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Cisatracurium Injection

[15 July 2014]

Products Affected - Description

Nimbex, AbbVie
2 mg/mL, 5 mL vial, package of 10 (NDC 00074-4378-05)
2 mg/mL, 10 mL vial, package of 10 (NDC 00074-4380-10)
10 mg/mL, 20 mL vial, package of 10 (NDC 00074-4382-20)

Reason for the Shortage

  • Sandoz could not provide a reason for the shortage.1
  • Nimbex injection is on shortage due to increased demand.2

Available Products

Cisatracurium, Sandoz
2 mg/mL, 5 mL vial, package of 10 (NDC 00781-3150-95)
2 mg/mL, 10 mL vial, package of 10 (NDC 00781-3152-95)
10 mg/mL, 20 mL vial, package of 10 (NDC 00781-3153-95)

Estimated Resupply Dates

AbbVie is reviewing orders for all Nimbex presentations and releasing product as it becomes available.

Implications for Patient Care

Cisatracurium 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.3

Safety

Clinicians must use extreme caution to prevent dosing errors when switching between the various vial sizes (eg, if 20 mL vials are used in place of 10 mL vials).

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.4-6
  • 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.4-6
  • Some presentations of alternative agents including pancuronium, rocuronium, and vecuronium may be in short supply.7

    Characteristics of NMBAs4-6 

    NMBA

    Type of NMBA

    Onset of Action (min)

    Clinical Duration After Initial Dose (min)

    Atracurium

    Nondepolarizing

    2 – 3 

    20 – 35

    Cisatracurium

    Nondepolarizing

    1.5 – 2

    20 – 35

    Pancuronium

    Nondepolarizing

    2 – 3 

    60 – 100

    Rocuronium

    Nondepolarizing

    1 – 2

    22 – 67 min (depending on initial bolus dose)

    Succinylcholine

    Depolarizing

    0.5 – 1

    4 – 6d

    Vecuronium

    Nondepolarizing

    2.5 – 3

    20 – 40

    dClinical duration of effects may increase or decrease with continued administration of succinylcholine; monitor patients carefully.4-6

Related Shortages

References

  1. Sandoz (personal communication). January 22 and 30, February 24, March 7, April 21, May 5, 12, and 19, June 16, and July 14, 2014.
  2. AbbVie, Customer Service (personal communication). January 22, February 4, 11, and 24, April 21, May 12, June 16, and July, 2014. 
  3. Abbott. Nimbex (cisatracurium besylate) Injection product label. North Chicago, IL; Abbott; May 2008.
  4. Baughman VL, Golembiewski J, Gonzales JP, Alvarez, W, eds. Anesthesiology and Critical Care Drug Handbook. 9th ed. Hudson, OH: Lexi-Comp; 2010.
  5. Muscle Relaxants – Adjuncts to Anesthesia. In: Wickersham RM, Novack KK et al., Eds. (2011). Drug Facts and Comparisons (eFacts). St. Louis, MO: Facts and Comparisons.
  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. American Society of Health-System Pharmacists. Drug Shortage Resource Center. Accessed on January 22, 2014.

Updated

Updated July 15, 2014 by David M. Peterson, PharmD, Drug Information Specialist, Drug Information Service. Created April 11, 2002 by Jane Chandramouli, PharmD, Drug Information Specialist, and Erin R. Fox, PharmD, Drug Information Specialist. Copyright 2014, Drug Information Service, University of Utah, Salt Lake City, UT.

Disclaimer

This information is provided through the support of Novation to ASHP solely as a service to its members, which shall not use this information for their further commercial use. The content was prepared by the Drug Information Center of University of Utah. Novation, ASHP, and the University of Utah make no representations or warranties, express or implied, including, but not limited to, any implied warranty of merchantability and/or fitness for a particular purpose, which respect to such information, and specifically disclaim all such warranties. Users of this information are advised that decisions regarding the use of drugs and drug therapies are complex medical decisions and that in using this information, each user must exercise his or her own independent professional judgment. Neither Novation, ASHP nor the University of Utah assumes any liability for persons administering or receiving drugs or other medical care in reliance upon this information, or otherwise in connection with this bulletin. Neither Novation, ASHP nor University of Utah endorses or recommends the use of any drug.

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