You need an antibiotic, but it's not available. How drug shortages force doctors to pick frustrating alternatives.

Diane Brys, 72, had battled back cancer before. But when she started chemotherapy for the second time this summer, she and her medical team were faced with a new problem almost entirely outside their control.

Brys was a 15-year survivor before her cancer recurred. A highly-used generic chemotherapy drug called carboplatin had helped her become cancer-free. But as she started treatment again this summer, her doctors at UW Carbone Cancer Center had worrisome news: carboplatin was in short supply.

"I was holding all my eggs in my basket that carboplatin would be available again, and then to hear that it wasn't available was a bit scary," said Brys, of Madison.

Thankfully, her doctors were able to find alternatives. A few times, they switched her to another set of chemo drugs, cisplatin and gemcitabine, which her doctors said would be equally effective, but stronger in terms of side effects.

Her second time in treatment was already difficult due to weakness and various other health issues. Brys dealt with the added nausea from the cisplatin as best she could. Eventually, the supply of carboplatin improved. For her last two treatments, she was back on it, at a slightly lower but still a therapeutic dosage.

"I was lucky," she said.

Historically, drug shortages have been occurring nationwide

Brys is one of countless Wisconsin patients who have for months grappled with near historic drug shortages. The shortages are worse today than in years past, doctors and drug policy experts agree, but they are not new. The shortages are also occuring nationally.

The list of medications that are, or have recently been, in short supply span many medical specialties: potentially life-saving chemotherapies; antibiotics, especially some used with pediatric patients; ADHD drugs; anti-inflammatory corticosteroids.

"We are a nation with many resources, and yet, generic medications across the board, and things like infant formula, are resources that some of our citizens don't have access to because we haven't really built the policies to ensure that there would be access," said Kari Wisinski, chief of hematology and oncology and palliative care at the University of Wisconsin-Madison's Department of Medicine.

Each drug shortage comes with its own trigger, said Michael Ganio, senior director for pharmacy practice and quality for the American Society of Health-System Pharmacists. Sometimes, demand takes off and manufacturers don't keep up. Other times, inspections find issues that shut a plant down. Even natural disasters can throw drug supply chains into chaos.

Just last month, the U.S. Food and Drug Administration announced it was working with Pfizer to determine the impact of storm damage at a plant in North Carolina. The company has one-third of the total sterile injectable drug market for hospitals in the U.S., and 8% of nation's consumption is supplied by this site.

But, the root causes of these shortages, Ganio and other experts said, come down to the way in which pharmaceuticals generally are sold and manufactured. Many of the most impactful shortages have been of old, generic drugs that are cheaper than new, name-brand medications. Because they sell for so little, it's not uncommon for there to be only one, or just a few, manufacturers who make them.

Any issues in accessing ingredients, failed inspections, natural disasters or other disruptions, and patients and their doctors are left to deal with the impact.

"Every week, it seems like there is a new generic product that is on shortage, unfortunately," Samantha White, a hematology and oncology pharmacist at La Crosse-based Gundersen Health System, said in late June. "It's those generic, low cost drugs that are the ones being affected."

While these shortages have long been an issue, they've gotten worse over the past few months, nearing record highs.

The American Society of Health System Pharmacists, which tracks drug shortages, found that in the second quarter of the year, there were 309 active, ongoing drug shortages, the highest number in nearly a decade. In a survey of more than 1,000 pharmacy professionals, more than 99% said they were experiencing shortages. Among the most critical have been chemotherapy drugs that have platinum in them, including carboplatin and cisplatin.

Benjamin Parsons, chair for hematology at Gundersen Health, said there is no clear answer to the shortages, but change is needed on a systemic level.

"It's a real travesty to run into this situation in a modern age where we would hope that we would have better supply chains that wouldn't run into these issues," he said.

From pediatrics to oncology, doctors adjust for their patients

Pediatrician Michael Gutzeit, president of primary care at Children's Wisconsin, has dealt with the impact that several drug shortages have had on young patients the health system serves.

"We have faced challenges with medications off and on for many years," Gutzeit said. "This was accelerated during the pandemic because of the significant impact to supply chain. We've had problems with things like Adderall, with inhalers, with penicillin, with amoxicillin. These are all significant disruptors to delivering the best and safest care to kids."

Adding to the complexity of dealing with drug shortages for children, Gutzeit said, is the fact that many pediatric medications are given based on the patient's weight. There are times doctors at Children's have had to get creative in finding alternatives to the medications they'd normally give patients.

"If there is a shortage of a medication commonly used for a specific condition, an unfamiliar alternative poses the potential for dosing errors," he said.

Whether it is for adults or children, the task of finding alternatives to go-to medications can be difficult work. In some scenarios, nationally, the decisions faced by providers have been stark.

Lu Anne Bankert is executive director for the Wisconsin Association of Hematology and Oncology and its counterparts in five other states through the national Association of Community Cancer Centers. She recalled a young physician in Washington telling her through tears that she was not used to deciding if the 10-year-old kid or 60-year-old woman should get a preferred drug.

"The doctors are working on different things that they can do like spacing dosages out, reducing dosages or taking a look at each patient individually to see: Is there something else that they can treat them with versus these drugs?" Bankert said. "It is compromising some care in some patients."

Is Wisconsin, there have been varying levels of impact.

Gundersen, UW Health and Bellin Health Systems said they've been able to manage the shortages in chemo drugs without compromising care, but week to week this summer, the window of comfort has varied. They've been keeping a close eye on supply while planning for what to do if there is not enough supply.

The shortages hit different locations at different times.

One of the most difficult periods at UW Health came in late-May, when the hospital was "very, very critically short of carboplatin," Wisinski said.

At that time, UW Health did not run out of the chemo drug, but did put conservation measures in place to make sure none of the supply was wasted. Hospital leaders told doctors to proceed with alternative treatment plans for patients where the effect of the alternative treatment would be equal to the preferred drug.

Then, for about a two-week window, the supply was even tighter. UW doctors were told to tell patients who were getting chemo for palliative reasons they wouldn't be able to get treatment in that window. At Green Bay-based Bellin Health Systems, clinical pharmacist Jim Zabel said in early-June doctors briefly reached a similar point, prioritizing patients receiving curative treatment ahead of those getting palliative care.

Today, supplies have stabilized and everyone is getting normal treatment. But Wisinski noted that shortages have been a multi-year issue. Without true policy changes, the threat of another shortage remains. In her 15 years in practice, Wisinski has seen at least three other drug shortages in breast cancer care.

"This was one of the most severe," she said.

Doctors are raising awareness and hoping for true change

In light of the drug shortages, doctors and advocates have been speaking out in an effort to raise awareness in the public sphere and in Congress.

The U.S. Food and Drug Administration has taken steps to ease shortages, for example, importing cisplatin from China.

But the solutions to the root causes of the shortages remain complex and elusive. David Kreling, an emeritus professor at UW-Madison, studies drug economics, marketing and policies and how they effect consumers. One challenge is that manufacturing of many generic drugs happens abroad. When an issue arises, there isn't enough infrastructure in the U.S. to fill the gap immediately.

"It is thorny," Kreling said. "There's not a quick fix and it might not be an inexpensive fix."

White, of Gundersen, also noted there are major workforce challenges at play, as health care organizations are dealing with a shortage of pharmacy technicians and purchasers. Such teams are highly-specialized and are "the key to surviving some of these drug shortages," she said.

"People think that they are replaceable and they are not," she said. "We have purchasers that have been with us for over 10, 20 years, and if you lose them because of the low pay, there is no way we'd be staying afloat."

Ganio, at the American Society of Health System Pharmacists, agreed, saying that the hourly pay pharmacy technicians receive is not equal to the value of the work they do. Some could make as much working at Starbucks or Walmart or Amazon, he said.

As for trying to stop or ease shortages at the manufacturer level, Ganio said some recent national policy changes have been proposed that he hopes will help. One suggested improvement has been to have manufacturers notify the FDA of early signs of a shortage. Another is to have manufacturers maintain a buffer amount of medication to cushion against increased demand.

But he wants to see more solutions that get at preventing shortages before they happen in addition to those that mitigate them in the moment.

That could make all the difference for patients like Brys. She called the systemic problems underlying the shortages "infuriating."

"We need to do something about making sure everybody has the medications they need," she said. "It could be a life and death situation for many patients."

This article originally appeared on Milwaukee Journal Sentinel: Shortages of antibiotics, ADHD drugs, chemo, plague doctors, patients