Potential ways to address shortage situations of Mo-99/Tc-99m

2837 Objectives Technetium-99m (Tc-99m) is a principal radioisotope used for medical diagnostic imaging, and accounts for approximately 80-85% of all nuclear medicine procedures. Tc-99m is the daughter product of molybdenum-99 (Mo-99), and it is typically supplied in the form of Mo-99/Tc-99m generator to the end users such as nuclear pharmacies and hospitals. Mo-99 is exclusively produced in a few research nuclear reactors which are >40 years old. Global shortages of Tc-99m emerged in 2009 due to two aging nuclear reactors (NRU in Canada and HFR in Netherlands) which provided about two-thirds of the world’s supply of Mo-99. Currently OSIRIS (France) ceased production permanently. BR-2 (Belgian) has initiated a 12-month refurbishment early last year with another projected six months to complete the rebuild. NRU (Canada) will end its Mo-99 production on October 31, 2016. Any Mo-99 production in NRU after that date would be subject to the discretion of the Canadian government. It has been proposed to keep the NRU in “hot standby” until March 31, 2018. The Canadian government has not released the decision-making process for restarting Mo-99 production in NRU after it ceases routine Mo-99 production on October 31, 2016. The global supply chain for Mo-99 has numerous complex problems which makes the Mo-99 supply system fragile and unreliable. It is difficult to predict as to when the next major outage will take place. As such, it is important for each nuclear medicine service facility to develop contingencies in order to deal with periods of shortage. The purpose of this study was to identify potential approaches to manage shortage situations of Mo-99/Tc-99m. Methods Strategies for managing Mo-99/Tc-99m in shortage situations were gathered and pooled from a variety of sources. These included our own approaches established to cope with the 2009-2010 shortage crisis, literature review, as well as survey. Questionnaires were sent to several nuclear pharmacies and nuclear medicine departments throughout the United States. Phone interviews were also conducted with our nuclear medicine technologists, pharmacy managers, and academic administrators. Each of these coping strategies was evaluated based on effectiveness for conserving Tc-99m while still meeting the needs of the patients. Results The viable responses were placed into five categories which include: (1) reducing or eliminating doses prepared for anticipated use, (2) alternative imaging protocols, (3) changes in imaging schedules, (4) software utilization, (5) generator management, and (6) having a contractual agreement with a commercial radiopharmaceutical supplier. (1) A common first approach is to prepare doses as needed, and thus reduce or eliminate standing orders and bulk Tc-99m prepared by the nuclear pharmacy. (2) Making slight alterations to imaging protocols, such as reducing activity administered or using alternative radiopharmaceutical would decrease the demand for Tc-99m. (3) Changes in imaging schedules include extending hours of operation, postponing/rescheduling patients, and grouping exams. (4) Nuclear medicine software can calculate theoretic activity and track Tc-99m usage to improve the selection of generator size and delivery schedules based on the amount of Tc-99m needed which optimize daily and weekly utilization of Tc-99m activity. (5) More frequent generator elutions can be made prior to equilibrium to increase the amount of Tc-99m available for the day. (6) A contractual agreement with a nuclear pharmacy may give an institution a higher priority when Tc-99m is scarce. Conclusions During a Mo-99/Tc-99m shortage, it is important to adequately manage the situation. By preemptively implementing these viable strategies, nuclear medicine departments would better be able to cope with a shortage.