U.S. May Get More Ventilators But Run Out Of Medicine For COVID-19 Patients

Apr 4, 2020
Originally published on April 6, 2020 8:33 pm

As hospitals across the country fill with COVID-19 patients, medical personnel are sounding the alarm about shortages of drugs essential to those patients' care.

"We have seen an increase in demand on pharmaceuticals that's unprecedented," says Daniel Kistner, who manages the pharmacy program for Vizient, a group purchasing organization that negotiates lower prices with drug manufacturers. "Never seen anything like this before across the whole country."

This week, Vizient released data showing dramatic spikes in demand for sedatives, pain medications, paralytics and other drugs that are crucial for patients who are on ventilators. According to Vizient's study, the rate at which those orders are filled is lagging far behind the demand.

"We're not at a rate yet where there's just no drug," Kistner says, "but we are quickly approaching it."

One complicating factor: "Injectable drugs take a long time to make," Kistner says. "For instance, there's a 21-day sterility period needed for all injectable drugs. So it's not something simple that you can do overnight."

If you ramp up production of ventilators but don't also get a jump on producing the necessary drugs, Kistner says, you have a problem: "We're gonna build all these cars, but if we don't have the gas, they can't go anywhere."

This week, Vizient sent recommendations to the Food and Drug Administration, urging the agency to expand access to drugs heavily used for ventilator patients. Among Vizient's recommendations was that the FDA approve new lines of manufacturing or facilities to make these medications.

According to Kistner, the FDA has been receptive.

"We are now actively working with government agencies, such as the FDA, to explore strategies to increase supply of these critical drugs," he says.

For a patient in acute respiratory distress, being put on a ventilator can be lifesaving. It's also really unpleasant.

"It is deeply uncomfortable," says Dr. Alix Morse, a pulmonary and critical care physician at Sturdy Memorial Hospital in Attleboro, Mass.

When patients are intubated, they're given strong sedatives and pain medicine such as propofol and fentanyl, and sometimes paralytic drugs, as well.

Without those medications, Morse says, "Most people will reach for the [breathing] tube and try to grab it and pull it out. They may fight against having it in their mouth. And if they're working against a breathing machine, it can actually damage their lungs."

Now, with a surge of COVID-19 patients on ventilators, hospitals are burning through their supplies of those essential drugs.

As Morse watches her hospital's supplies dwindle, she worries about her patients.

"It's the human cost of being scared, maybe being aware on the breathing machine when you really shouldn't be, that really keeps me up at night," she says.

The drug shortages are especially acute in a COVID-19 hot spot like Albany, Ga.

Phoebe Putney Memorial Hospital in Albany has seen its caseload of patients on ventilators soar from the typical 12 to 15 to as many as 46 at one time.

"At present we're running through anywhere up to 134 bags of fentanyl," says Dr. Shanti Akers, pulmonary and critical care physician at Phoebe Putney. "Pre-COVID that would have lasted us two to three weeks. And now we're running through that quantity in simply a day."

The problem isn't just the overwhelming number of COVID-19 patients, Akers says. They're also in such extreme respiratory distress that they stay on ventilators much longer — instead of a few days, it might be two weeks or more – and thus require that much more medication.

"The nightmare really is that I won't have enough ventilators to treat them all at the same time," Akers says. "And even if I get them on a ventilator, I won't be adequately able to sedate them to know that they're safe. And my real worry is that a lot of people will die as a result of that."

The coronavirus pandemic has exposed a serious capacity problem in the pharmaceutical supply chain, according to Erin Fox, a pharmacist at University of Utah Health who has tracked drug shortages for years.

"Most of drug manufacturing is on a just-in-time schedule," Fox says. "It's pretty rare for companies to have more than a three-month supply, six-month supply on hand. And with the [COVID-19] surge, we are going to just burn through that at an incredible rate. A three-month supply could go in a week."

What's more, she says, "to prevent hoarding, wholesalers are holding hospitals to past-use history orders. It's completely irrelevant in this situation."

Compounding the problem: There aren't many companies that make these drugs. "These hospital drugs are very, very cheap. It's just not a big profit-making arm for these companies," Fox explains.

Just as the federal government has put pressure on manufacturers to produce more ventilators, Fox says, it's time for the government to exert the same pressure on drugmakers.

"I think these companies should be held accountable and asked, 'What are you doing to ramp up supply?' " she says. " 'What are you doing to make sure we have enough medicines to treat all the Americans who are sick?' "

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MARY LOUISE KELLY, HOST:

We've heard a lot about the critical shortage of protective gear for health care workers and about the urgent need for more ventilators to help keep patients with COVID-19 alive. Well, there is another shortage of grave concern. Hospitals are running out of the drugs those patients on ventilators require. NPR's Melissa Block has that story.

MELISSA BLOCK, BYLINE: For a patient in acute respiratory distress, being put on a ventilator can be lifesaving. It's also really unpleasant.

ALIX MORSE: It is deeply uncomfortable.

BLOCK: Alix Morse is a pulmonary critical care physician at Sturdy Memorial Hospital in Attleboro, Mass. She explains when patients are intubated, they're given strong sedatives and pain medicine and sometimes paralytic drugs. Without them...

MORSE: Most people will kind of reach for the tube and try to grab it and pull it out. They may fight against having it in their mouth. And if they're working against a breathing machine, it can actually damage their lungs.

BLOCK: Now, with the surge of COVID-19 patients on ventilators, hospitals are burning through their supplies of those essential medications. Some have run out of certain drugs entirely. Others are down to just a few days' supply. They're even having to ration the use of albuterol, the common drug used to treat asthma. Doctors say they've been urging patients to bring in their albuterol inhalers from home.

Dr. Morse has been watching her hospital's drug stocks dwindle and worrying about her patients.

MORSE: It's the human cost of being scared - maybe being aware on the breathing machine when you really shouldn't be. That really keeps me up at night.

BLOCK: The drug shortages are especially acute in a COVID-19 hot spot like Albany, Ga. That's where Shanti Akers works as a pulmonary critical care doctor at Phoebe Putney Memorial Hospital. They've seen their caseload of patients on ventilators soar from the typical 12 or 15 to as many as 46 at one time.

SHANTI AKERS: At present, we're running through anywhere up to 134 bags of fentanyl. Typically, pre-COVID, that would've lasted us two to three weeks. And now we're running through that quantity in simply a day.

BLOCK: Akers says the problem isn't just the overwhelming number of COVID-19 patients. They're also staying on ventilators much longer. Instead of a few days, it might be two weeks or more. And they require that much more medication.

AKERS: The nightmare really is that I won't have enough ventilators to treat them all at the same time. And even if I get them on a ventilator, I won't be adequately able to sedate them to know that they're safe. And my real worry is that a lot of people will die as a result of that.

DAN KISTNER: We have seen an increase in demand on pharmaceuticals that's unprecedented.

BLOCK: Dan Kistner manages the pharmacy program for Vizient, a group purchasing organization that negotiates lower prices with drug manufacturers. Vizient released data last week showing dramatic spikes in demand for the sedatives, pain meds and paralytics crucial for patients who are on ventilators. But while demand is soaring, Kistner says, the supply chain is lagging far behind. Here's one complicating factor.

KISTNER: Injectable drugs take a long time to make. For instance, there's a 21-day sterility period needed for all injectable drugs. And so it's not something simple that you can do overnight.

BLOCK: Which means, he says, if you ramp up production of ventilators but don't also get a jump on producing the necessary drugs, you've got a big problem.

KISTNER: We're going to build all these cars, but if we don't have the gas, they can't go anywhere.

BLOCK: Adding to the problem, there aren't that many companies that make these drugs, says Erin Fox, a pharmacist at University of Utah Health.

ERIN FOX: These hospital drugs are very, very cheap. It's just not a big profit-making arm for these companies.

BLOCK: Fox has tracked drug shortages for years. She says just as the Trump administration has put pressure on manufacturers to produce more ventilators, it's high time for them to exert the same pressure on drugmakers and ask...

FOX: What are you doing to ramp up supply? What are you doing to make sure that we have enough medicines to treat all the Americans who are sick?

BLOCK: Melissa Block, NPR News.

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