/publications/issue/2005/2005-04/2005-04-9428

Similar Drug Names Prompt New Concerns About Dispensing Errors

Author: Ken Rankin

The FDA and pharmaceutical industry leaders are joining in an effort to alert pharmacists to a troublesome risk of dispensing errors involving 2 similarly named drugs: Eli Lilly's antipsychotic drug, Zyprexa, and Pfizer's antihistamine, Zyrtec.

The FDA has posted a warning of the problem on the agency's Web site, while Lilly announced plans for an "awareness direct mail campaign to pharmacists,"urging that they take precautions to avoid dispensing errors that could result in "unnecessary adverse events or potential relapse in (Zyprexa) patients suffering from schizophrenia or bipolar disorder."

In a letter sent to pharmacists and other health care professionals throughout the country, Lilly cited a number of instances "where Zyprexa was incorrectly dispensed for Zyrtec and vice versa."

Although the similarity of names is partially responsible for the confusion, Lilly said other factors are at play.

Both drugs are available in the same dose strengths (5-mg and 10-mg tablets) with the same dose interval (once daily), and the 2 products are "generally stored near each other on pharmacy shelves,"the manufacturer said.

For its part, Lilly will be making label changes for its drug to reduce the risk of dispensing errors. The company also urged pharmacists to follow recommendations from the Institute for Safe Medication Practices to store drugs with reports of dispensing errors in different locations, and to print both the brand and generic names of these products on Rx labels.

Mr. Rankin is a freelance medical writer.