Atracurium Injection Shortage

• • West-Ward discontinued atracurium in September 2014.[1]
  • Hospira has atracurium available.[2]
  • Sagent had atracurium on shortage due to product recall.[3] Additional information available at: http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm435440.htm.

• • Atracurium Besylate injection, Pfizer, 10 mg/mL, 10 mL multiple dose vial, 10 count, NDC 0040-1105-02
  • Atracurium Besylate injection, Pfizer, 10 mg/mL, 5 mL single dose vial, 10 count, NDC 00409-1109-01
  • Atracurium Besylate injection, Sagent, 10 mg/mL, 10 mL multiple dose vial, 10 count, NDC 25021-0672-10
  • Atracurium Besylate injection, Sagent, 10 mg/mL, 5 mL single dose vial, 10 count, NDC 25021-0659-05

Estimated Resupply Dates

• • All presentations are currently available.

Implications for Patient Care

• • Atracurium is an intermediate-acting neuromuscular blocking agent (NMBA) used to facilitate intubation and relax skeletal muscles as an adjunct to general anesthesia during surgery or mechanical ventilation.[4]

Safety

• • Clinicians must use extreme caution when switching between NMBAs.

Alternative Agents & Management

• • Alternative NMBAs vary in onset time and duration of action, particularly based on dose; see the table below. Times to re-dose also differ based on agent and dose. Doxacurium, mivacurium, and tubocurarine have been discontinued.[5,6,7]
  • Non-depolarizing neuromuscular blocking agents may be reversed with neostigmine or edrophonium. Depolarizing NMBAs (ie, succinylcholine) are not reversed by these agents and their toxicity may be worsened by concomitant administration.[5,6,7]
  • Some presentations of alternative agents including pancuronium and vecuronium are in short supply.[8]

  Table 1. Characteristics of NMBAs5,6,7

  NMBA	Type of NMBA	Onset of Action (min)	Clinical Duration After Initial Dose (min)
  a Clinical duration of effects may increase or decrease with continued administration of succinylcholine; monitor patients carefully.5,6,7
  Atracurium	Nondepolarizing	2 to 3	20 to 35
  Cisatracurium	Nondepolarizing	1.5 to 2	20 to 35
  Pancuronium	Nondepolarizing	2 to 3	60 to 100
  Rocuronium	Nondepolarizing	1 to 2	22 - 67 min (depending on initial bolus dose)
  Succinylcholine	Depolarizing	0.5 to 1	4 to 6a
  Vecuronium	Nondepolarizing	2.5 to 3	20 to 40

  
  

References

• 1. West-Ward, Customer Service (personal communications and website). August 5 and September 5, 2014.
  2. Hospira, (personal communication and website). August 26, October 15, November 15, 2013; February 10, March 20, April 30, May 15, July 18, September 5 and 29, November 4 and 14, December 12, 2014; January 9 and 16, February 3, 23, and 27, March 5, 12, and 27, May 21, June 22, July 17, and September 17, 2015.
  3. Sagent, Customer Service (personal communications). May 21 and 29, July 2 and 12, August 29, September 24, October 22, November 15, December 18, 2012; January 28, February 25, March 29, May 29, July 22, August 19, October 14, November 13, 2013; February 3, March 19, April 24, May 15, July 18, September 5 and 25, October 30, November 13, December 12, 2014; January 8, 15, and 29, February 19 and 26, March 5, 12, and 27, May 21, and June 22, July 16, and September 17, 2015.
  4. Bedford. Atracurium Besylate Injection product label. Bedford, OH; Bedford; October, 2010.
  5. Muscle Relaxants - Adjuncts to Anesthesia. In: Wickersham, R. M., Novak K. K., et al., Eds. (2011). Drug Facts and Comparisons (eFacts). St. Louis, MO, Wolters Kluwer Health, Inc.
  6. Neuromuscular Blocking Agents. In: McEvoy GK, Snow EK, Miller J, eds. AHFS 2011 Drug Information. Bethesda, MD: American Society of Health-System Pharmacists; 2011:1422-1441.
  7. Baughman VL, Golembiewski J, Gonzales JP, Alvarez, W, eds. Anesthesiology and Critical Care Drug Handbook. 9th ed. Hudson, OH: Lexi-Comp; 2010.
  8. American Society of Health-System Pharmacists. Drug Shortage Resource Center. Accessed on November 2, 2011.