What's In A Drug Name? Sometimes, Enough To Cause Mix-Ups

Aug 17, 2011

If a pharmacist heard the name Clindesse (a vaginal antibiotic cream) or Clindets (antibiotic cream for acne) while filling a prescription over the phone, you could see how they might confuse them, especially if one was more familiar. But the patient receiving end of such a mix-up might not be amused.

The government has a system in place to try to keep similar looking and sounding drugs from ending up on the market together. But the pharmaceutical industry has been pushing to kill the system.

There are nearly 800 pairs of drugs like Clindesse and Clindets that look or sound alike, according to the Institute for Safe Medication Practices, or ISMP, a patient safety group that compiled a list of them. And the ISMP says all of these similarly named drugs are a big problem, because name mix-ups are responsible for about 25 percent of all medication errors.

"We see errors all the time," Michael Cohen, president of ISMP, tells Shots. "And though it's rare, some of these mix-ups are fatal."

The Food and Drug Administration has a name review process that's supposed to prevent pharmaceutical companies from using a name that's too close to another one already on the market. And they have forced drug companies to change the names of about a dozen drugs over the years, says Cohen.

But this summer, the Pharmaceutical Research and Manufacturers of America, or PhRMA, called this current system "burdensome and disruptive" to doing business. PhRMA also wants the policy repealed because it says FDA officials have an arbitrary way of deciding which names are better than others.

In a blog post this week on Philly.com, Cohen acknowledged that the system is far from perfect, but it "provides a crucial safety benefit."

"Of course it's not a scientific process," Cohen tells Shots. "But instead of repealing it, couldn't there be a public meeting to explain where the problems are?"

There have been a few recent incidents where the need for such a system seems to have been validated. In late July, the FDA announced it had received 226 reports of confusion involving Risperdal, a drug for schizophrenia and other psychiatric disorders, and Requip, used to treat Parkinson's and restless legs syndrome. The two drugs had similar labels with matching colors, and also are prescribed at the same doses at the same frequency. The companies were asked by the FDA to change the packaging and lettering to help differentiate the drugs.

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