Diltiazem Shortage – Metoprolol Substitution

Good morning, everyone.
To answer this simply, the low incidence of use and the high cost of glucagon are the two biggest factors.
I ran a report in emeds for glucagon use since Jan 2024. There have been no administrations for suspected beta blocker overdose.
A little cost perspective: the cost to add 2 additional glucagon to 20+ medic units would be over $9,000.
All medic units should be carrying one glucagon. All supervisors should be carrying 3. For the rare instances you should need more than one dose, please have your units call a supervisor for the additional glucagon upon the outset of suspicion. It’s not the “ideal” situation, but I think we can safely and confidently say this is a cost-effective approach justified by a rare patient population.
Be safe out there!

<www.washco-md.net/emergency-services/>
Melanie Higgins, BS, NRP Captain – EMS Quality Assurance Division of Emergency Services 16232 Elliott Parkway Williamsport, MD 21795 (cell) 240-527-5940 (office) 240-313-2911 (fax) 240-313-4375 www.washco-md.net<www.washco-md.net/>
From: Justin Ruppenthal <[email protected]> Sent: Wednesday, March 11, 2026 3:12 PM To: Higgins, Melanie <[email protected]> Cc: Abraham Jefferson <[email protected]>; Adam Hess <[email protected]>; Adam Metz <[email protected]>; [email protected]; Aly3lyons <[email protected]>; Amos, Christopher N. <[email protected]>; Oyster, Andrew <[email protected]>; Angie Wolff <[email protected]>; Ann Jochum <[email protected]>; Aubrey McKittrick-Troop <[email protected]>; Austill, Emily R. <[email protected]>; Austin Buck <[email protected]>; Baileigh Phelps <[email protected]>; Baker, William <[email protected]>; Baumgardner, Adam D. <[email protected]>; Bobby Follin <[email protected]>; Brandon Bolyard <[email protected]>; Brandon Neuenschwander <[email protected]>; [email protected]; Buskirk, Brianna N. <[email protected]>; Jill Bulley <[email protected]>; [email protected]; Carol Thomas <[email protected]>; Chisholm, David E. <[email protected]>; Chuck Smith <[email protected]>; Stottlemyer, Clinton <[email protected]>; Cory Lescalleet <[email protected]>; Crippen, Derek <[email protected]>; Deanna Adkins <[email protected]>; Deanna Pelton <[email protected]>; [email protected]; Dennis Browne <[email protected]>; Carsen Departee <[email protected]>; Devin Shirk <[email protected]>; Doyle, Terry <[email protected]>; Eisenhower, Joshua <[email protected]>; Emily Kofoet <[email protected]>; Erin Keefer <[email protected]>; Evan T Bowman <[email protected]>; Giancola, Luke <[email protected]>; Grace Herman <[email protected]>; James Grissom <[email protected]>; Hahn, Isaiah G. <[email protected]>; Haley Theilgaard <[email protected]>; Hartman, Colton <[email protected]>; Hasri, Alexander I. <[email protected]>; Hays, David <[email protected]>; Hayter, Michael <[email protected]>; Hess, Ashley <[email protected]>; Hoffman, Gary <[email protected]>; Hopkins, Lauren <[email protected]>; James Grove <[email protected]>; James Meunier <[email protected]>; James Ulrich <[email protected]>; [email protected]; Jeffrey Metz <[email protected]>; Jennifer Hineman <[email protected]>; Jeremy Ardinger <[email protected]>; Mackrell, Jeremy P. <[email protected]>; Joseph Muller <[email protected]>; Johnson, Charles P. <[email protected]>; Jonas Zeigler <[email protected]>; Joseph Chlebowski <[email protected]>; JP Miller <[email protected]>; Kaitlyn Cline <[email protected]>; [email protected]; Katherine Dixon <[email protected]>; Kent Rilling <[email protected]>; Kevin Demmons <[email protected]>; Kimberly Mose <[email protected]>; Kristen Grey <[email protected]>; Kurtis Meunier <[email protected]>; [email protected]; Lehman, Donald <[email protected]>; Lewis, Kevin <[email protected]>; Duncan Ludwig <[email protected]>; Lynch, Brandon M. <[email protected]>; Mark Harrington <[email protected]>; Matheny, Alan <[email protected]>; Matheny, Colten K. <[email protected]>; McKnight, Casey <[email protected]>; Edward Mersman <[email protected]>; Michael McAtee <[email protected]>; Natalie Coffman <[email protected]>; Mitchell, Peter J. <[email protected]>; Priscilla Morgan <[email protected]>; Rachael Moran <[email protected]>; Rachel Rosebrock <[email protected]>; Robert Buck <[email protected]>; Rhea Dennis <[email protected]>; Riley Witmer <[email protected]>; Rob Matschat <[email protected]>; Rob Rinkinen <[email protected]>; Rob Snider <[email protected]>; Robert Scott <[email protected]>; Routzahn, Travis R. <[email protected]>; Samantha Sutterman <[email protected]>; Sauser, Nathan <[email protected]>; Scott Deibler <[email protected]>; [email protected]; Brashears-Danner, Skyler P. <[email protected]>; Smith, Richard <[email protected]>; Alasdair Storer <[email protected]>; [email protected]; Tommy Cleveland Jr <[email protected]>; Virden, Paul M. <[email protected]>; Michael Wegner Jr <[email protected]>; Woods, Billy <[email protected]>; Zachary Culler <[email protected]>; Zach.robinson <[email protected]>; website QA <[email protected]> Subject: Re: Diltiazem Shortage – Metoprolol Substitution
WARNING!! This message originated from an External Source. Please use proper judgment and caution when opening attachments, clicking links, or responding to this email. Any claims of being a County official or employee should be disregarded. Hey Mel,
What are your thoughts on carrying additional Glucagon on the medic units for potential Beta Blocker OD, And the since it requires more than your traditional Hypoglycemia?
Justin Ruppenthal Operations Captain Community Rescue Service Hagerstown Md 21740 Office 301-733-1112 Ext 130 Cell 304-268-7237
On Mar 11, 2026, at 13:15, Higgins, Melanie <[email protected]<mailto:[email protected]>> wrote: Good afternoon, everyone. Please read the below message from Capt. Hopkins regarding the TRANSITION to metoprolol from Cardizem.
When you use your Cardizem, you will now replace it with metoprolol from the pyxis. Do NOT carry both.
Capt. Hopkins’ email has more important information about quantity and administration, and the protocol is attached for reference.
I encourage local shift training scenarios as this transition occurs. Reach out to your local supervisor if you have any questions or want to complete training.
<www.washco-md.net/emergency-services/>
Melanie Higgins, BS, NRP Captain – EMS Quality Assurance Division of Emergency Services 16232 Elliott Parkway Williamsport, MD 21795 (cell) 240-527-5940 (office) 240-313-2911 (fax) 240-313-4375 www.washco-md.net<www.washco-md.net/>
From: Hopkins, Lauren <[email protected]<mailto:[email protected]>> Sent: Wednesday, March 11, 2026 12:55 PM To: Higgins, Melanie <[email protected]<mailto:[email protected]>> Subject: Fw: Diltiazem Shortage – Metoprolol Substitution
Mel,
Can we send this out to the ALS clinicians in the county please? It looks like I’m going to have to have pharmacy stock this in pyxis today.
Attention ALS providers:
We will be adding a new medication to pyxis and to our units. Metoprolol is replacing the Diltiazem ADDvantage as the manufacturer has stopped producing it. Please also note the rate of administration…it is a SLOW IVP over 2 minutes at minimum.
Units can replace their Diltiazem with 2 vials of Metoprolol (5mg/5ml vials) at the pyxis as they use it or as it expires. Please do NOT just go pull this medication-it is being utilized to replace Cardizem and units should not be carrying both meds.
Clinicians should make themselves familiar with the attached protocols regarding this new medication.
Any questions please do not hesitate to reach out.
Thank you,
Lauren Hopkins
Captain
Division of Emergency Services
16232 Elliott Parkway
Williamsport, MD 21795

________________________________ From: Chisholm, David E. <[email protected]<mailto:[email protected]>> Sent: Monday, February 23, 2026 4:39 PM To: Hopkins, Lauren <[email protected]<mailto:[email protected]>> Subject: FW: Diltiazem Shortage – Metoprolol Substitution
These documents should tell you what we need to know about the metoprolol concentration.

David E. Chisholm, RN, BSN, NRP
Deputy Director – Operations
Division of Emergency Services
16232 Elliott Parkway
Williamsport, Maryland 21795

Office (240) 313-2906
Cell (240) 500-5045
Fax (240) 313-4375
www.washco-md.net<www.washco-md.net/>

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WARNING!! This message originated from an External Source. Please use proper judgment and caution when opening attachments, clicking links, or responding to this email.
Any claims of being a County official or employee should be disregarded.
Good afternoon,

Please refer to the attached memorandum and supporting protocols in reference to a medication shortage/discontinuance.

Direct any questions to Dr. Chizmar. Thank you.

Regards,

Stephanie J. Ermatinger

Stephanie J. Ermatinger
Administrative Officer III
Office of State EMS Medical Director, Dr. Timothy Chizmar
Office of State Aeromedical Director, Dr. Doug Floccare
Office of Care Integration Director, Chief Kenny Barajas
MD Institute for <192.168.110.213/home/omd> Emergency Medical Services Systems<192.168.110.213/home/omd> 653 West Pratt Street, 4th Floor
Baltimore, MD 21201
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From: Timothy Chizmar <[email protected]<mailto:[email protected]>> Sent: Tuesday, December 16, 2025 2:53 PM To: Stephanie Ermatinger <[email protected]<mailto:[email protected]>> Subject: Diltiazem Shortage – Metoprolol Substitution

Stephanie,

Please distribute the memo and attached documents to:

JAC
Medical Directors
Commercial Services via Scott Legore.

Thank you,

Timothy P. Chizmar, MD, FACEP, FAEMS
State EMS Medical Director
Maryland Institute for Emergency Medical Services Systems
653 West Pratt Street
Baltimore, Maryland 21201

Email: [email protected]<mailto:[email protected]>
Office: 410-706-0880
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