It’s a serious risk that can turn any prescription drug deadly — and you’ll never read about it on a warning label.

Just last week the FDA issued an urgent alert that patients prescribed the antidepressant Brintellix could end up with the blood thinner Brilinta instead — and vice-versa.

The names are so close that a doctor’s scrawl on an Rx pad or a nurse hitting the wrong key on a computer can set off a fatal chain reaction of errors.

But this isn’t a new problem and it’s only getting worse. Drug name confusion is now accounting for at least 10 percent of the estimated one million medication mistakes that happen in America each and every year.

These avoidable mistakes have already killed thousands — but there are three easy things you can do to avoid becoming the next statistic.

What’s in a name?When a pharmacist confuses a drug name and gives you the wrong med, it’s more than a nuisance. It’s a mistake that could cost you your life.

For example, a child expecting methylphenidate (the generic form of Ritalin) died after he was accidentally given methadone, a drug for heroin addicts.

And countless patients who were expecting a prescription for Volmax to treat their asthma ended up with the prostate drug Flomax instead.

And you can bet Flomax wasn’t much help during an asthma attack.

Now, with all the unique and unpronounceable drug names out there, you wouldn’t think these types of mistakes would happen too often. But with so many new brand and generic drugs hitting the market each year, Big Pharma must be running out of imagination — because drug names are getting awfully similar.

Throw in a pharmacist trying to decipher your doc’s chicken scratch handwriting, and you have a recipe for disaster. Like the time there were 200 known mistakes in one year alone between the antipsychotic drug Risperdal and a med for Parkinson’s disease called Requip.

So, for over a decade now, the Institute for Safe Medication Practices has been trying to alert hospitals and pharmacists to the problem by calling attention to similar drug names in its newsletter. And sometimes drugmakers even agree to rename a med, which is something the FDA can’t force them to do.

For example, the Merck blockbuster stomach acid med Prilosec was first called Losec. But there was so much confusion with water pill Lasix that a patient died and pharmacists demanded a name change.

But the drug companies, as you can imagine, aren’t always so accommodating. When Pfizer was asked to add one letter — a K — to its high blood pressure med Norvasc so it wouldn’t be confused with the schizophrenia drug Navane, it refused.

Your life wasn’t worth one letter to the Pfizer marketing team, and there wasn’t a thing our government could do about it.

Of course, the safest way to protect yourself from name mix-ups is to take as few drugs as possible. But when you’re taking prescription meds, there are three easy things you can do to stay safe:

  1. Know the name, both brand and generic, of any meds you’re taking, as well as why they’ve been prescribed.
  2. Talk to your pharmacist every time you pick up a prescription. Confirm what you’ve been given, and what condition that med treats.
  3. Become familiar with a drug’s appearance. All drugs can be identified by their unique imprint as well as their size, shape and color. There’s even an online pill identifier you can check out here.

Sources:

“Brintellix (vortioxetine) and Brilinta (ticagrelor): Drug Safety Communication — Name Confusion” FDA, July 30, 2014, fda.gov

“Brilinta? Brintellix? FDA warns of drug name mix-ups” Marley Jay, July 30, 2015, ABC News, abcnews.go.com


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Allan Spreen, M.D.
Dr. Allan Spreen, Chief Medical Advisor

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