The shortage of some drugs is not something new. From the Federation of Pharmacy Associations of Catalonia (Fefac), for example, they have been warning about this since even before the pandemic emerged. The problem is that it is getting more and more. For example, a button. As of today, there is a lack of supply in more than 900 presentations of medicines in Spain, according to figures from the Spanish Agency for Medicines and Health Products (Aemps). And what is more worrying, at least in the eyes of pharmacists: there is a shortage of products that in some cases are irreplaceable as there is also, at the same time, a lack of supply of other medications with which they share the same active ingredient.
During the third week of August, drugs such as Apocard (for cardiac arrhythmias), Fixaprost (eye drops for glaucoma), the well-known Primperan (nausea) or Ozempic and Victoza (both for diabetes) were in short supply in pharmacies in the province of Barcelona, according to data provided by Fefac. At that time, they were also irreplaceable because there was no stock of other medications with the same active ingredient.
At the state level, pharmacists - in that same week - also had detected the lack of supply of a whole string of products with a notable demand. However, fortunately, all of them had a substitute (with the same active ingredient) available, so the problem was solved, at least temporarily.
It should be taken into account that this shortage does not have the same impact in all cases. The medication that most worries a family doctor consulted by La Vanguardia of those mentioned above is Apocard, prescribed for cardiac arrhythmias. “It is more problematic because it is a medication that you cannot skip.” He understands that there may be patients who stop taking it while they search for it “from pharmacy to pharmacy.”
He points out that this is not the first time that there is little stock of this drug, that it has already happened on other occasions and that doctors prescribed Rytmonorm (which contains another active ingredient) as a substitute. He emphasizes, however, that it is still a setback, since the family doctor has to generate another prescription - in many cases consulting the cardiologist about the new dose - since it is another medication.
“The main problem is the delay in treatment. If you generate a prescription and the patient cannot find the drug, everything is delayed until they come back to get another one.” In this type of case, doctors usually overcome the lack of a specific drug by prescribing another with a different active ingredient but from the same family of medications.
Another family doctor consulted expressed a similar opinion. He understands that in most situations the medication can be replaced with another without too much problem and he only detects, like the previous doctor, that setback with Apocard, "although it is not a drug that many people use," he clarifies.
He asserts that in these cases the patient should go to the cardiologist again, “although it may take a while to be able to make an appointment.” Therefore, he defends that a solution would be for the doctor to contact the specialist so that the latter could advise him on the dose of the new medication to be prescribed or prescribe Rytmonorm and monitor the patient daily until he had the appointment with the cardiologist. .
Regarding Ozempic and Victoza -for diabetics-, the doctor consulted says that they have become “very fashionable to lose weight.” “There is a lot of consumption at the private healthcare level. They are people who go to nutritionists or endocrinologists, they are prescribed and then they are missing for diabetics,” she adds.
One of the graphs that accompanies this writing (which precedes this paragraph) and whose source is the Aemps, shows the problem of drug supply grouped by therapeutic group and healthcare impact. The data (the latest published) correspond to the second half of 2022 in Spain. “But this, today, remains the same,” says Antoni Torres, president of Fefac. “Drug shortages are a problem that continues to grow,” he warns.
If we look at the group of nervous system medications, the graph indicates that there is a lack of supply in a total of 160 products. It clarifies that in 124 of them the problem is minor (green), in 14 it is medium (yellow) and in 22 it is major (red). Seen in this way, one might think that the lack of supply is not alarming if one takes into account that the problem is classified as minor in 124 of the total of 160 products. But it's not like that. “That there are 22 products identified as a major nervous system problem is serious. Also having 11 in the cardiovascular system group is a serious problem,” Torres emphasizes.
The second graph shows the trend of shortages. And the data are not at all encouraging: in most drug groups there has been a worsening of the situation in the first half of 2022 compared to the second. In medicines classified within the nervous system therapeutic group, for example, the lack of supply has gone from 201 products to 248, which represents an increase of 23%. In the other groups, something similar occurs, in less than two cases: cardiovascular system (8% increase); anti-infectives (136%); alimentary tract and metabolism (74%); antineoplastic and immunomodulatory agents (21%); respiratory system (88%)…
Torres argues that the shortage of drugs responds to a multifactorial problem and that therefore “the solution is not simple.” On the one hand, there is the global cause (especially since the economic crisis of 2008): the search of governments to reduce the cost of the pharmaceutical bill and of laboratories to reduce costs. The consequence? Outsourcing of production to China and India. Thus, when a setback occurs in these countries, supply suffers (the pandemic is the most paradigmatic case). Direct or indirect dependence on Asia amounts to 74%.
On the other hand, there are the European and Spanish regulatory frameworks. Medicines are cheaper in Spain than in other neighboring countries – up to 10 times more, Torres argues. Laboratories and distributors obtain a higher margin if they market them in other countries. Many companies, she says, adjust stocks as much as possible to Spanish demand to be able to sell more packaging in other countries. And of course, when there is a peak in demand due to an outbreak - as happened at the end of last year with childhood bronchitis - there is a lack of stock.
Pharmacists are authorized by Health to change a medication, if they do not have it, for an equivalent one from another brand. But if the doctor prescribes a syrup, they cannot exchange it for sachets of the powdered principle or pills, for example. That requires exceptional authorization, as was done during the pandemic.
Likewise, the Aemps may authorize the importation of a drug from another country in cases of shortages. Torres, however, asserts that this process is very slow and that in other countries there are faster purchasing systems through pharmaceutical wholesalers.
It also demands that the exceptions become fixed regulations and vindicates the knowledge of pharmacists. He believes that if more drug changes were authorized, they would resolve many more specific product shortages.
