Expert Q&A: Global Supply Chain Pressures and the Future of Drug Availability

In this Q&A, Michael Ganio, PharmD, MS, BCPS, FASHP, senior director of pharmacy practice and quality at ASHP, discusses how global conflicts and trade disruptions could affect the US drug supply chain, particularly for older generic medications sourced overseas. He explains that although immediate impacts may be limited, upstream disruptions in manufacturing and shipping—especially through critical routes like the Strait of Hormuz—could lead to delayed shortages and rising costs over time.

Pharmacy Times: How could the ongoing Middle East conflict impact the global medical supply chain, particularly for essential medications and raw materials?

Michael Ganio, PharmD, MS, BCPS, FASHP: Well, there are really 2 ways that the ongoing conflict could affect our drug supply chain. The first is through directly affecting manufacturing sites in the region. There are some pharmaceutical manufacturing sites in Jordan, in Israel, and in Turkey. Some of those are bound for the United States; some of them may not be coming to the United States. So clearly, if there's any direct effect on those facilities, we could see an impact here.

The good news is it does not appear we're overly reliant on that region. Anything that's manufactured there, there tend to be other sources for those medications, or they're things where supply disruption wouldn't be the most clinically critical shortage that we have seen over the past several years.

And then the other way that supplies could be disrupted is a longer-term disruption, as trade is halted through the Strait of Hormuz. That's a really important trade zone to move materials from Europe and the rest of the world across into India and China, where a lot of our drug manufacturing, precursor chemicals, and active pharmaceutical ingredients are made.

That doesn't mean it's something that would have an immediate impact, and these aren't specific chemicals used in any particular class of medication, so it'd be really challenging to predict where we could see disruptions downstream. But as the price of gasoline and fuel goes up, and these chemicals, solvents, key starting materials, etc, might be impacted, we could see, several months from now, costs start to go up, and we could see some lingering supply disruptions.

Pharmacy Times: Are there specific drug classes or products that pharmacists should be most concerned about in terms of potential shortages?

Ganio: Because the trade disruptions are so far upstream, it's hard to pinpoint any particular drug or drug classes that might be affected. I think the important thing is to be aware that at any given time, especially for older generic drugs, there could be a shortage.

Traditionally, shortages that we've reported on the ASHP [American Society of Health-System Pharmacists] website have been older generic drugs. That tends to be what we source from overseas, particularly in India and China, and because of the trade routes being affected, those supplies could be delayed or stopped. That really could have a pretty broad effect on drug supplies.

Shortages aren't anything new, and so unfortunately, the pharmacy profession has become quite adept at navigating them. In some cases, patients may never know that there's been a shortage, but the reality is that because of our drug supply chain being overly reliant on specific regions of the world, these kinds of threats exist.

Pharmacy Times: What early warning signs should pharmacists and health systems watch for that may indicate supply chain disruptions are worsening?

Ganio: Typically, the pharmacy will find out about a shortage when something doesn't come in from a wholesaler. Again, because any supply disruption will be so far upstream in the manufacturing process, it'll be really challenging to know that a particular duration of time is going to be an indicator of when there will or might not be a shortage.

A particular chemical that is making its way through the region may be tied to a whole group of drugs, multiple classes of drugs, or may not be tied to any drugs. A lot of these chemicals are used in nonpharmaceutical manufacturing as well. So it's not only the drug supply chain that's under threat, and that would just make it challenging to know whether or not drugs are going to be at risk.

I think paying attention to other supply chains and seeing whether or not there are disruptions could indicate that the drug supply chain, at some point, may be affected. But for now, as long as this resolves and it doesn't escalate, and we resolve quickly, we may not see any shortages at all.

Pharmacy Times: What proactive steps can pharmacists take now to prepare for or mitigate the effects of potential shortages?

Ganio: Well, as I mentioned, there have been ongoing shortages in the US for quite a while. We've had over 200 shortages for the past several quarters, according to ASHP data, and so we really should be in a constant state of readiness for drug shortages.

That means having the infrastructure in place for a hospital or health system where clinician groups can implement restrictions or alternative therapies if needed. There really needs to be a process in place for managing shortages. If in 2026 that doesn't exist in a hospital or health system, it's really something that needs to be started, whether it's through a pharmacy and therapeutics committee or through some other hospital committee. There needs to be a process for vetting potential shortages, actual shortages, and what the response will be.

For the community setting, it's a little bit more challenging because that oversight and ability to direct clinicians toward alternatives in a hospital or health system setting doesn't really exist in a community pharmacy. So those pharmacists may also be hearing questions from their patients about, "Well, I've heard there's going to be a shortage of this or of that," and really, there may not be an answer for it.

So, I think for community pharmacies, being prepared for those conversations with patients, knowing when there actually is a shortage, and having recommendations on navigating that shortage—whether it's for the prescriber, with the insurance, or directly with the patient—means having that plan in place.

Pharmacy Times: How should pharmacists approach patient communication and care if medication availability becomes uncertain or limited?

Ganio: This goes back to the previous response about having a plan for how to engage patients about shortages, and that could mean getting involved with the prescriber's office, recommending alternatives to the prescriber. Obviously, as pharmacists, we're the medication experts, so we're likely to have more insight into what's available and what may be unaffected by a shortage.

Helping the patient navigate that conversation with the prescriber, and then potentially navigating challenges with the payers, especially if the brand name is the only product available. If generics are not available, that can lead to some problems with the payers. So, getting them to recognize that the generic is not available and only the brand could reduce barriers for the patient still being able to access that medication.

Pharmacy Times: Do you think geopolitical conflicts like this will accelerate shifts toward domestic manufacturing or diversified sourcing in the pharmaceutical industry?

Ganio: I think it could do both. I think seeing the threats directly to the regions in the Middle East where there's manufacturing really reinforces the need to have production on US soil. The question then is, how much of the drug supply chain do we move onshore? If we're only making the final products here, but we're still relying on other countries and other regions for the active pharmaceutical ingredients and the key starting materials, all we've done is delay the impact.

But at the same time, seeing how there are challenges with products moving through the Strait of Hormuz underscores the need to not have manufacturing rely on any one geographic region, and that includes the United States. It's great to have that finished product here; we can control where it goes. There have been instances in the past where borders have been closed to prevent drugs from leaving the country. India, for example, during COVID-19, blocked export of some drugs, as did Europe. If the drug supply is here, we can control where it goes during an emergency.

But this conflict and the closure of the Strait of Hormuz underscore how long that drug supply chain is. No matter how much we move on US soil, there is still going to be some amount that relies internationally. So having diverse sources internationally of those key starting materials and active pharmaceutical ingredients will be critical to prevent conflicts like this from creating disruptions.