Travel Alert: Same Name, Different Drug

The Institute for Safe MedicationPractices has received a numberof reports involving brand namemedications that may contain differentactive ingredients in another country.

In one report, a patient was prescribedDilacorXR (diltiazem extended-release)120 mg daily for hypertension. While travelingto Serbia, he ran out of medication.A Serbian pharmacist filled the prescription,but he actually dispensed digoxin0.25 mg because, in Serbia, Dilacor is abrand name for digoxin. The patientdidnot notice the change in tabletstrength,so he continued to take the medicationfor 3 days upon return to the UnitedStates. He took extra doses each day (2-3tablets), however, because he felt that hisblood pressure medication was not working.By the third day, the patient experiencedsigns of digoxin toxicity, includingnausea, vomiting, headaches, and chestpain worsened by exertion. He went to anemergency department and was admittedfor monitoring and treatment withDigibind (digoxin immune FAB).

In another case, a hospitalized patientdeveloped gastrointestinal (GI) bleeding,and the medical team was trying todeterminethe cause. A pharmacy studenton the team was asked to find outwhat ?Cartia? was, since the patient hadapparentlybeen taking that medicationprior to admission. The student foundthat several Web sites, as well as Micromedex,described Cartia as a 100-mg,enteric-coated tablet of aspirin. Whenthe student reported this information tothe team, a decision was made to discontinuethe drug, as aspirin can causeGI bleeding. Fortunately, a medicationerror was averted when it was discoveredthat the patient was actually takingCartia XT (diltiazem in the United States),which is bioequivalent to Cardizem CD,to treat hypertension and angina.

Cartia is a trademark for enteric-coatedaspirin in New Zealand and Australia.This product can be purchased over theInternet in the United States, however,and both products could be consideredheart medications, increasing the riskof error. If a patienttaking Cartia XTsearches the Web and finds that ?Cartia?is available without a prescription andinexpensive (one site advertised 28 tabletsfor $1.94 in US dollars), a medicationerror could occur. Confusion also couldexist among physicians trained outsidethe United States or patients who travelbetween the United States and NewZealand or Australia.

Finally, the trademark Entex LA isused for 2 different products in theUnited States and Canada. In the UnitedStates, Andrx Pharmaceuticals marketsa capsule formulation of Entex LA thatcontains phenylephrine hydrochloride(30 mg extended-release) and guaifenesin(400 mg immediate-release). InCanada, PurduePharma Canada suppliesEntex LA as a tablet that containspseudoephedrine (120 mg) and guaifenesin(600 mg). Compoundingthe confusion,the indicated adult dose for eachproduct is one tablet every 12 hours.

Safe Practice Recommendations

Be cautious of drug information obtainedonly from the Internet. The Internetknows no national boundaries, soinformation?even drug names?foundmay be inaccurate and/or not applicableto health care in the United States.Always question patients on the reasonthey are taking their medications so asnot to rely solely on drug references.Remind patientswhen they travel tocarry an adequate supply of medicationsand a list by generic and brand name.Those needing a temporary supply whileoverseas should confirm that the correctdrug has been dispensed, as brandname products may contain differentactive ingredients in different countries.

For a list of drug names in whichidenticalor nearly identical namesused in other countries reflect differentingredients, please visitthe FDAWeb site at: www.fda.gov/oc/opacom/reports/confusingnames.html.