotherapy drug to the Average Sale Price plus 6%. 

Why does that matter?  An article by the Director of the National Library of Medicine, and one in the New England Journal of Medicine, outlines the financial issues.  Because so many of the older chemotherapy drugs are available as generics and are consequently very inexpensive.  Consider the case of carboplatin.  A vial of carboplatin once sold for $125, but recently the cost has fallen to $3.50.  Add 6% to that, and you certainly don't recoup the cost of administering the drug in your office. Similarly, paclitaxel costs $312 per vial, while Abraxane (albumin-bound paclitaxel) costs $5,824 (all cost data come from this article in the New England Journal of Medicine).  There is almost no financial incentive to pharmaceutical companies to make generic chemotherapy drugs, nor is there a financial incentive to private oncology practices to use generics.

But this is just part of the problem.  There is currently a nationwide shortage of Doxil (liposomal doxorubicin), which is not a generic.  Why?  Through industry consolidation, there are fewer and fewer plants that manufacture these drugs, so when something happens at even a single plant, the entire market is affected.  Quality control issues at the only plant in the world that makes Doxil shut the plant down and with it, all drug production. 

So, it seems that industry consolidation, downward pressure on pricing of generics, as well as contamination, other quality control problems, and shortages of raw materials have conspired to create a perfect storm.

The consequences of these shortages go beyond just drug availability.  As the New York Times article discussed, and Dr. Hudspeth mentioned, medication errors are increasing as oncologists are forced to use less familiar drugs.  Research is affected, too. This article, published in the scientific journal Nature in October, discusses the effect of drug shortages on clinical trial enrollment.  Closer to home, the clinical trial I am running looking at Doxil and temsirolimus for sarcoma patients is on hold because Doxil is unavailable.  We haven't enrolled a new patient in months, and there is no end to the shortage in sight.

The shortages are not limited to chemotherapy drugs (which, of course, is evidence that the problem is not due to the inability of oncologists to make a profit giving drugs to patients).  Drugs for ADHD, the components for iv nutrition, anesthetics, and many others are affected.  In fact, on Friday I was told our hospital has only a 5 day supply of Zofran, the mainstay anti-nausea drug used for patients receiving chemotherapy. 

I sure hope they get more.  I'm not looking forward to giving chemotherapy without it.

Related Posts:
My Name is FDA, and I Approve of this Message
A Smarter War on Cancer
When Translational Research Really Translates


Mary said...

I shared this post with the Team Sarcoma Facebook group. When I was really sick after giving birth, zofran saved me! I was familiar with the drug name because I know so many young adults who have needed it while in treatment. I never had chemo, but I can only imagine how sick I would have been with it. It is hard to comprehend sarcoma specialists not having access to so many drugs that they need. Is there anything we can do? Would you be willing to write about this in ESUN??

Anonymous said...

I read the op-ed in the ny times when it was first written and wrote letters to my congressman and 2 senators, never having done so before. I got a personalized reply from one of the senators, which was encouraging, instead of the canned response from the other 2. And I can't imagine going through chemo without Zofran; the nausea was bad enough with it.

Hopefully this is solved soon!

Just the Tip said...

Coming from someone who has worked in pharmacy for 10 years and also happens to have an anaphylaxis reaction to phenergan, I think the only way to summarize this is that we're all doomed!

Kathleen Blanchard, RN, CCM said...

Get out the ginger snaps. This is truly sad. What about old timey drugs? Thorazine, compazine? Just wondering if they're effective.

Doctor David said...

Mary, thanks for sharing with the FB group. Unfortunately, I'm not sure that there's much that can be done at the grassroots level, other than perhaps making sure your Representatives and Senators are aware of the magnitude of the problem.

Kathleen, we are breaking out the old-timey drugs... but sadly many of those are also generic and are also in short supply. This morning on rounds I was told that the only anti-emetic we regularly use that is NOT in short supply is Ativan.

Elizabeth Munroz said...

Is this situation also the same in other countries? Or are we the only ones?

Kathleen Blanchard, RN, CCM said...

Oh my - Thanks Dr. David.

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Vidalista 80 is one of a few clinically successful PDE5 inhibitors that are effective for the majority of men suffering from Erectile dysfunction ED, a condition in which a man is unable to get or keep a solid penis (erection) that is suitable for sexual exercise.

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Cenforce 200 citrate relaxes the muscles that line the walls of blood vessels and increases blood flow to [1] particular areas of the body. That is why it is used by men in erection disorders. In addition to sildenafil, other medications are also used for the same condition. Make sure the two drugs are not used simultaneously; Otherwise, you can make the situation worse.

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Fildena 150 is an excellent treatment to treat erectile dysfunction in all men. Fildena 150 belongs to the class of drugs called PDE inhibitors. This medication contains the PDE 5 inhibitor compound. The main component of this type of inhibitor, sildenafil, helps men achieve erections and withstand contractions during s*xual intercourse.

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Vidalista 20 is a pill that provides temporary hardness in your penis and allows you to get an erection when Sildenafil's actions kick in. This is a pill that is especially useful for anyone who has lost their natural abilities to become hard on stimulation. Therefore, these patients need what we call external inducers and pills like Vidaisita 20 work very well.

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Vilitra60is a drug that inhibits PDE-5, that is, it works by limiting the function of this enzyme. This enzyme causes impotence or erectile dysfunction because it destroys cyclic guanosine monophosphate (cGMP) molecules that help with erections. cGMP relaxes/dilates the blood vessels present in the corpora cavernosa and draws more blood into them, which causes an erection. Its destruction by the PDE-5 molecules is prevented by the drug which binds to it and saves the cGMP molecules.It is important to note that Vilitra can only work when you are s*xually aroused. S*xual stimulation releases nitric oxide in the smooth muscle of the p*nis, which is needed to increase the concentration of cGMP molecules. Vilitra does not increase s*xual desire or s*xual performance.

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Vidalista 20 can get various reactions. As a result, manufacturers have produced this drug in different and alternate doses to avoid overdose. As you can see, the name Vidalista is made up of numbers. The dosage power is represented by the number.However, before prescribing Vidalista, your doctor may ask you a few questions. It's only natural that you want to know what you think of Vidalista or other erectile dysfunction drugs.Increased levels of cGMP lead to optimal muscle relaxation, blood flow expansion and erection promotion. Vidalista helps men achieve and maintain erections during s*xual arousal.

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Super Kamagra is more than just generic Sildenafil. It also contains Dapoxetine, a generic ingredient that allows you to have more control over your ejaculations.It is a p*ll that finds its use to treat two ailments at the same time. With the use of p*lls you can effectively achieve the effectiveness of your erections and control ejaculation for longer.

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Vilitra 40 is an oral pill that hardens your penis and allows you to restore the ability of a harder erection. The pills have a generic substance which is Vardenafil which belongs to the family of a group of generic substances called the PDE-5 hormone. inhibitors. This drug helps men build strength and helps them lead a sustainable s*x life. Viltra is the safest and most beneficial drug used to treat erectile dysfunction in men.

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Vidalista 20 It is a much cheaper replacement for a more expensive brand called Tadalafil indicated for erectile dysfunction. This drug can alleviate any problem related to erectile dysfunction, so it is becoming more and more in demand, making it a more popular option for erectile dysfunction problems.

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Fildena 100 It is known by many other names like magic pill or magic potion etc. Sildenafil helps to achieve the correct type of erection and to maintain it for a longer period of time. Sexual impotence or erectile dysfunction is one of those ailments that leaves a negative impact on a man's self-confidence and morale.

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Cenforce 200 in the most useful drugs for the treatment of erectile dysfunction and impotence in men. It is a drug used by people all over the world that helps men to have an erection. The erection caused by this drug is long-lasting and lasts for a longer period of time.

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Vidalista 60 When it comes to erectile dysfunction (impotence) in men, Vidalista 60 mg, a Tadalafil pill used to treat infertility, conveys pleasure like no other. Vidalista-60 is a particularly effective prescription drug in the treatment of erectile dysfunction. Tadalafil is the active ingredient in Vidalista 60mg, making it a PDE5-restricted drug.Vidalista 20mg It is an erectile dysfunction medication generally recommended by professionals for the treatment of erectile dysfunction

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Vilitra 20 Men who experience the negative effects of erectile rupture produce the chemical PDE5 in their body, which hinders the creation of nitric oxide, which is essential for solid erections. Each Vilitra 20 contains the active ingredient Vardenafil, a PDE5 inhibitor.Vilitra oral pill powered with PDE-5 inhibitor inhibits the activity of PDE-5 compound and helps in the development of cGMP and nitric oxide in the body.Vilitra 40 The delivered cGMP widens the v*ins and smooth muscles in the s*xual organ and makes a prolonged passage of blood and nitric oxide at the time of s*xual sensation and makes good erections possible.

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Cenforce 150mg treats impotence (erectile dysfunction) in men. It works by spiking the blood flow to the penile area of the body. This helps men gain and maintain an erection. It belongs to the medicines' phosphodiesterase type 5 (PDE 5) inhibitors family. You can take this medicine on an empty stomach or with food. You must take this medicine exactly as directed by your doctor. Take it about an hour before engaging in any s*xual activity. This medicine can help you get an erection once you've been s*xually aroused. On the other hand, this drug will not work without s*xual stimulation.

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