Mesaton Shortage in Russian Hospitals

Dear Readers:

I saw this piece  in the Russian press.  There is a medication called mesaton, The drug has many uses, but this particular story is about its role in the world of anesthesia.  The story also involves hospital regulation and price controls in Russia.

For many years, apparently, the main source of the drug in Russia is via import from the Ukraine.  Mesaton is produced at a research facility in Kharkov, Ukraine, under the auspices of the university science labs.

The generic, non-patented, name of the drug is phenylephrine.   According to the wiki entry:

Phenylephrine is commonly used as a vasopressor to increase the blood pressure in unstable patients with hypotension, especially resulting from septic shock. Such use is common in anesthesia or critical-care practices; it is especially useful in counteracting the hypotensive effect of epidural and subarachnoid anesthetics, as well as the vasodilating effect of bacterial toxins and the inflammatory response in sepsis and systemic inflammatory response syndrome. The elimination half life of phenylephrine is about 2.5 to 3.0 hours. The clinical effects of a single intravenous bolus dose of phenylephrine are short lived and needs to be repeated every 10–15 minutes. Commonly the drug is given as a carefully titrated intravenous infusion with a syringe pump or volumetric pump.

Because of its vasoconstrictive effect, phenylephrine can cause severe necrosis if it infiltrates the surrounding tissues. Because of this, it should be given through a central line if at all possible. Damage may be prevented or mitigated by infiltrating the tissue with the alpha blocker phentolamine by subcutaneous injection.

There is much anecdotal evidence that during the recent civil war in the Donbass, both sides used this drug heavily while treating combat injuries in the field.  There were frequent requests (from both sides in the conflict) to obtain more supplies of the drug, via humanitarian convoys.

Mesaton is also used by midwives when performing caesarian sections.  In addition to these uses, mesaton is said to be a regular component of any EMT kit used by an ambulance crew.

The lede to the VZGLIAD story is that Ukraine has stopped exporting this drug to Russia.  With implications that there are political reasons for this.

Anesthesiologists Complain

According to VZGLIAD, the first indications of a mesaton shortage in Russia appeared at the beginning of this month (June) in an internet forum frequented by anesthesiologists.  A forum participant from Rostov-on-Don (Russia) complained to his colleagues about a mesaton shortage in his city.

Other doctors have confirmed that the impression is correct:  there is indeed a mesaton shortage in Russian operating rooms.  As a substitute, Russian doctors have been forced to use noradrenaline instead.  Here’s the thing, through:  noradrenaline is much more expensive.  According to the forum commenter:  “A box of mesaton only cost 40 rubles, but norik [noradrenaline] 1,600 rubles.”

The Russian Ministry of Health oversees and regulates hospitals.

Subsequently, anesthesiologists and rheumatologists from several regions of Russia, including Moscow, have confirmed that mesaton has practically disappeared from their supply cabinets.  “We still have a few boxes left over from last year, but they already warned us that there will not be any more coming in,” one doctor commented.  This is causing a glitch in the bureaucracy as well, because the Russian Ministry of Health, which oversees and regulates these hospitals, has placed mesaton on the list of “Vitaly Necessary and Important Medications” (ЖНВЛП) which every hospital is expected to have on hand, when inspected.  As a result, hospitals are placed in a Catch-22 situation, and several Russian hospitals already have appealed to the Ministry, to either supply them with more mesaton, or to remove it from the ЖНВЛП list.

According to Nikolai Bespalov, the Director of an analytical firm called RNC Pharma, imports of mesaton into Russia appeared to have stopped in August 2015, that was when the Donbass civil war was at its peak.  By comparison:  In 2014 Russia imported from the Ukraine 670,000 packets of mesaton worth 15.8 million rubles.  In 2015 corresponding figures were 201,000 packets worth 4.8 million rubles.  And then — since August 2015 — nothing.

According to Bespalov, Russia does not produce its own version of mesaton and therefore is dependent on imports of this substance.

Regulatory Issues

VZGLIAD had picked up the story from the Kommersant newspaper.  The Kommersant piece focuses on the issues of price regulation and less on the conflict between Russia and Ukraine.

Alvils Pharmaceuticals, Taganska Street, Moscow

Mesaton is produced in the Ukraine but distributed in Russia by a company called “Alvils“, whose General Director is a man named Alexei Yonov.  Yonov told the Kommersant reporter that mesaton is not the only drug experiencing possible shortages.  But Yonov denies that the Ukraine-Russia conflict has anything to do with this:  “It doesn’t matter one whit that the drug is produced in Kharkov.  There are no political problems.  The Ukrainian producers are our partners and friends.”  Instead, Yonov blames the situation on market forces and government price controls:  Pharmaceuticals fall under price controls regulations which, according to Yonov, were put in place “when there were 30 dollars to a ruble”.  The government establishes a formulary of “vitally necessary medications” and then sets a price ceiling on these drugs, with only a small index for inflation.  As the dollar strengthened and the ruble declined (due to the economic crisis), the prices were not adjusted accordingly, according to Yonov.  The Ukrainians base their costs upon the importation of foreign raw materials, and also foreign equipment which they use, to prepare the drug.  Therefore, it was no surprise that they raised the prices.  A packet of mesaton now costs around 26-27 rubles to produce.  Its registered price is 28 rubles.  And Alvils is not allowed to charge anything over that.

As a result, Alvils stopped importing the drug, leaving Russian hospitals to fall back on their stocked supplies.

The slant of the Kommersant piece is to push for the Russian government to end price regulation on “inexpensive” drugs such as mesaton.

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