Chlordiazepoxide (Librium) injection is one of the latest products added to a growing list of drug shortages. A change in the drug manufacturing site has resulted in the unavailability of this dosage form of the drug. The oral dosage form is still available. The shortage is expected to last until December of this year. This may be a time to consider the potential benefits of alternative agents. Diazepam (Valium) and lorazepam (Ativan) are also available for injection, but unlike chlordiazepoxide, the diazepam and lorazepam injections are available for immediate use and do not have to be reconstituted and are stored at room temperature. Chlordiazepoxide powder is packaged in glass ampules which can pose a hazard when breaking open.

Although not frequently prescribed, the OSF St. Francis Medical Center Pharmacy has carried two sustained-release forms of procainamide. The ‘regular’ sustained-release (Procan SR) product is intended to be dosed primarily on an every 6hour schedule, while the extended release product (i.e. Procanbid) is dosed every 12 hours. To avoid potential errors and duplication of formulary items, the Pharmacy and Therapeutics Committee voted to delete procainamide sustained-release and to allow the pharmacist to substitute Procanbid. Although the frequency of dosing will be different, the same daily dose will be administered. 

The neuromuscular blocker rapacurium (Raplon), has been placed on backorder from the manufacturer. Vecuronium (Norcuron), which was the standard neuromuscular blocker on the Blue Alert Carts within the hospital before rapacurium was available, will replace the rapacurium during the shortage. 

The introduction of Depakote ER has caused some confusion in the ordering and dispensing of the appropriate sustained-release valproate product. Depakote tablets and sprinkle capsules are delayed-release formulations containing divalproex sodium. These products are approved for use in the treatment of mania associated with bipolar disorder or seizures and are typically dosed on a twice-a-day schedule. Depakote ER, on the other hand is also an extended-release product, which is indicated for the prophylactic treatment of migraine headaches in adults. Dosing of this product is 500mg to 1000mg, once daily with an evening meal.

It is unfortunate that the manufacturer has chosen similar trade names for products with distinctly different indications. It is suggested that physicians write the treatment indication when ordering either of these products. Depakote ER is not on the OSF St. Francis Medical Center Formulary.