Beware of drug names that look, sound alike

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Beware of drug names that look, sound alike

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Take the generic drug clonidine for high blood pressure? Double-check

that you didn't leave the drugstore with Klonopin for seizures, or

the gout medicine colchicine.

Mixing up drug names because they look or sound alike — like this

trio — is among the most common types of medical mistakes, and it can

be deadly. Now new efforts are aiming to stem the confusion, and make

patients more aware of the risk.

Nearly 1,500 commonly used drugs have names so similar to at least

one other medication that they've already caused mix-ups, says a

major study by the U.S. Pharmacopeia, which helps set drug standards

and promote patient safety.

Last week the influential group opened a Web-based tool to let

consumers and doctors easily check if they're using or prescribing

any of these error-prone drugs, and what they might confuse it with.

Try to spell or pronounce a few on the site — http://www.usp.org/ —

and it's easy to see how mistakes can happen. Did you mean the

painkiller Celebrex or the antidepressant Celexa?

Due out later this fall is a more patient-oriented Web site, a

partnership of the nonprofit Institute for Safe Medication Practices

and online health service iGuard.org, that will send users e-mail

alerts about drug-name confusion.

And the Food and Drug Administration — which currently rejects more

than a third of proposed names for new drugs because they're too

similar to old ones — is preparing a pilot program that would shift

more responsibility to manufacturers to guard against name confusion.

The goal is to spell out how to better test for potential mix-ups

before companies seek approval to sell their products.

" There are so many new drugs approved each year, this problem can

only get worse, " warns USP vice president Diane Cousins.

At least 1.5 million Americans are estimated to be harmed each year

from a variety of medication errors, and name mix-ups are blamed for

a quarter of them.

Rarely does a company change a drug's name after it hits the market,

although it's happened twice since 2005. The Alzheimer's drug Reminyl

now is named Razadyne, after mix-ups, including two reported deaths,

with the old diabetes drug Amaryl. The cholesterol pill Omacor is now

named Lovaza, after mix-ups with blood-clotting Amicar.

Doctor's penmanship only part of problem

Doctors' notoriously bad handwriting isn't the only culprit. A

hurried pharmacist faced with alphabetized bottles on a shelf might

grab the wrong one.

Nor are computerized prescriptions a panacea. A doctor who e-

prescribes still can click the wrong row on the alphabetized screen,

picking the bone drug Actonel instead of the diabetes drug Actos.

Phone or fax a prescription, and static or smudged ink can turn the

epilepsy drug Lamictal into the antifungal pill Lamisil.

How to avoid mix-ups

Tips to avoid medication errors, including mix-ups of drugs whose

names look or sound alike:

— Ask your doctor what drug is being prescribed, at what dose, and

for written instructions for use.

— Ask your doctor to write a short description of the diagnosis

directly on the prescription — " for heart " or " for allergies " — right

next to the drug name. That helps pharmacists avoid confusion if two

drugs have similar names but treat different conditions.

— Check the label on the drug bottle before leaving the pharmacy, to

ensure the name is what your doctor told you. If it's a refill, open

the bottle to make sure the pills are the same color, shape, size and

dosage as the original prescription. Ask the pharmacist if there's

any doubt.

— Keep a frequently updated list of all your medications in your

wallet, ready to share with the doctor or pharmacist before getting a

new prescription or starting a new over-the-counter drug. The list is

key to spotting drugs that might interact dangerously with one

another.

— If your drugstore doesn't provide leaflets with drug instructions

and side effect warnings, ask your pharmacist for one.

Sources: U.S. Pharmacopeia, Institute for Safe Medication Practices.

Harder to measure but perhaps more common: A doctor means to

prescribe a new drug but spells out a similar-sounding old one out of

habit. Or the patient misspells or mispronounces one of his drugs,

and a health worker assumes it's the schizophrenia drug Zyprexa, not

the antihistamine Zyrtec.

" We've had cases where a health care professional repeats what they

think the patient's on, and the patient thinks they must know what

they're talking about and agrees, " says USP's Cousins.

Enter the new Web tool. Cousins advises consumers to check it against

their current medications, so they know to pay more attention to

confusing ones at refill time.

Do pills look different?

Question the pharmacist if the tablets look different than last time —

it might just be a new generic, or it might be the wrong drug

altogether, says pharmacist Marjorie , medication safety

coordinator at MCGHealth, the Medical College of Georgia's health

system.

Patients also can ask their doctors to write the diagnosis on the

prescription, a step that pharmacists told the Institute for Safe

Medication Practices would help them prevent errors.

" What they consider most important is knowing why the medication is

used, " says institute president Cohen. " It would go a long

way to interrupt a lot of these mix-ups. "

Write " for heart " next to " clonipine, " for example, and a pharmacist

is less likely to grab similar-sounding gout pills.