Many years ago a drug named Atracurium (Tracrium) was introduced into the anesthesia drug armamentarium.  This was a neuromuscular blocker that was unique in that in the absence of liver or kidney function, the drug was eliminated by the body by a process called “Hoffman degradation.”  Patients with renal failure or the most severe liver disease benefitted from the addition of this great drug.  Then it disappeared.  Without explanation.

Years later, another neuromuscular blocking drug, Mivacurium (Mivacron) appeared.  This was an extremely short acting drug that in many cases took the place of succinylcholine, a life saving drug that causes very rapid but short acting paralysis.  Then it disappeared.  Without explanation.

The replacement drugs were not the same.  They simply didn’t offer the same benefit profile, but that’s all we had.  We didn’t like using succinylcholine too much because of its association with a potentially fatal adverse effect called malignant hyperthermia.  There was simply no choice, though.

Then succinylcholine became scarce.  Completely out of options, we turned to a local pharmacy that was also in the compounding business.  ”Sure. We can provide you with succinylcholine.”  They were already compounding hyaluronic acid, as I’ve written previously.  

This all seemed fishy to me.  The demand for mivacurium and succinylcholine and even the old dinosaur atracurium was there.  No one was making these drugs, however.  Why?  

We will probably never know.  I can live without hyaluronidase in my anesthesia practice because we don’t do cataract surgery at our facility.  Those who do cataract surgery are in trouble, though.  They will have to make a tough choice:  either spend another $100 on the new genetically engineered hyaluronidase, which is essential when performing the nerve block so these sick, frail and elderly patients can avoid a general anesthetic…..or put these folks all the way to sleep, a much more risky proposition.  Another option, of course, is to not buy in to this Faustian bargain and stop doing cataract surgery altogether.  

Some combination of these three paths will probably be the result of the FDA’s mysterious relationship with the drug companies.  Somewhere there is a secret winner.   It won’t take long to pick out the losers in this deal, I’m afraid.

G. Keith Smith, M.D.