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

Originally published on August 18, 2011 10:56 am

If a pharmacist heard the name Clindesse or Clindets while filling a prescription over the phone, he might understandably confuse the two drugs, especially if one were more familiar. But the first one is a vaginal antibiotic cream while the other is an antibiotic for acne, and so the patient receiving end of such a mix-up might not be amused.

The government has a system in place to try to keep drugs that look or sound alike from ending up on the market together. But the pharmaceutical industry has been pushing to stop 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 PhRMA wants the policy repealed because it says FDA officials have an arbitrary way of deciding which names are better than others.

Cohen acknowledges that the system is far from perfect. But in a blog post this week on Philly.com, he also offered a spirited defense of the name review process, saying 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?"

An incident just this summer showed why some kind of naming review process is necessary. In late July, the FDA announced it had received 226 reports of prescription errors 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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