Confusion over AIDS drugs could cause errors
September 1, 1997 2 minutes read
Confusion over AIDS drugs could cause errors
Antiviral drugs used to treat AIDS sometimes have similar and confusing names that have led to medication errors, according to the United States Pharmacopeial (USP) Convention in Rockville, MD.
The pharmacists’ group is warning health care providers that patients could receive the wrong drug or dose if practitioners are unfa- miliar with the names and careful about avoiding mixups. The first example of potential confusion involves Retrovir, a brand name of the antiviral zidovudine, manufactured by Glaxo Wellcome. There have been instances in which Retrovir was confused with ritonavir, a generic antiviral.
Both drugs are antivirals and both are provided in 100 mg oral doses. But the maintenance doses for the two drugs are different: The daily regimen for ritonavir is twice as much as for Retrovir. Mixing up the medications can cause overdose, unexpected drug interactions, or subtherapeutic medication levels.
The USP notified Glaxo Wellcome, which recently sent letters to pharmacists cautioning them about the potential error. The USP advises risk managers to get the word out to their own staff as well.
The USP also is warning health care providers about these potential mixups:
• Lamivudine, an antiviral, may be confused with lamotrigine, an anticonvulsant.
• Saquinavir, an antiviral, may be confused with Sinequan.
• The name "AZT" used to be the common name for zidovudine, but it now can be confused with other drugs. In one instance, a physician ordered Azactam (generic aztreonam), an antibiotic, and the nurse wrote down the abbreviation "AZT." The pharmacist assumed the "AZT" was a reference to zidovudine, but questioned the dosage and refused to fill the order.
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