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Drug Mix-Ups

Worst Pills, Best Pills Newsletter article June, 2011

As activists for your own health, the purpose of this article is to alert you to a drug mix-up issue that can be dangerous — and that happens all too often — so that you might be able to help prevent it: drug mix-ups due to confusing drug names.

There is always a chance that your health care provider (physician or pharmacist) will mistakenly give you or a family member the wrong drug. Factors contributing to dispensing errors include busy prescribers with poor handwriting, drug labels...

As activists for your own health, the purpose of this article is to alert you to a drug mix-up issue that can be dangerous — and that happens all too often — so that you might be able to help prevent it: drug mix-ups due to confusing drug names.

There is always a chance that your health care provider (physician or pharmacist) will mistakenly give you or a family member the wrong drug. Factors contributing to dispensing errors include busy prescribers with poor handwriting, drug labels that look similar, overworked pharmacists who fill hundreds of prescriptions per shift, and drugs with brand and generic names that are too easy to confuse.

Travelers to foreign countries who need to fill their prescriptions face even further risks with drug names. In 2006, the Food and Drug Administration (FDA) released a public health advisory about consumers filling U.S. prescriptions abroad, stating that the consumers could receive the wrong active ingredient because prescribers in other countries may mix up confusing and similar drug names. The agency found 18 foreign drug products that used the same brand name as FDA-approved medication but contained different active ingredients. The FDA also found 105 U.S. brand-name drugs for which there were foreign brand names that looked or sounded so similar to the U.S. brand names that foreign pharmacists could easily dispense the wrong active ingredient.

The warning about the problem of foreign drug names can be found on the FDA’s website at: www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/
DrugSafetyInformationforHeathcareProfessionals/PublicHealthAdvisories/ucm173134.htm
. Unfortunately, the advisory has not been updated since its original release in 2006.

What You Can Do

You should always be vigilant about the chance of a dispensing error. The Institute for Safe Medication Practices (ISMP) has compiled a list of easily confused drugs, including pairs of look-alike and sound-alike drugs (www.consumermedsafety.org). Table 1 is our version of the list, which focuses on drugs most likely to be encountered outside of the hospital.

You should bookmark the online ISMP list for future reference, as it will be updated. And with the approval of more new, brand-name drugs, the chance for confusion and error increases. You should keep in mind the FDA’s 2006 Public Health Advisory about foreign drug names.

You should ask the health professional prescribing your medications to write down both the brand and generic names of the drugs, and you should check them against what you receive at the pharmacy. You also can use your prescriber’s list of brand and generic names when traveling overseas to make sure you receive the right medication. Make sure that both the brand and generic names of your prescriptions match what your doctor prescribed.

If your prescription will be phoned into the pharmacy, ask the prescriber to carefully spell out for you both the brand and generic names of the drugs before you hang up, and then you should check them against what you receive at the pharmacy.

Table 1. Easily Confused Drugs

Drug Name

Confused Drug Name

ACCUPRIL

ACIPHEX

ACETAZOLAMIDE

ACETOHEXAMIDE

ACETOHEXAMIDE

ACETAZOLAMIDE

ACIPHEX

ACCUPRIL

ACIPHEX

ARICEPT

ACTONEL

ACTOS

ACTOS

ACTONEL

ADDERALL

ADDERALL XR

ADDERALL

INDERAL

ADDERALL XR

ADDERAL

ADVAIR

ADVICOR

ADVICOR

ALTOCOR

AFRIN (oxymetazoline)

AFRIN (saline)

AFRIN (saline)

AFRIN (oxymetazoline)

AGGRASTAT

argatroban

ALDARA

ALORA

ALKERAN

LEUKERAN

ALLEGRA

VIAGRA

ALORA

ALDARA

alprazolam

lorazepam

ALTOCOR

ADVICOR

amantadine

amiodarone

AMARYL

REMINYL

amiloride

amlodipine

amiodarone

amantadine

amlodipine

amiloride

ANACIN

ANACIN-3

ANACIN-3

ANACIN

antacid

ATACAND

ANTIVERT

AXERT

ANTIVERT

AVANDAMET

APRESOLINE

PRISCOLINE

argatroban

AGGRASTAT

argatroban

ORGARAN

ARICEPT

ACIPHEX

ARICEPT

AZILECT

aripiprazole

proton pump inhibitors

aripiprazole

rabeprazole

ASACOL

OS-CAL

ATACAND

antacid

ATROVENT

NATRU-VENT

AVANDAMET

ANZEMET

AVANDIA

COUMADIN

AVANDIA

PRANDIN

AVINZA

EVISTA

AXERT

ANTIVERT

azacitidine

azathioprine

azathioprine

azacitidine

AZILECT

ARICEPT

BENADRYL

benazepril

benazepril

BENADRYL

BENICAR

MEVACOR

BEXTRA

ZETIA

BICITRA

POLYCITRA

BRETHINE

METHERGINE

bupropion

buspirone

buspirone

bupropion

CAPEX

KAPIDEX

CARAC

KURIC

captopril

carvedilol

carbamazepine

oxcarbazepine

CARDURA

COUMADIN

carvedilol

captopril

CASODEX

KAPIDEX

CEDAX

CIDEX

cefazolin

ceftriaxone

CELEBREX

CELEXA

CELEXA

CELEBREX

CELEXA

ZYPREXA

CELEXA

CEREBYX

CEREBYX

CELEXA

cetirizine

sertraline

chlordiazepoxide

chlorpromazine

chlorpromazine

chlordiazepoxide

chlorpropamide

chlorpromazine

CIDEX

CEDAX

cisplatin

carboplatin

CLARITIN (loratadine)

CLARITIN EYE (ketoprofen)

CLARITIN-D

CLARITIN-D 24

CLARITIN-D 24

CLARITIN-D

CLARITIN EYE (ketoprofen)

CLARITIN (loratadine)

CLINDESSE

CLINDETS

CLINDETS

CLINDESSE

clomiphene

clomipramine

clomipramine

clomiphene

clonazepam

clonidine

clonazepam

lorazepam

clonidine

clonazepam

clonidine

KLONOPIN

CLOZARIL

COLAZAL

codeine

LODINE

COLACE

COZAAR

COLAZAL

CLOZARIL

colchicine

CORTROSYN

CORTROSYN

colchicine

COUMADIN

CARDURA

COZAAR

COLACE

COZAAR

ZOCOR

cycloserine

cyclosporine

cyclosporine

cycloserine

CYMBALTA

SYMBYAX

dactinomycin

daptomycin

daptomycin

dactinomycin

DARVOCET

PERCOCET

DARVON

DIOVAN

DENAVIR

indinavir

DEPAKOTE

DEPAKOTE ER

DEPAKOTE ER

DEPAKOTE

desipramine

disopyramide

dexmethylphenidate

methadone

DIABINESE

DIAMOX

DIABETA

ZEBETA

DIAMOX

DIABINESE

DIFLUCAN

DIPRIVAN

DILACOR XR

PILOCAR

DILAUDID

DILUDID-5

DILUDID-5

DILAUDID

dimenhydrinate

diphenhydramine

DIOVAL

DIOVAN

DIOVAN

DARVON

DIOVAN

DIOVAL

DIPRIVAN

DIFLUCAN

DIPRIVAN

DITROPAN

disopyramide

desipramine

DITROPAN

DIPRIVAN

DOXIL

PAXIL

DULCOLAX (bisacodyl)

DULCOLAX (docusate sodium)

DULCOLAX (docusate sodium)

DULCOLAX (bisacodyl)

duloxetine

fluoxetine

DURASAL

DUREZOL

DUREZOL

DURASAL

DURICEF

ULTRACET

DYNACIN

DYNACIRC

DYNACIRC

DYNACIN

EFFEXOR

EFFEXOR XR

EFFEXOR XR

EFFEXOR

ENBREL

LEVBID

ENJUVIA

JANUVIA

ESTRATEST

ESTRATEST HS

ESTRATEST HS

ESTRATEST

ethambutol

ETHMOZINE

ETHMOZINE

ethambutol

EVISTA

AVINZA

FEMARA

FEMHRT

FEMHRT

FEMARA

fentanyl

sufentanil

FIORICET

FIORINAL

FIORINAL

FIORICET

flavoxate

fluvoxamine

FLONASE

FLOVENT

FLOVENT

FLONASE

fluoxetine

duloxetine

fluoxetine

paroxetine

fluvoxamine

flavoxate

FOLEX

FOLTX

folic acid

folinic acid (LEUCOVORIN CALCIUM)

folinic acid (LEUCOVORIN CALCIUM)

folic acid

FOLTX

FOLEX

fomepizole

omeprazole

FORADIL

FORTICAL

FORADIL

TORADOL

FORTICAL

FORADIL

glipizide

glyburide

glyburide

glipizide

GRANULEX

REGRANEX

guaifenesin

guanfacine

guanfacine

guaifenesin

HUMALOG

HUMULIN

HUMALOG

NOVOLOG

HUMALOG MIX 75/25

HUMULIN 70/30

HUMAPEN MEMOIR (FOR USE WITH HUMALOG)

HUMIRA PEN

HUMULIN

NOVOLIN

HUMULIN

HUMALOG

HUMULIN 70/30

HUMALOG MIX 75/25

hydralazine

hydroxyzine

hydrocodone

oxycodone

HYDROGESIC

hydroxyzine

hydromorphone

morphine

hydroxyzine

hydralazine

hydroxyzine

HYDROGESIC

INDERAL

ADDERALL

indinavir

DENAVIR

infliximab

rituximab

INSPRA

SPIRIVA

INVANZ

AVINZA

iodine

LODINE

ISORDIL

PLENDIL

isotretinoin

tretinoin

JANTOVEN

JANUMET

JANTOVEN

JANUVIA

JANUMET

JANTOVEN

JANUMET

JANUVIA

JANUMET

SINEMET

JANUVIA

ENJUVIA

JANUVIA

JANTOVEN

JANUVIA

JANUMET

K-PHOS NEUTRAL

NEUTRA-PHOS-K

KAOPECTATE (bismuth subsalicylate)

KAOPECTATE (docusate calcium)

KAOPECTATE (docusate calcium)

KAOPECTATE (bismuth subsalicylate)

KADIAN

KAPIDEX

KALETRA

KEPPRA

KAPIDEX

CAPEX

KAPIDEX

CASODEX

KAPIDEX

KADIAN

KEFLEX

KEPPRA

KEPPRA

KALETRA

KEPPRA

KEFLEX

KETALAR

KETOROLAC

ketorolac

KETALAR

ketorolac

methadone

KINERET

AMIKIN

KLONOPIN

clonidine

KURIC

CARAC

KWELL

QWELL

LAMICTAL

LAMISIL

LAMISIL

LAMICTAL

lamivudine

lamotrigine

lamotrigine

lamivudine

lamotrigine

levothyroxine

LANOXIN

levothyroxine

LANOXIN

naloxone

lanthanum carbonate

lithium carbonate

LANTUS

LENTE

LARIAM

LEVAQUIN

LASIX

LUVOX

LENTE

LANTUS

leucovorin calcium

LEUKERAN

LEUKERAN

ALKERAN

LEUKERAN

MYLERAN

LEUKERAN

leucovorin calcium

LEVAQUIN

LARIAM

LEVBID

ENBREL

levetiracetam

levofloxacin

levofloxacin

levetiracetam

levothyroxine

lamotrigine

levothyroxine

LANOXIN

LEXAPRO

LOXITANE

LIPITOR

LONITEN

LIPITOR

ZYRTEC

lithium carbonate

lanthanum carbonate

LODINE

codeine

LODINE

iodine

LONITEN

LIPITOR

LOPRESSOR

LYRICA

lorazepam

alprazolam

lorazepam

clonazepam

lorazepam

LOVAZA

LOTRONEX

PROTONIX

LOVAZA

lorazepam

LOXITANE

LEXAPRO

LOXITANE

SORIATANE

LUNESTA

NEULASTA

LUVOX

LASIX

LYRICA

LOPRESSOR

MAALOX

MAALOX TOTAL STOMACH RELIEF

MAALOX TOTAL STOMACH RELIEF

MAALOX

MATULANE

MATERNA

MATERNA

MATULANE

MAXZIDE

MICROZIDE

MENACTRA

MENOMUNE

MENOMUNE

MENACTRA

MEPHYTON

methadone

METADATE

methadone

METADATE CD

METADATE ER

METADATE ER

METADATE CD

METADATE ER

methadone

metformin

metronidazole

methadone

dexmethylphenidate

methadone

ketorolac

methadone

MEPHYTON

methadone

METADATE ER

methadone

methylphenidate

METHERGINE

BRETHINE

methimazole

metolazone

methylphenidate

methadone

metolazone

methimazole

metoprolol succinate

metoprolol tartrate

metoprolol tartrate

metoprolol succinate

metronidazole

metformin

MEVACOR

BENICAR

MICRONASE

MICROZIDE

MICROZIDE

MAXZIDE

MICROZIDE

MICRONASE

midodrine

MIDRIN

MIDRIN

midodrine

mifepristone

misoprostol

MIRALAX

MIRAPEX

MIRAPEX

MIRALAX

misoprostol

mifepristone

morphine

hydromorphone

morphine – non-concentrated oral liquid

morphine – oral liquid concentrate

morphine – oral liquid concentrate

morphine – non-concentrated oral liquid

MOTRIN

NEURONTIN

MS CONTIN

OXYCONTIN

MUCINEX

MUCOMYST

MUCINEX D

MUCINEX DM

MUCINEX DM

MUCINEX D

MUCOMYST

MUCINEX

MYLERAN

ALKERAN

MYLERAN

LEUKERAN

naloxone

LANOXIN

NARCAN

NORCURON

NATRU-VENT

ATROVENT

NAVANE

NORVASC

NEO-SYNEPHRINE (oxymetazoline)

NEO-SYNEPHRINE (phenylephrine)

NEO-SYNEPHRINE (phenylephrine)

NEO-SYNEPHRINE (oxymetazoline)

NEULASTA

LUNESTA

NEULASTA

NEUMEGA

NEUMEGA

NEUPOGEN

NEUPOGEN

NEUMEGA

NEURONTIN

MOTRIN

NEURONTIN

NOROXIN

NEUTRA-PHOS-K

K-PHOS NEUTRAL

NEXAVAR

NEXIUM

NEXIUM

NEXAVAR

nicardipine

nifedipine

nifedipine

nicardipine

nifedipine

nimodipine

nimodipine

nifedipine

NORMODYNE

NORPRAMIN

NOROXIN

NEURONTIN

NORPRAMIN

NORMODYNE

NORVASC

NAVANE

NOVOLIN

HUMULIN

NOVOLIN

NOVOLOG

NOVOLIN 70/30

NOVOLOG MIX 70/30

NOVOLOG

HUMALOG

NOVOLOG

NOVOLIN

NOVOLOG FLEXPEN

NOVOLOG MIX 70/30 FLEXPEN

NOVOLOG MIX 70/30 FLEXPEN

NOVOLOG FLEXPEN

NOVOLOG MIX 70/30

NOVOLIN 70/30

OCCLUSAL-HP

OCUFLOX

OCUFLOX

OCCLUSAL-HP

olanzapine

quetiapine

OMACOR

AMICAR

omeprazole

fomepizole

opium tincture

paregoric (camphorated tincture of opium)

ORACEA

ORENCIA

ORENCIA

ORACEA

ORTHO TRI-CYCLEN

ORTHO TRI-CYCLEN LO

ORTHO TRI-CYCLEN LO

ORTHO TRI-CYCLEN

OS-CAL

ASACOL

oxcarbazepine

carbamazepine

oxycodone

hydrocodone

oxycodone

OXYCONTIN

OXYCONTIN

MS CONTIN

OXYCONTIN

oxycodone

PAMELOR

PANLOR DC

PAMELOR

TAMBOCOR

PANLOR DC

PAMELOR

paregoric (camphorated tincture of opium)

opium tincture

paroxetine

fluoxetine

PATANOL

PLATINOL

PAVULON

PEPTAVLON

PAXIL

DOXIL

PAXIL

PLAVIX

PAXIL

TAXOL

pentobarbital

phenobarbital

PEPTAVLON

PAVULON

PERCOCET

DARVOCET

phenobarbital

pentobarbital

PILOCAR

DILACOR XR

PLATINOL

PATANOL

PLAVIX

PAXIL

PLENDIL

ISORDIL

pneumococcal 7-valent vaccine

pneumococcal polyvalent vaccine

pneumococcal polyvalent vaccine

pneumococcal 7-valent vaccine

POLYCITRA

BICITRA

PRANDIN

AVANDIA

PRECARE

PRECOSE

PRECOSE

PRECARE

prednisolone

prednisone

prednisone

prednisolone

PRILOSEC

PROZAC

PRISCOLINE

APRESOLINE

probenecid

PROCANBID

PROCANBID

probenecid

PROCANBID

PROCAN SR

PROCAN SR

PROCANBID

PROCARDIA XL

PROTAIN XL

PROCET

PERCOCET

PROGRAF

PROZAC

propylthiouracil

PURINETHOL

PROSCAR

PROVERA

PROTAIN XL

PROCARDIA XL

protamine

PROTONIX

PROTONIX

LOTRONEX

PROVERA

PROSCAR

PROVERA

PROZAC

PROZAC

PRILOSEC

PROZAC

PROGRAF

PROZAC

PROVERA

PURINETHOL

propylthiouracil

quetiapine

olanzapine

quinidine

quinine

quinine

quinidine

QWELL

KWELL

rabeprazole

aripiprazole

RAZADYNE

ROZEREM

REGRANEX

GRANULEX

REMINYL

AMARYL

REMINYL

ROBINUL

RENAGEL

RENVELA

RENVELA

RENAGEL

REPREXAIN

ZYPREXA

RESTORIL

RISPERDAL

RETROVIR

RITONAVIR

RIFADIN

RIFATER

RIFAMATE

rifampin

rifampin

RIFAMATE

rifampin

rifaximin

RIFATER

RIFADIN

rifaximin

rifampin

RISPERDAL

RESTORIL

risperidone

ropinirole

RITALIN

ritodrine

RITALIN LA

RITALIN SR

RITALIN SR

RITALIN LA

ritodrine

RITALIN

ritonavir

RETROVIR

rituximab

infliximab

ROBINUL

REMINYL

ropinirole

risperidone

ROXANOL

ROXICET

ROXANOL

ROXICODONE INTENSOL

ROXICET

ROXANOL

ROXICODONE INTENSOL

ROXANOL

ROZEREM

RAZADYNE

SALAGEN

selegiline

SANDIMMUNE

SANDOSTATIN

SANDOSTATIN

SANDIMMUNE

saquinavir

SINEQUAN

saquinavir (free base)

saquinavir mesylate

saquinavir mesylate

saquinavir (free base)

SARAFEM

SEROPHENE

selegiline

SALAGEN

SEROPHENE

SARAFEM

SEROQUEL

SEROQUEL XR

SEROQUEL

SERZONE

SEROQUEL

SINEQUAN

SEROQUEL XR

SEROQUEL

sertraline

cetirizine

sertraline

SORIATANE

SERZONE

SEROQUEL

SINEMET

JANUMET

SINEQUAN

saquinavir

SINEQUAN

SEROQUEL

SINEQUAN

SINGULAIR

SINEQUAN

ZONEGRAN

SINGULAIR

SINEQUAN

sitagliptin

sumatriptan

SONATA

SORIATANE

SORIATANE

LOXITANE

SORIATANE

sertraline

SORIATANE

SONATA

sotalol

SUDAFED

SPIRIVA

INSPRA

SUDAFED

sotalol

SUDAFED

SUDAFED PE

SUDAFED PE

SUDAFED

sulfadiazine

sulfisoxazole

sulfisoxazole

sulfadiazine

sumatriptan

sitagliptin

sumatriptan

zolmitriptan

SYMBYAX

CYMBALTA

TAMBOCOR

PAMELOR

TAXOL

PAXIL

TAXOL

TAXOTERE

TAXOTERE

TAXOL

TEGRETOL

TEGRETOL XR

TEGRETOL

TEQUIN

TEGRETOL

TRENTAL

TEGRETOL XR

TEGRETOL

TEQUIN

TEGRETOL

TEQUIN

TICLID

TESTODERM

TESTODERM TTS

TESTODERM

TESTODERM WITH ADHESIVE

TESTODERM TTS

TESTODERM

TESTODERM TTS

TESTODERM WITH ADHESIVE

TESTODERM WITH ADHESIVE

TESTODERM

TESTODERM WITH ADHESIVE

TESTODERM TTS

THALOMID

THIAMINE

THIAMINE

THALOMID

tiagabine

tizanidine

TIAZAC

ZIAC

TICLID

TEQUIN

tizanidine

tiagabine

TOBRADEX

TOBREX

TOBREX

TOBRADEX

tolazamide

tolbutamide

tolbutamide

tolazamide

TOPAMAX

TOPROL-XL

TOPROL-XL

TOPAMAX

TORADOL

FORADIL

TRACLEER

TRICOR

tramadol

trazodone

trazodone

tramadol

TRENTAL

TEGRETOL

tretinoin

isotretinoin

TRICOR

TRACLEER

TYLENOL

TYLENOL PM

TYLENOL PM

TYLENOL

ULTRACET

DURICEF

valacyclovir

valganciclovir

VALCYTE

VALTREX

valganciclovir

valacyclovir

VALTREX

VALCYTE

VESANOID

VESICARE

VESICARE

VESANOID

VEXOL

VOSOL

VIAGRA

ALLEGRA

VIOKASE

VIOKASE 8

VIOKASE 8

VIOKASE

VIOXX

ZYVOX

VIRACEPT

VIRAMUNE

VIRAMUNE

VIRACEPT

VOSOL

VEXOL

WELLBUTRIN SR

WELLBUTRIN XL

WELLBUTRIN XL

WELLBUTRIN SR

XANAX

ZANTAC

XELODA

XENICAL

XENICAL

XELODA

YASMIN

YAZ

YAZ

YASMIN

ZANTAC

XANAX

ZANTAC

ZYRTEC

ZEBETA

DIABETA

ZEBETA

ZETIA

ZEGERID

ZESTRIL

ZELAPAR (ZYDIS formulation)

ZYPREXA ZYDIS

ZESTRIL

ZEGERID

ZESTRIL

ZETIA

ZESTRIL

ZYPREXA

ZETIA

BEXTRA

ZETIA

ZEBETA

ZETIA

ZESTRIL

ZIAC

TIAZAC

ZOCOR

COZAAR

ZOCOR

ZYRTEC

zolmitriptan

sumatriptan

ZONEGRAN

SINEQUAN

ZOSTRIX

ZOVIRAX

ZOVIRAX

ZOSTRIX

ZOVIRAX

ZYVOX

ZYBAN

DIOVAN

ZYPREXA

CELEXA

ZYPREXA

REPREXAIN

ZYPREXA

ZESTRIL

ZYPREXA

ZYRTEC

ZYPREXA ZYDIS

ZELAPAR (ZYDIS formulation)

ZYRTEC

LIPITOR

ZYRTEC

ZANTAC

ZYRTEC

ZOCOR

ZYRTEC

ZYPREXA

ZYRTEC

ZYRTEC-D

ZYRTEC (cetirizine)

ZYRTEC ITCHY EYE DROPS (ketofifen fumarate)

ZYRTEC-D

ZYRTEC

ZYRTECITCHY EYE DROPS (ketofifen fumarate)

ZYRTEC (cetirizine)

ZYVOX

VIOXX

ZYVOX

ZOVIRAX