SDIS

DRUG SHORTAGES

Drug shortages can occur for a variety of reasons.The factors currently affecting drug supply are shortages of raw materials, quality control issues which led to voluntary withdrawal and longer production times for some products and competition among drug manufacturers. The problem is expected to ease somewhat with renewed production in some cases and takeover of supply by another company in others. For more details see the environmental scan on Drug Supply Disruptions recently posted on the CADTH website.

In the meantime, healthcare providers are responsible for ensuring patients continue to receive appropriate drug therapy. A general protocol to follow in handling drug shortages is offered below:

Ensure there is a valid indication for the drug. Review the patient’s drug and medical history. For a checklist of criteria to consider, check the CPhA Drug Shortages Guide pg 4 - 6.
Substitution of a different brand of the same drug (molecule):
- Check the Saskatchewan Prescription Drug Plan (SPDP) Formulary for interchangeable brands of the same drug; then check for availability of these brands. (Call wholesalers, manufacturers)
- If none are available, is there a non-interchangeable brand of the same drug.in the same dosage form? Obtain authorization for substitution from doctor, start at same dose or a reduced dose and titrate to desired effect (especially important if drug has a narrow therapeutic index) and monitor for beneficial and adverse effects. Follow-up with the patient in 24 – 48 hours, as indicated by kinetic and pharmacologic characteristics of the drug.
- If no Formulary drug in the same dosage form is available, check Health Canada Drug Product Database for other brands that may be available and proceed as above.
- If none available, is there a different dosage form of the same drug? Obtain authorization for substitution from doctor, start at appropriate dose and titrate to desired effect (especially if narrow therapeutic index) and monitor for beneficial and adverse effects. Follow-up with the patient in 24 – 48 hours as indicated by kinetic and pharmacologic characteristics of the drug.
- If no Formulary drug is available, check Drug Product Database for other dosage forms that may be available and proceed as above.
- As necessary, consult SPDP regarding coverage for substituted brand.
If no other forms of the same molecule are available, substitution of another drug in the same therapeutic class can be considered. Check the references below for dose equivalence data. This information is not always available. Even when a therapeutically equivalent dose is administered, patients may react differently. Pharmacists should follow-up with the patient frequently until the patient is stabilized on the new medication.
- Rx Files Charts - www.rxfiles.ca
- e-therapeutics + (available at SHIRP)
- Handbook of Clinical Drug Data , 2010, 11th edition - hardcopy text
If there is not a therapeutic equivalent, check treatment guidelines and recommend a drug from another pharmacologic class. Monitor and titrate to desired effect.
- e-therapeutics+
- RxFiles
- Others, e.g. Healthcare Network Clinical Guidelines, NHS Clinical Knowledge Summaries, National Guideline Clearinghouse, etc. .
Compounding capsules or tablets in the desired doses when other strengths of drug are available or from bulk powders may be another option, especially in instances where there is not a readily available or acceptable substitute.

The following tables provide suggestions for handling shortages of specific drugs. This information is intended for use by healthcare providers for general informational purposes only. It remains the responsibility of the healthcare provider to use professional judgment in evaluating this information in light of any relevant clinical or situational data. This information is provided without warranty of any kind and SDIS and the University of Saskatchewan assume no responsibility and/or legal liability whatsoever for any errors, omissions or inaccuracies contained therein.

PARENTERAL DRUGS

To check current availability status of parenteral drugs go to the Sandoz website and click on Product Supply Information for Healthcare Professionals.

Click on colored text to link to additional information.

DRUG

AVAILABILTY / ALTERNATIVES

Diltiazem

Paroxysmal Supraventricular Tachycardia

1st line:
Adenosine 6 mg (0.1 mg/kg) rapid IV bolus

2nd line:
Calcium Channel Blockers
Verapamil 2.5-5 mg IV over 2 min (3 min in older patients). May repeat 5-10 mg q15 min up to 20 mg

Beta Blockers
Metoprolol tartrate 5 mg IV q 5 min up to 15 mg
OR
Esmolol HCl 500 mcg/kg IV bolus over 60 s, followed by an infusion starting at 50 mcg/kg/min. May repeat 500 mcg/kg bolus if inadequate response after 2-5 min
OR
Propranolol HCl 0.1 mg/kg divided into 3 doses given slowly at 2 min intervals. May repeat dose once.

Rate Control of Atrial Fibrillation:

1st Line:
Calcium Channel Blockers
Diltiazem

Beta Blockers
Metoprolol tartrate 5 mg IV q 5 min up to 15 mg

OR
Esmolol HCl 500 mcg/kg IV bolus over 60 s, followed by an infusion starting at 50 mcg/kg/min. May repeat 500 mcg/kg bolus if inadequate response after 2-5 min
OR
Propranolol HCl 0.1 mg/kg divided into 3 doses given slowly at 2 min intervals. May repeat dose once.
     Sandoz (DIN 02225883)100% allocation

2nd Line:
Amiodarone HCl 5 mg/kg IV over 30 min, followed by 1200 mg over 24 hr

Digoxin 400-600 mcg IV single initial dose (if not taking digoxin).

Dimenhydrinate

Change to alternate route (oral or rectal)

Therapeutic Alternatives:

Prochlorperazine 5 to 10 mg PO/IV/IM q6h PRN (max 40 mg/day)
Metoclopramide 5-20 mg PO/IV q6h PRN
Ondansetron 4-8 mg PO q8h prn

Fentanyl

Procedural sedation -See PDF

Chronic pain - fentanyl patch - do NOT use in opioid naïve pts

Powder available at Medisca, Galenova

Folic acid

Oral: 5 mg tablets

5 mg IV = 5 mg PO

ENTERAL: Dispersed tablets can be administered enterally

Furosemide

Alternative Manufacturers:
Omega – furosemide HCl 10 mg/ml available in 2, 4 and 25 ml vials. 2 and 4 ml vials are reserved for contract customers. 25 ml vials reserved for contract customers but Omega may distribute to non-customers depending on situation (case-by-case basis). Call Omega 1 800 363 0584.

Alternative Routes:
- oral: 20 mg IV = 40 mg PO
- administration through enteral feeding tube. It is reasonable to administer furosemide oral solution (can dilute with equal volume water if needed) through a feeding tube. Caution with doses > 140 mg daily (14 ml) which contain nearly 10 g sorbitol. 10 g sorbitol per day may cause flatulence and bloating; 20 g daily may cause diarrhea and cramping.

Therapeutic Alternatives:
Ethacrynic acid: 50 mg/vial (close to $500 acquisition cost per vial)
Bumetanide: IV available through Special Access?

Glycopyrrolate

Preoperative inhibition of salivation and excessive respiratory tract excretions:

Assess need for premedication on an individual patient basis. Routine use not recommended.

Atropine sulfate parenteral: Adult: 0.4 mg (range: 0.2–1 mg) SC, IM, IV 30 - 60 min prior to anesthesia Pediatric: 0.1 mg for children weighing 3 kg, 0.2 mg for 7 to 9 kg, 0.3 mg for 12 to 16 kg and 0.4 mg for those weighing more than 20 kg

Scopolamine hydrobromide parenteral : 0.3 mg to 0.6 mg SC, IM, IV 45 to 60 minutes prior to anesthesia

Scopolamine 1.5 mg transdermal patch: Apply 12 hours before surgery

Atropine (Other routes):

Oral solution (ophthalmic drops, compound) Pediatric dose: 0.02 mg/kg to 0/03 mg/kg. (Note: Significantly less effective than IV atropine for decreasing bronchial secretions)
Rectal solution (compound) - Pediatric dose: 0.05 mg/kg (Max 1.5 mg)

Intraoperative and postoperative use:

Atropine sulfate IV, scopolamine hydrobromide IV

Management of gastrointestinal disorders:

Hyoscine butylbromide (Buscopan), atropine sulfate, scopolamine hydrobromide SC. IM. IV

Hydromorphone

Acute or chronic pain:

ORAL: – IR tablet; solution, SR capsule
1 mg IV = 2 mg PO opioid naïve pts, chronic pain
RECTAL - 3 mg suppository

ENTERAL: Syrup, dispersed IR tablets can be given enterally

COMPOUND STERILE SOLUTION for parenteral use (if facilities available) – powder can be purchased from Medisca

Alternative IV analgesics: morphine, fentanyl, methadone

Fentanyl patch for chronic pain only - do NOT use in opioid naïve patients

Ketorolac

Step down to oral NSAIDs as soon as therapeutically appropriate.
Use rectal NSAIDs if oral route not available.

NSAIDs available as rectal suppositories: diclofenac, indomethacin, ketoprofen, naproxen, piroxicam

Use parenteral opioids.

30 mg IM or IV ketorolac ̴ 12 mg IM morphine

Morphine

Precedural sedation - See PDF for alternatives

Acute or chronic pain:

ORAL: IR tablet; syrup, SR tablet/capsule
10 mg IV = 20 mg PO opioid naïve pts, chronic pain

RECTAL: 5, 10, 20, 30 mg suppository
10 mg IV = 10 mg PR

ENTERAL: Syrup, dispersed IR tablets can be given enterally

COMPOUND STERILE SOLUTION for parenteral use (if facilities available) – powder can be purchased from Medisca, Galenova

Alternative IV analgesics: hydromorphone, fentanyl

Fentanyl patch for chronic pain only - do NOT use in opioid naïve patients

Naloxone

No alternative. Health Canada has secured an out of country source for nalaxone to cover the Sandoz shortage.

Contact Poison Control for emergency information in the event naloxone is unavailable.

Neostigmine Methylsulfate

Reversal of Post-op neuromuscular blockade
- reduce/ avoid use of muscle relaxants when possible

Urinary Retention
- catheterization

Post-operative ileus
-no specific therapy

Acute Exacerbation of Myasthenia Gravis
-treatment of underlying cause (e.g. Infection)
-pulmonary physiotherapy
-IVIg: 2 g/kg given over 5 days (400 mg/kg /day) or, if tolerated, over 3-4 days

Nitroglycerin

Ischemia:

Sublingual nitroglycerin

0.4 mg every 5 min x 3 doses

I.V./oral beta blockers in absence of contraindication (if so consider non-dihydropyridine calcium channel blocker – avoid immediate release nifedipine)

Metoprolol 50 mg PO q12h OR if significant, 5 mg I.V. over 2 minutes q 5 minutes up to 15 mg.
Atenolol 25-50 mg PO q12h OR if significant, 5 mg I.V. over 5 minutes, repeat once after 10 minutes.

Morphine sulfate if ischemic pain not adequately treated.
Oral long acting nitrate to prevent recurrent episodes of ischemia

Hypertensive Emergency (HE)/Intraoperative Hypertension (IH)

Labetalol (HE)
20-80 mg I.V. bolus q 10 minutes until target BP

0.5-2 mg/minute I.V. infusion to target BP
Esmolol (IH)
1.5 mg/kg bolus over 30 seconds. Follow with 0.15 mg/kg/min. Adjust rate as required up to 0.3 mg/kg/min to desired heart rate/BP.
Phentolamine (HE)
5-15 mg I.V. bolus
Sodium nitroprusside (HE)
0.25 – 10 mcg/kg/minute as immediate I.V. infusion
Hydralazine (HE)
10 – 20 mg I.V. q 20-30 minutes as needed for desired BP.

Pantoprazole

Restriction: Active GI Bleed; dose restricted

Dose: 80 mg IV x 1 dose, followed by 40 mg IV q12h x 6 doses Note: Doses greater than this may be subject to autosubstitution

Alternatives:
Patients With No Active GI Bleed (i.e., do not meet restriction criteria):

Dose: Esomeprazole 40 mg PO or via NG once daily

Dose: Lansoprazole Fastabs 30 mg PO once daily (quick dissolving tabs)

Phenytoin

Alternatives to Phenytoin for Treatment of Status Epilepticus (In order of preference):

Phosphenytoin 20 mg/kg phenytoin equivalents IV at 150 mg/min
Lorazepam 1-2 mg/min IV to max 0.1 mg/kg
Midazolam 10 mg IV bolus, then 0.05 – 0.4 mg/kg/h OR diazepam 5 mg/min IV to max dose of 0.25- 0.4 mg/kg OR diazepam 20 mg rectally if no IV access.
Phenobarbital up to 20 mg/kg IV (50-75 mg/min)
Propofol 2-5 mg/kg IV bolus followed by infusion at 2-10 mg/kg/h

Alternatives to Injectable Phenytoin for Treatment
of Tonic Clonic (TC) or Partial/focal (P) Epilepsy:

1. Administer phenytoin orally
- phenytoin suspension can be administered via enteral feeding tube if patient can’t swallow

2. Use alternative oral anti-epileptics

Oral Alternatives to Phenytoin for Treatment of Tonic-Clonic or Partial Seizures
Drug	Seizure Type	Usual Daily Maintenance Dose (Adults/Children)	Number of Doses per Day	NG Tube Administration Feasible?
Carbamazepine	Tonic Clonic Partial	800-1200 mg	2 to 4	Yes
		10-40 mg/kg/day
Lamotrigine	Tonic Clonic Partial	300- 400 mg	2 to 3	Yes – Chewables/dispersibles
		10-12 mg/kg/day*
Valproic Acid	Tonic Clonic Partial (2nd line)	750-1000 mg	2	Yes - syrup
		60-80 mg/kg/day
Levetiracetam	Tonic Clonic (2nd line) Partial	750-1000 mg	2	Yes
		60 mg/kg/day**
Oxcarbazepine	Partial (2nd line)	1200-2400 mg	2	No
		20-50 mg/day†
Topiramate	Tonic Clonic (2nd line) Partial (2nd line)	200-400 mg	2	Yes – tablets, not contents of capsules
		4-10 mg/kg/day
Lamotrigine not indicated in children (<16yo) except for seizures associated with Lennox-Gastaut syndrome; dose is based on monotherapy. *Not indicated in children † See weight-based dosing in monograph

3. If parenteral is required:
Fosphenytoin – dose as phenytoin equivalents. For example, if dose of phenytoin had been 100 mg, dose of fosphenytoin will be 100 mg phenytoin equivalents.
Off-label routes: phenobarbital subcutaneous (i.e.: if need parenteral)
Seizure type – ether and UpToDate Epileptic syndromes and recommended antiepileptic drugs

Pipotiazine palmitate
(Piportil L4)

All strengths are currently unavailable. Expected availability date - 2012/08/06.

Alternative depot antipsyhotic: flupentixol, fluphenazine, risperidone, halperidol long-acting, paliperidone (See Depot Antipsychotic Shortages PDF)

Ranitidine

Change to oral route whenever possible:
-ranitidine 50 mg IV = ranitidine 150 mg PO
-oral solution can be administered NG (Teva oral solution available DIN 02242940)

Change to alternative if required:
Alternative H2 antagonists:
-IV: famotidine (APX, Omega) – in short supply
-Oral: famotidine 40 mg ~ nizatidine 300 mg ~ ranitidine 150 mg BID or 300 mg HS

Alternative PPIs:
IV: Pantoprazole (currently shorted)
Oral: Pantoprazole 40 mg ~ Lansoprazole 30 mg ~ Omeprazole 20 mg ~ Esomeprazole 40 mg ~ Rabeprazole 20 mg
Nasogastric administration: lansoprazole, esomeprazole

Rocuronium

Alternatives: Vecuronium (intermediate/long), atracurium (intermediate)

Testosterone
Testosterone enanthate 200 mg/ml
(Delatestryl)
Testosterone cypionate 100 mg/ml (Pfizer, Sandoz)

Delatestryl (testosterone enanthate) and Depo-testosterone (testosterone cypionate) are available. Sandoz testosterone cypionate unavailable.

Option: Testosterone enanthate and testosterone cypionate (100 mg/ml) can be substituted at same mg/dose and same frequency (Note different concentrations of testosterone cypionate products and Delatestryl - e.g. a patient receving 0.5 ml (100 mg) Delatestyl would require 1 ml (100 mg) of testosterone cypionate.)

Alternatives: Oral or topical formulations of testosterone (See PDF)

Vitamin B 12

1 ml Vit B12 1000 mcg ampoules are or will soon be out of stock. 10 ml and 30 ml multidose vials are still available.

Restrict parenteral use: severe neurologic involvement or with vomiting, diarrhea or bowel resection, or chidlren with severe deficiency when rapid restoration of stores is desired.

Alternatives: Oral or sublingual route:

Adult - 1,000 to 2,000 mcg/day inititally to treat deficiency, followed by maintenance dose of 1000 mcg/day
Children - Not well defined. Doses of up to 1000 mcg/day orally are used for pernicious anemia.

Vitamin K

RESTRICTIONS: Reserve injectable Vit K for patients with oral absorption concerns or very high INRs, or NPO patients where oral route is not available (eg TPN).

ORAL: Vitamin K 5 mg tablets- Special Access Drug. No restrictions per SAP.

COMPOUND: Vitamin K powder available from Galenova, Medisca - prepare capsules, powders, suspensions

ORAL DRUGS

* Click on colored text to link to additional information.

Drug	Availability / Alternatives

Allopurinol (Zyloprim)	Zyloprim currently available. Discontinuation in patients with mild gout and no attacks for years may be considered. Alternatives: Xanthine oxidase inhibior: febuxostat (Uloric) 80 mg PO once daily. (new, $$) 2nd line prophylaxis: Colchicine 0.6 - 1 mg PO once daily; reduce dose in elderly, renal impairment Uricosuric agents: ineffective if CrCl <50 ml/min; not in urate over-producers; not if history of nephrolithiasis; liberal fluid intake required: - Probenecid: inital dose 250 mg PO BID, titrate to 0.5 - 2 g / day in two to three divided doses - Sulfinpyrazone: inital 100-200 mg PO BID, increase dose to 200 - 400 mg PO BID
Acetazolamide	AA Pharma brand available Alternatives: Glaucoma – methazolamide Altitude sickness - dexamethasone
Amitriptyline	One brand available - Elavil FCT by AAPharma - all strengths Alternatives: Nortriptyline (convert at roughly ½ the dose of amitriptyline and titrate as needed), Imipramine (convert at same dose as amitriptyline); beta-blockers (migraine prophylaxis); SSRIs, SNRIs
Amoxicillin trihydrate / potassium clavulanate	Available: Apo-Amoxi Clav 250/125 and 500/125 mg tablets Clavulin 125/31.25 (100 ml), 200/28.5 (70 ml), 250/62.5 (100 ml), 400/57mg (70 ml) Alternatives: macrolides, clindamycin (but not if need Gram neg coverage), fluroquinolones, cefixime, cefuroxime
Ampicillin Oral Suspension	No manufacturers are currently marketing oral ampicillin suspension Alternatives Compound suspension from oral ampicillin capsules (See detail document) Another antibiotic which is active against the organism causing the infection
Beclomethasone nasal spray Budesonide nasal spray Flunisolide nasal spray (Rhinalar)	Apo- and Mylan-beclomethasone now available Mylan- budesonide 64 ug, 100 ug now available Apo-flunisolide 0.025 % biw available Alternatives: Fluticasone Ciclesonide (Omnaris)
Betahistine (Serc, generics)	Currently available Alternatives: Compounding pharmacies may be able to make capsules for patients
Carbamazepine	Available in all strengths and quantities
Cefaclor	Ceclor capsules available; liquid unavailable Alternatives: trimethoprim-sulfamethoxazole; fluoroquinolones
Cephalexin	All formulations and strengths available Alternatives: Cellulitis: cloxacillin UTIs: TMP/SMX, nitrofurantoin, fluoroquinolone Skin infections: cloxacillin, clarithromycin, azithromycin, clindamycin, cefadroxil
Chlorthalidone	Currently available. Alternatives: If also on atenolol and strengths match, can go to the combination product (Tenoretic, generics) Hydrochlorothiazide at equivalent dose for hypertension or edema
Cotrimoxazole	DS tablet may be available May 7/12. All brands of oral suspension are being shorted. Options: Crush tablets, compound oral suspension Alternatives: Another antibiotic with similar spectrum of activity
Desipramine	All strengths are available Alternatives: Nortriptyline and desipramine are both secondary amine TCAs and generally better tolerated than tertiary amine TCA's (convert to nortripytline at roughly ½ the dose of desipramine and titrate as needed), Imipramine, amitriptyline, clomipramine (convert at same dose as desipramine); beta-blockers (migraine prophylaxis); SSRIs, SNRIs
Diazepam	All strengths are currently available. Alternatives for 2 mg: Use ½ x 5mg tablet short term; 0.5mg lorazepam approximately equivalent to 2.5 mg diazepam (may require shorter dosing interval due to shorter half-life compared to diazepam)
Diltiazem ER 180mg, 240mg and 360mg	Diltiazem CD and Tiazac XC are available in all strengths. Certain generic brands are unavailable. Alternatives: Same daily dose of alternative dilitazem formulations Hypertension: verapamil, amlodipine, felodipine and nifedipine XL Stable angina: amlodipine, nifedipine, and verapamil IR are indicated. IR diltiazem and IR nifedipine not recommended for monotherapy.
Ethosuximide	Zarontin 250 mg capsules unavailable Options: Zarontin 50 mg/ml syringe available Alternatives: switch to another anticonvulsant- monitor for tolerability and seizure control
Fluconazole	Apo- fluconazole 150 mg now available 150mg single dose capsule available OTC as Canesoral without Rx
Folic Acid	Euro-folic 5 mg tablets in 1000's is in stock. 5 mg tablets packaged in 100's are now available
Fosfomycin	Fosfomycin currently not available in Canada and future availability unknown. It is a one-dose oral antibiotic indicated only for uncomplicated UTI in females. There are no other one-dose oral antibiotics for UTI currently available.
Gentamicin ophth/otic	Ophthalmic drops/ ointment and otic drops are available Alternatives: SPDP covers Optimyxin, Polytrim, PMS-Polytrimethoprim Polysporin available OTC
Gliclazide MR	Diamicron MR 30 mg and 60 mg available; Gliclazide MR 30 mg (AA Pharma Inc) available Alternatives: Gliclazide 80 mg immediate release (various brands) - to substitute for MR, start with 80 mg IR per 30 mg MR. Doses higher than 80 mg daily should be divided BID. Dose should be adjusted based on blood glucose monitoring after switch.
Hepatitis B vaccine	Engerix B adult and pediatric now available; Recombivax Thiomersol Free also available No alternatives available
Hydroxyzine	10mg, 25mg & liquid Apo-hydroxyzine, 50 mg expected April 30/12 (Teva); June 1/12 (APO).
Iron Dextran	Infufer 50 mg/ml out of stock indefinitely; Dexiron 50 mg/ml available.
Isosorbide Dinitrate	AA Pharma has taken over marketing from Apotex. Now available. Alternatives: isosorbide mononitrate, nitroglycerin
Linessa (ethyinyl estradiol 25mcg/desogestrel 100/125/150 mcg)	Available
Medroxyprogesterone acetate	All strengths currently available. MPA powder is available. Options: Compound capsules from bulk powder Alternatives: micronized progesterone, norethindrone acetate, megestrol acetate, estradiol/progestin combinations (See PDF for detailed information.)
Methotrimeprazine (Nozinan & generics)	50 mg strength available. 2mg, 5mg, 25 mg expected May 5, 2012. Alternatives: Chlorpromazine, haloperidol (note do not have analgesic effects)
Penicillin V	Tablets currently available in all strengths. Suspensions and injections are being shorted Alternatives: Strep throat : amoxicillin, erythromycin (if penicillin allergic)
Pentoxifylline	Currently available. Alternatives: aspirin, clopidogrel, dipyridamole, ticlopidine
Primidone	AA Pharma 125 mg and 250 mg tablets now available
Phenytoin	Dilantin® 100 mg and 30 mg extended release capsules shorted off and on in Saskatchewan. Pfizer has been trying to ship out about every two weeks with what is available. Alternatives: Infatabs, oral suspension, injectable. Important - see PDF for instructions on switching.
Pizotifen (Sandomigran)	0.5mg tablets unavailable indefinitely Sandomigran DS (1 mg) is still available.
Prochlorperazine (Stemetil & generics)	Stemetil d/c Generic versions available.. Alternatives: Antinauseant: metoclopramide, chlorpromazine
Spironolactone	Currently available Capsules can be compounded from bulk powder Alternatives: Aldactazide, Novo-spirozine if patient is also taking hydrchlorothiazide Amiloride, triamterene, eplenerone depending on indication
Terconazole (Terazol 3 ovules or duopack)	7 day cream (0.4%) and Duopak are now available Alternatives: various brand name and generic vaginal antifungals are available OTC; single-dose oral fluconazole 150mg is now available OTC; SPDP reimburses Canesten (clotrimazole) creams and ovules and single-dose fluconazole 150mg (Fluconazole may be in short supply)
Tetracycline	Apo- / AA Pharma Inc 250 capsules available
Verapamil	Isoptin SR, Mylan-verapamil SR 120 mg, 180mg, 240 mg available. IR 80mg, 120mg expected May 3, 2012 Alternatives: Immediate release at same daily dose (or as close as possible) Hypertension: amlodipine, diltiazem (CD, Tiazac reg, Tiazac XC), felodipine , nifedipine (XL) Stable angina: amlodipine, diltiazem and nifedipine XL are indicated. IR diltiazem and IR nifedipine not recommended for monotherapy.
Zostavax	Supply of Zostavax is currently limited - check www.zostavax.ca - some doses may still be available in certain areas. No alternatives available

Adapted with permission from chart compiled by: Kelly Crotty, BScPhm, Desjardins Pharmacy, Cynthia Way, BScPhm, The Ottawa Hospital and Barry Power, PharmD, Rideau Family Health Team and L’Équipe de santé familiale communautaire de l'Est d'Ottawa