Why Drug Names Get Confused and What the FDA Is Doing About It

Hydrocodone Combo Products Now Schedule II
Hydrocodone Combo Products Now Schedule II

Similarities in prescription drug names as well as drug abbreviations, acronyms, dose designations, and other symbols used in prescribing medication can cause drug name confusion – for both the physician prescribing the drug and the dispensing pharmacy – and lead to medication errors.

Implications of Drug Name Confusion

Although some medication errors may cause little or no harm to the patient, others can result in serious side effects.

“For example, a low-dose oral contraceptive is prescribed by the physician, and the patient ends up getting a higher strength or a different dose. Typically, there are no serious adverse events,” said Kellie Taylor, PharmD, MPH, of the Center for Drug Evaluation and Research at the Food and Drug Administration (FDA) in Silver Spring, MD. Another example includes a family physician who intended to electronically prescribe Brintellix (vortioxetine) 10mg daily for major depressive disorder. However, after the physician entered the drug name into his computer system, he accidentally prescribed Brilinta (ticagrelor), an antiplatelet agent used in cardiovascular disease. The patient realized the doctor prescribed the wrong drug and never took any doses of Brilinta.1

However, in other cases, the drug mix up can lead to serious adverse events, including death. “For example, Amaryl is a drug prescribed [to regulate] blood sugar [JR1] and Reminyl is a drug for Alzheimer's disease. In some cases, Amaryl was given to patients with Alzheimer's disease and actually resulted in low blood sugar that resulted in fatality over time,” said Taylor.

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Drug Name Confusion Can Arise From New Indications and Doses

Safety concerns related to confusion over a drug name sometimes arise as new indications, doses, and dosage forms are developed. “There was a seizure medication called Lamictal for seizures and another drug named Lamisil for the treatment of fungal infections. The drug for antifungal use was first marketed [as a] cream, then developed into a tablet. All of sudden the tablet had the same dosage form and strength or doses as Lamictal. At that point, the two drugs became confused with each other,” said Taylor.

Other issues that could arise may be attributed to the first letter of a drug's name. For example, in a recent correspondence to the New England Journal of Medicine (NEJM), Marc Garnick, MD, of Harvard Medical School and Beth Israel Deaconess Medical Center in Boston, MA, noted that multiple drugs approved for metastatic castration-resistant prostate cancer start with either and X, Z, or J.2  “It makes it confusing not only for patients but for physicians, especially when taking a history or providing a second opinion and not having all the patient's records in front of you,” said Garnick.  

In response, the FDA submitted a correspondence to the NEJM to educate the general public, in which the author pointed out that the problem may not be as serious as outlined in the original publication.3 “We still have not been aware of cases of drug mix-ups with the drugs referenced in the NEJM, but sometimes these events are under-reported so it is hard to say with absolute certainty that there is no confusion within the metastatic castration-resistant prostate cancer space,” said Taylor.

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