Canada-wide amoxicillin shortage has pharmacists looking for alternatives

Dr. Sally Kenawy's patients are sick young children, and for the past week, they haven't had access to a medication she prescribes to help make them better.

One of the most common antibiotics the Vaughan, Ont. pediatrician prescribes – amoxicillin – is becoming increasingly hard for pharmacies across Canada to stock in a format appropriate for small children.

"This week, for every single amoxicillin prescription I'm giving, I'm getting a call back from parents saying 'I can't find it,'" Kenawy told CTVNews.ca in a phone interview on Friday.

Doctors like Kenawy prescribe amoxicillin to treat many different types of infection caused by bacteria, including chest and ear infections.

The antibiotic comes in pill or capsule form for adults, and in the form of a powder for suspension, which pharmacists mix with liquid, for children. Pharmacists say prescriptions for the version formulated for children are becoming harder to fill, with some manufacturers saying they won't be able to supply it again until January 2023.

This is an issue Jen Belcher has faced recently as a community and hospital pharmacist.

Belcher, who is also vice-president of strategic initiatives at the Ontario Pharmacists Association, said pharmacists replenish their drug supplies by ordering stock from wholesale distributors. Those distributors source their stock from pharmaceutical companies such as Apotex, Teva, Sanis Health Inc. and Aurobindo Pharma, all of whom manufacture amoxicillin in Canada.

"Right now at our distributors, many of the different generic brands of amoxicillin for oral suspension are in short supply," Belcher told CTVNews.ca in a phone interview on Thursday.

"Many of the generic brands are on backorder. There are some that have messages indicating they could be back available to be ordered as early as next week or the week after."

She said other manufacturers, like Apotex, say they won't have any stock available until January.

Dr. Danielle Paes, chief pharmacist officer for the Canadian Pharmacists Association, confirmed the shortage isn't limited to pharmacies in Ontario.

"In Canada, manufacturers must report any shortages to a national drug shortage database so we know there's a number of active shortage reports for antibiotics like amoxicillin," she told CTVNews.ca in a phone interview on Thursday.

"What we're hearing now is that these supply issues are starting to be seen at the pharmacy level across Canada."

Neither Belcher nor Paes know why there's a shortage of the antibiotic, but both agreed it could be related to the rise in respiratory syncytial virus (RSV) infections in children across the country. Viruses like RSV don't respond to antibiotics, however amoxicillin is commonly used to treat secondary bacterial infections, such as pneumonia, that can sometimes occur alongside RSV.

While RSV infections don't normally peak until December or January, the Public Health Agency of Canada's Oct. 29 Respiratory Virus Report warns the number of RSV cases is “above expected levels for this time of year.”

"When we look at the rates of viral illness going around communities, it's been particularly bad this year. We've had RSV and other respiratory viruses going around that will increase the rate of secondary infections," Belcher said.

"It could very well be…that this much higher rate of utilization is driving this shortage."

The U.S. Food and Drug Administration added the antibiotic to its Drug Shortage Database on Oct. 28, amid a nation-wide surge of RSV infections. The agency cites an increase in demand as the main reason for the shortage.

Belcher doesn't want parents to panic though. She said pharmacists have other tools at their disposal for when certain formulations of antibiotics aren't available.

In some provinces, including Ontario and Alberta, pharmacists have the ability to alter or adapt prescriptions if they can't fill the original prescriptions. If a child is above a certain weight threshold, and depending on the nature of their infection, Belcher might prescribe an adult oral amoxicillin tablet or capsule. Or she might instruct a parent to mix the powder contents of a gel capsule into food, like apple sauce, and administer the medication that way.

In provinces where they have the ability, pharmacists can also work independently or with prescribers to find a similar alternative to amoxicillin.

Finally, although Belcher said this option is not as common as it once was, pharmacies with the ability to compound medications can make their own non-commercial formulations of amoxicillin for suspension.

"If I'm a compounding pharmacy that has a recipe for amoxycillin and I can make it in my pharmacy, I can prepare that drug from raw ingredients," she said.

Helpful as they might be in many cases, these alternative solutions won't work for every patient. That is why Kenawy said it's critical that amoxicillin can reach the people who need it most.

"I've had some pharmacists call where we try to find an alternative, like if the child is old enough there's a chewable form of the tablet or there's an adult capsule," she said. "The problem is a lot of the time we're prescribing to kids who are under the age of two, and that's not an option for them."

Paes said everyone can help reduce the demand for drugs like amoxicillin by staying up to date with their routine immunizations and COVID-19 boosters, and by following good hand hygiene.

But the job of getting to the root causes of shortages like this one lies with governments. Paes said the federal government should do more to ensure Canada is a competitive marketplace for drug manufacturers, and to develop contingency plans for drug shortages like this one.

"One of the things we think would be really helpful would be if Canada had a really comprehensive drug action plan," she said. "We think the federal government should develop a comprehensive list of critical drugs that layers on other factors that might make those more at risk of shortage…that would help us plan ahead for contingencies."