The Ontario Poison Centre (OPC) has been made aware of a shortage of CYANOKIT® (hydroxocobalamin)

Cyanokit® Shortage 

As of December 12, 2024, this shortage is expected to last until February 2025.

For the current status of drug shortages and discontinuations, refer to Drug Shortages Canada at www.drugshortagescanada.ca.  

These recommendations are intended as guidance for healthcare professionals to select alternatives and mitigation strategies during the acute drug shortage of IV hydroxocobalamin.  The severity of the current shortage varies by facility and thus, each hospital will need to assess the degree to which conservation strategies are necessary to preserve IV hydroxocobalamin for patients with the most urgent situations.      

TABLE 1: Hydroxocobalamin products marketed in Canada¹  

*sole distributer in Canada

Health Canada approved indications for Cyanokit injection²:  

• Treatment of known or suspected cyanide poisoning in all age ranges.  

Management strategies 

Critical Conservation Strategies:  

1. Consider limiting prehospital use or empiric use of hydroxocobalamin until emergency department assessment with laboratory diagnostics (e.g. serum lactate) to support the diagnosis of cyanide toxicity. Consult your local poison centre for guidance on indications for antidote use.
2. In the case of insufficient availability of hydroxocobalamin, alternative antidotes for cyanide poisoning may be used when needed:
   • Sodium nitrite: Due to the mechanism of action of induction of methemoglobinemia, it is contraindicated in smoke inhalation victims who already have impaired oxygen carrying capacity secondary to

carboxyhemoglobinemia or methemoglobinemia, but may be used for other types of suspected or known cyanide exposures. 

• Sodium thiosulfate: Slower onset and less effective than hydroxocobalamin but is the only available alternative for all types of suspected or known cyanide exposures.

General Conservation Strategies:

3. Restrict use of hydroxocobalamin in refractory vasoplegic shock in the critical care setting.
4. Consider alternate treatments for refractory vasoplegic shock in the critical care setting, including methylene blue.

References   

1. Health Canada. Drug product database online query [internet]. Ottawa: Health Canada; 2024. Available from: https://healthproducts.canada.ca/dpd-bdpp/index-eng.jsp. Accessed December 11, 2024.
2. CPS: Drug Information. Cyanokit [drug monograph]. Canadian Pharmacists Association; 2024. Available from:

https://cps.pharmacists.ca. Subscription required. Accessed Dec 11, 2024.

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October 11, 2024

The Ontario Poison Centre (OPC) has been made aware of a shortage of CYANOKIT® (hydroxocobalamin).  The end date for this shortage is not known at this time.

Hydroxocobalamin is a Health Canada approved antidote for use in patients with known or suspected cyanide poisoning.  Hydroxocobalamin is also occasionally used off-label for treatment of refractory vasoplegic shock in the critical care setting.

The Poison Centre recommends that hospitals keep expired stock to be used if necessary.

In the case of insufficient availability of hydroxocobalamin, alternative antidotes for cyanide poisoning may stocked and used when needed:

• Sodium nitrite (relatively contraindicated in fire exposed patients)

AND

• Sodium thiosulfate

See OPC Guideline for Stocking Emergency Antidotes for minimum stocking recommendations.

Urgent borrowing of antidotes from surrounding hospitals may be necessary. Prior arrangements to do this should be considered.

Consult the Poison Centre via the Priority Queue for cases of known or suspected cyanide poisoning: 416-813-5900 or 1-800-268-9017 (Toll-free); press “1” for Priority Queue.

The following recommendations may be considered by local and regional health care centres to conserve stock of hydroxocobalamin:

• Consider limiting prehospital use of hydroxocobalamin until laboratory confirmation of possible cyanide exposure is available (i.e. blood gas showing arterialization of venous blood gas with high lactate). Consult OPC for guidance on indications for antidote use.
• Consider alternate treatments for refractory vasoplegic shock in the critical care setting, including methylene blue.

Constance Mackenzie, MD, MSc
Assistant Medical Director
Ontario Poison Centre