Don't Confuse Idarucizumab with Idarubicin

The Institute for Safe Medication Practices (ISMP) is alerting pharmacists about the risks of mixing up idarucizumab (Praxbind) with idarubicin.

Praxbind was recently approved by the FDA as a reversal agent of Boehringer Ingelheim’s anticoagulant, dabigatran (Pradaxa).

“Hospital pharmacies may stock Praxbind if dabigatran patients are treated in the hospital or seen in the emergency department,” ISMP stated in a November newsletter. “Unfortunately, the drug’s nonproprietary name, idarucizumab, shares the first 5 letters with the antineoplastic drug idarubicin.”

ISMP noted that in addition to the similar spelling of the drug names, the 2 products are also both refrigerated.

One incident has been reported to ISMP. A carton of idarucizumab was placed next to a bag containing idarubicin in a refrigerator. The idarubicin was being readied for a patient, but a vial of idarucizumab was spiked with a closed system transfer device.

However, a pharmacist noticed the mistake before the wrong drug was administered to the individual.

As hospitals begin to stock up on idarucizumab through electronic orders, barcodes will be placed on the medication, and these codes may prevent future incidents from occurring.

In the event that the wrong drug is scanned, a professional will be alerted to the difference.

However, experts are encouraging facilities to keep idarucizumab away from idarubicin in storage containers, as well.

There is also a color difference between idarucizumab and idarubicin, which may help staff more easily identify the drugs.

ISMP has informed Boehringer-Ingelheim of the mix-up. The institute encourages others to report similar events to www.ismp.org/MERP, and ISMP will notify the FDA.