Confusing brand names: Nightmare of medical professionPV Rataboli, Amit Garg
Department of Pharmacology and Therapeutics, Goa Medical College, Bambolim, Goa 403202, India
OBJECTIVE: India has more than 20,000 registered pharmaceutical manufacturers. Consequently, there is a flood of brand names to choose from. We conducted this study to analyse and sort out the multitudinous brand names thronging the Indian market, and identified those that could create a possible confusion. MATERIALS AND METHODS: Recent issues of drug formularies like Indian Drug Review, Drug Index, and Monthly Index of Medical Specialities-India were checked and all the brand names given were included. Some other brand names that are available with the pharmacists but are not included in these indexes were also included in the study for analysis. OBSERVATIONS: Potentially confusing brand names were sorted out and categorised according to the severity of damage they can cause if misinterpreted by the pharmacist or the patient. Subgroups were made according to the brand name, the generic name, and the manufacturers of the drug. CONCLUSION: Several brand names are strikingly identical, similar looking (orthographic), or similar sounding (phonological). Preventing this possible confusion is not the work of any one person involved. We describe the role of prescribing doctors, dispensing pharmacists, consumer patients, and the manufacturing companies to prevent "wrong prescribing" due to similarities in brand names.
Keywords: Identical; look-alike; sound-alike; confusing; brand names
Prescribing drugs with their brand name is an essential part of medical practice. The recent issues of the Indian Drug Review (IDR) lists more than 8000 brand names of drugs. Many additional brand names not listed by drug formularies like IDR, Monthly Index of Medical Specialities (MIMS)-India, or Drug Index are also available. This plethora of branded formulations has the potential for creating confusion amongs the practising doctors, pharmacists and patients. Many brand names have been confused due to illegible handwriting, poor pronunciation and other factors. Numerous case reports and studies have thrown light on the confusion over similar drug names.,,,,,,, Considering this confusion, we undertook a study to categorise the available confusing brand names in the Indian market with an aim to inform the medical profession.
Recent issues of commonly used drug formularies i.e. Indian Drug Review (IDR) (May-June, 2004) and Monthly Index of Medical Specialities (MIMS)- India (June 2004) were referred to and the brand names included in them were analysed. Some other brand names available with the pharmacists but not included in these two formularies were also checked. Same name (identical), similar-looking (orthographic), and similar-sounding (phonological) names that could cause confusion among the prescribing doctors and dispensing pharmacists were sorted out. They were then divided into twelve categories and the risk-benefits of wrong prescribing and dispensing to the patients, doctors, pharmacists, and the drug manufacturers were assessed.
Confusing brand names according to the category are listed in [Table - 1], [Table - 2], [Table - 3], [Table - 4], [Table - 5], [Table - 6], [Table - 7], [Table - 8], [Table - 9], [Table - 10], [Table - 11], [Table - 12]. The confusing brand names were broadly divided into three groups: identical, orthographic, and phonological. These groups were then reclassified into twelve categories based on the nature of the drug group, dosage forms, and the drug manufacturing companies.
The twelve categories of confusing brand names listed above present a bird's eye view of the difficulties posed by the prescribers and dispensers due to exactly identical, look-alike and sound-alike names. Needless to say, the names mentioned above are just the 'tip of the iceberg' and there could be many more confusing brand names available in the Indian and the world drug market.
Categories I, II, IV, VII, VIII, and XII pose a very high danger to the prescribing doctors, pharmacists, and patients. A slight deviation of legibility on the part of the prescribing doctor or lack of observation and careless attitude of the dispensing pharmacists can cause serious damage or injury to the patient. Dispensing Celin (vitamin C) instead of Celib (celecoxib) to a patient with arthritis or taking Tobitil (tenoxicam) in place of Tibitol (ethambutol) can not only cause failure of treatment but can cause aggravation of disease and often serious toxicity.
Although Category III listed above appears harmless to the consuming patients, it is of definite concern to the practitioners and manufacturers. A new manufacturing company often competes with a reputed brand by giving a similar name to its drug. Categories V, X, and XI are interesting but harmless. Although the names are look-alike or sound-alike, there is less likelihood of 'prescription-dispensing error' as the drug dosage forms of the two preparations are different.
Category IX will do no harm if the names are interchanged in topical preparations like Acnesol (erythromycin) and Acnesol-T (erythromycin + tretinoin) or oral preparations like Novolid (nimesulide) and Novolid-S (nimesulide + serratiopeptidase). However, in antihypertensive preparations, substitutions of a combination product like Aamin-A (amlodipine + atenolol) in place of a single drug product like Aamin (amlodipine) can induce hypotension and cause harm to the patient. Secondly, the combination may not be indicated in some patient or may even be contraindicated.
The problem of confusing brand names is commonplace all over the world. In 2001, the U.S. Pharmacopoeia released 'Use caution, avoid confusion', an updated list highlighting confusing brand name sets and identified more than 750 unique drug names that have been reported to the USP Medication Errors Reporting (MER) Program. Similar drug names, either in writing or in speaking, account for approximately 15% of all reports to USP's MER Program.
Practitioners and pharmacists often report confusion between look-alike and sound-alike brand names, between similar generic names, and between similar brand and generic names. To add to this, doctors' illegible handwriting, incomplete knowledge of drug names, newly available products, and similar packing and labelling of drugs marketed by the same company contribute largely to wrong prescribing and dispensing.
Various recommendations have come forth to do away with the confusion regarding similar drug names.,,,, To sum up a few of them:
Most of these recommendations are quite far-fetched and remote and may take time before they are actually put into practice. Therefore, considering the Indian scene, we propose a few simple and immediate steps to prevent brand name confusion:
1. The practitioner: Doctors should be well-versed with pharmacological (generic) names and the brand names that are available in their local setting. We should try to write drugs in legible handwriting. Although 'legibility' is something 'impossible' for most of us, a tip can be very helpful. Every time we have to write a prescription we should think as if we are writing a cheque to withdraw money from the bank, this will make us write clearly paying due attention to the spellings. It could be even more appropriate to write the generic names below the brand names in parentheses to avoid any confusion. Abbreviations should be strictly avoided. The doses should be mentioned without fail, as this would settle the conflict most of the time. We should also avoid giving prescriptions over the phone. In case it is the need of the hour, the drug name should be clearly spelt out and the patient should be asked to repeat it for confirmation. Finally, if we feel that two drugs have confusing brand names then it should be reported to the medical representatives of the companies involved and they should be asked to consider revising their product names.
2. The dispenser/pharmacist: The pharmacists should be wholly convinced about the nature of the brand they are dispensing. If there is any doubt about the name, they should not hesitate to consult the prescribing doctor before dispensing. It is always desirable for the pharmacist to have knowledge of the doses of commonly used drugs. It is observed that many times they dispense the brands available at their shop rather than what is written in the prescription. This practice should stop.
3. The patient: A literate patient can himself check if the dispensed product is 'exactly the same' as per the doctor's prescription. He should bring to the notice of the pharmacist in case of any doubt and refuse to accept any variations being handed over. Illiterate patients should make it a habit to verify the dispensed drug with the doctor or any literate person at home or in the neighbourhood.
4. The manufacturer: Now is the time when the manufacturing companies should also join hands in the battle against this common enemy. They should do a thorough check about the available brand names before naming their product. Any reports of confusing brand names should be taken seriously and renaming their product should be considered.
In conclusion, look-alike and sound-alike brand names of various drugs are here to stay. As new products are made available, additional confusion is bound to occur. Numerous errors have occurred in the past due to misinterpretation of written or spoken names. Thus, it is the need of the hour to give a wake-up call and all those concerned should get themselves together to solve this gigantic problem. We should not forget that the unfortunate patient, for whom all the brand names are made, is ultimately at the receiving end of this confusion. We hope that this study serves as a base to have a cautionary approach and to make practitioners aware of these potential hazards.
[Table - 1], [Table - 2], [Table - 3], [Table - 4], [Table - 5], [Table - 6], [Table - 7], [Table - 8], [Table - 9], [Table - 10], [Table - 11], [Table - 12]