Update on BAL backorder and shortage
The Ontario Poison Centre recommends that a parenteral heavy metal chelator be available for the encephalopathic or vomiting patient secondary to a heavy metal poisoning. (See Antidote Stocking Guidelines, October 2020.) BAL has been the only parenteral chelator approved for sale in Canada.
British Anti-Lewisite (BAL In Oil)(dimercaprol) is manufactured by Akorn Pharmaceuticals. Akorn had filed for bankruptcy early in the pandemic in 2020. BAL, lot number 111767A with an expiry date of May 2020, had been the only stock available in hospital emergency departments and pharmacies. Its expiry had been extended to November 2020 as per the FDA. This expiry has not been further dated.
Poison Centres have become aware that Akorn has emerged from Chapter 11 bankruptcy protection, and have a proposed release date for BAL in Oil (dimercaprol) of December 2020. (Personal communication between Akorn Pharmaceuticals & Drug & Information Centre, BC.)
As per our previous communications, the Poison Centre, suggests that in the event of a heavy metal exposure, requiring immediate parenteral chelation therapy, that your local Poison Centre be contacted. In the absence of an alternative and in discussion with the Toxicologists, use of expired product WILL be recommended. The capable patient should sign an acknowledgement of its use. Expired product should be maintained until new product can be obtained. Quantities greater than stock may need to be borrowed from adjacent hospitals. As BAL is formulated in peanut oil, it would be contraindicated in the setting of peanut allergy.
The Ontario Poison Centre is also aware that some hospitals have ordered and obtained DMPS (Dimaval®) through the Special Access ‘For Future Use’ Approval Program. This product is given intravenously and can be substituted or added instead of BAL if available or sourced when continuing treatment is necessary. DMPS represents a safer parenteral chelator in the event of peanut allergy. Once a patient has stabilized, oral chelation, in consultation with the Poison Centre may later be recommended.
As per our previous communication regarding DMPS, the cost of shipping is quoted as being $2500. This is for shipping in a controlled temperature environment. According to our colleagues at the IWK Poison Centre who have been using this product since 2012, regular shipping is adequate. Using this method, the cost per vial is quoted as ~$40 (Canadian dollars). Please see materials on the OPC website to assist in one’s application for this product.