Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

Drug Shortages Update – IV Nitroglycerin

While I was finishing writing my 3 part Valentine to IV (IntraVenous) nitroglycerin (Corrections of Misleading Charts Comment – Part I, Part II, and Part III.), the FDA (Food and Drug Administration) sent out a notice that there is a shortage of IV NTG.

It breaks my heart.

On the other hand, it is great that people are using IV NTG, even if it is rare for 911 EMS to use IV NTG for hypertensive CHF (Congestive Heart Failure).

Baxter has all premix nitroglycerin in dextrose presentations on back order, the manufacturing delays are short term and the company anticipates having all presentations available by end of February.

Hospira has all premix nitroglycerin in dextrose presentations on back order with no estimated release date at this time.[1]

and –

Luitpold released product on 1/27/11 and have an additional lot scheduled for release at the end of February.[2]

This isn’t due to increased demand, just manufacturing delays. Manufacturing delays do seem to be the trend, lately.[3] I will write more about this in Hospital Pharmacists Scrambling Amid Vast Drug Shortages.

The IV furosemide (Lasix) drug shortage should have been the final nail in the coffin of IV furosemide for CHF, but too many of us still do not seem to understand appropriate treatment of CHF.

Many of us have demonstrated our lack of understanding of acute pulmonary edema by switching to IV bumetanide (Bumex). Wrong move.

Most of these patients are volume depleted, not volume overloaded. Therefore, diuresis will only make things worse. I repeatedly point this out in posts such as More on Lasix in EMS.

But this is EMS, we often resist the opportunity to learn, as long as it seems that everyone else is harming patients the same way, we insist on maintaining this dangerous standard of care.

Footnotes:

[1] Nitroglycerin in Dextrose 5%
FDA
2/10/2011
Drug Shortage Update

[2] Nitroglycerin Solution 5mg/ml 10ml (NDC 00517-4810-25)
FDA
2/10/2011
Drug Shortage Update

[3] Hospital Pharmacists Scrambling Amid Vast Drug Shortages: Emergency Physicians Between Roc and a Hard Place
Annals of Emergency Medicine News
Maryn McKenna (Special Contributor to Annals News & Perspective)
Free Full Text from Annals of Emergency Medicine with link to Free PDF download

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Comments

  1. Excellent as always!!!! As a pharmacist EMS educator and consultant, you are always on point!!! Do you think more EMS agencies are using Enalpril for CHF?

    • Mark Albert,

      Excellent as always!!!! As a pharmacist EMS educator and consultant, you are always on point!!! Do you think more EMS agencies are using Enalpril for CHF?

      Thank you.

      This is what we have in the Pennsylvania ALS protocols as of November 2008 (the next update will probably be after they can agree on how to implement the 2010 ACLS). As you can see, the use of captopril or enalapril is only after medical command permission orders, but it is a start. As CPAP becomes more common and as people start to realize the difficulty of combining SL NTG and CPAP (assuming that paste is not as good an option), I expect that ACE in hibitors and IV NTG will become more commonly used and will become standing orders.

      As more systems do this, there will be papers published about the safety and efficacy of these as EMS treatments. Then, maybe, they will become more widely adopted. A lot still depends on good oversight, since these are not the kind of treatments we want given without understanding of the possible complications.

      Possible MC Orders:
      A. Additional Nitroglycerin

      B. Dopamine or dobutamine (if available) infusion

      C. Captopril (if available) 25 mg sublingual or enalapril (if available) 0.625 – 1.25 mg IV

      D. Endotracheal Intubation

      E. Morphine sulfate

      There are reported to be pilot projects that are using IV NTG on 911 calls in Pennsylvania, but I don’t know anything about their protocols.

      PS Endotracheal intubation is not only on medical command order, but somebody felt the need to include this here. I don’t know why.