Products Affected - Description

Reason for the Shortage

• Bedford discontinued lorazepam in May, 2011 to concentrate on the manufacturing of other products.¹
• West-Ward acquired Baxter’s lorazepam injection products in May, 2011. NDC numbers for the lorazepam and Ativan products were changed in April, 2012.
• West-Ward has Ativan on back order due to increase surplus of the lorazepam presentations.²
• Hospira states lorazepam vials are on shortage due to increased demand. The 1 mL iSecure syringes were discontinued in September 2011.³
• Akorn has increased production to help meet demand.⁴
• Amphastar launched lorazepam injection in November, 2012.⁵

Available Products

Estimated Resupply Dates

• West-Ward has most Ativan presentations on back order and cannot estimate a release date.²
• West-Ward had lorazepam 2 mg/mL 10 mL vials on intermittent back order and is releasing product as it becomes available. Lorazepam 2 mg/mL 1 mL Novaplus vials are on back order and the company cannot estimate a release date.²
• Hospira has lorazepam 4 mg/mL 1 mL vials available in limited supply. Lorazepam 2 mg/mL 1 mL vials are on intermittent back order and the company is releasing supplies as they become available. Lorazepam 4 mg/mL 10 mL vials are on back order and the company estimates a release date of early-June 2013. Lorazepam 4 mg/mL 1 mL Carpuject syringes have an estimated release date of 2013.³
  

Implications for Patient Care

Lorazepam injection is labeled for treatment of status epilepticus and as premedication for the relief of anxiety and tension in patients undergoing surgical procedures. Off-label uses of lorazepam injection include sedation in the critical care setting for patients on mechanical ventilation, treatment of acute delirium, and adjunctive treatment of chemotherapy induced nausea and vomiting.^6,7,8

Alternative Agents & Management

• During this shortage, use alternative injectable benzodiazepines.
• There are no direct dosage conversions between the benzodiazepines because each has a distinct pharmacokinetic profile that dictates the agent’s therapeutic use and dosing. The table below compares the pharmacokinetics of injectable benzodiazepines.
• Institutions may consider reserving injectable benzodiazepines for initial treatment of status epilepticus, as no other well established injectable therapeutic options are available for this indication. Diazepam rectal gel may be an alternative for some patients.^9-13

Related Shortages

• Amobarbital Injection— Resolved
• Chloral Hydrate Oral Solution and Capsules— No Longer Available
• Droperidol Injection
• Hydroxyzine Injection
• Midazolam Injections

1. Bedford (personal communications). April 4 and 20, May 3 and 18, and July 6, 2011.
2. West-Ward (formerly Baxter) (personal communications). April 4 and 20, May 18, June 13, July 5, August 10, September 23, October 25, November 23 and 30, December 15 and 20, 2011; and January 12 and 20, February 29, March 28, April 20, May 17, June 21, July 5, 2012, August 6 and 16, September 4 and 26, October 11, November 5, 16, and 30, December 17, 2012; January 23, March 27, April 1 and 17, and May 22, 2013.
3. Hospira (personal communications). April 4 and 22, and May 20, June 17, August 8, September 22, October 25, November 23 and 30, December 12 and 20, 2011; and January 9 and 26, February 29, March 28, April 17, May 17, June 18, July 3 and 24, August 6 and 27, September 5 and 24, October 11, November 5 and 14, December 5 and 19, 2012; January 23, March 27, April 1 and 17, and May 14, 2013.
4. Akorn (personal communications). December 16 and 20, 2011; January 11 and 26, March 30, April 17, May 9, June 12, July 26, August 9 and 16, September 5, and October 11, 2012; May 22, 2013. 
5. Amphastar (personal communications). November 9, 2012; January 7, April 17, and May 13, 2013.
6. Ativan injection product information. Deerfield, IL: Baxter Healthcare Corp., November 2006.
7. McEvoy, G. K., E. K. Snow, et al., Eds. (2011). AHFS DI (Lexi-Comp Online). Bethesda, MD, American Society of Health-System Pharmacists.
8. Wickersham, R. M., K. K. Novak, et al., Eds. (2010). Drug Facts and Comparisons (eFacts). St. Louis, MO, Wolters Kluwer Health, Inc.
9. Aminoff MJ, Greenberg DA, Simon RP, eds. Clinical Neurology. 6^th ed. New York, NY: Lange Medical BooksMcGraw-Hill; 2005.
10. Meierkord H, Boon P, Engelsen B, et al. EFNS guideline on the management of status epilepticus in adults. Eur J Neurol. Mar 2010;17(3):348-355.
11. Millikan D, Rice B, Silbergleit R. Emergency treatment of status epilepticus: current thinking. Emerg Med Clin North Am. Feb 2009;27(1):101-113, ix.
12. Rabinstein AA. Management of status epilepticus in adults. Neurol Clin. Nov 2010;28(4):853-862.
13. Rowland LP, ed. Merritt's Neurology. 6^th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2005.
14. Baughman, V. L., J. Golembiewski, et al., Eds. (2010). Anesthesiology and Critical Care Drug Handbook. Hudson, OH, Lexi-Comp.
15. Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill. Am J Health-Syst Pharm. 2002;59:150-178.
16. Mosby’s Drug Consult 2006. St Louis, MO: Elsevier-Mosby; 2006.

Updated

Updated: May 22, 2013, by Kristen Jeffries, PharmD, Drug Information Specialist; April 19, 2013, by Leslie Jensen, PharmD, Drug Information Specialist. Created April 8, 2011, by Jane Chandramouli, PharmD, Drug Information Specialist. Copyright 2013, Drug Information Service, University of Utah, Salt Lake City, UT.