WHO Information Vol. 31, No. 4, 2017

Naming of medicines

Survey about International Nonproprietary Names (INN)

Level of familiarity with the INN nomenclature system among students, academics, scientists and healthcare practitioners

WHO assigns International Nonproprietary Names (INN) to pharmaceutical substances. A recent survey among health sciences students and professionals showed that not all respondents were equally aware of what INN are and how they are constructed. The findings of the survey will support efforts to promote the use of INN in practice. Furthermore, more knowledge about INN could enhance students’ understanding of the different classes and modes of action of medicines.

Introduction students to recognize the classes of The INN nomenclature system provides and their modes of action. But are academics unique identifications for pharmaceutical and students familiar with the INN substances. The INN are constructed with nomenclature system? For that matter, are a prefix and a stem, occasionally an infix scientists and healthcare practitioners aware is included where necessary. The stem in of how INN are constructed? In March 2016 the INN gives an indication to the mode the INN Programme of the World Health of action or pharmacological class of Organization (WHO) conducted a survey the substance being named. In addition to evaluate a sample of participants on how each stem is developed with a definition familiar they are with the INN nomenclature that describes the agonistic, antagonistic, system. The purpose of the study was to modulating or inhibitory property of the obtain an overview of the use of INN in ligand. practice and education around the world, The use of INN in the education of and to identify gaps with a view to develop a pharmacology and therapeutics is an strategic plan to promote the use of INN in excellent way to facilitate learning and help practice and education.

Authors: Wai-Keung Chui1, Gilles Mignot2, Antonio Romeo3, Sarel F. Malan4, Menico Rizzi5, Raffaella Balocco3 1 Department of Pharmacy, National University of Singapore, Singapore 2 Independent expert, France 3 International Nonproprietary Names Programme, WHO Essential Medicines and Health Products Department 4 School of Pharmacy, University of the Western Cape, South Africa 5 Department of Pharmaceutical Sciences, University of Piemonte Orientale, Italy

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Survey about International Nonproprietary Names

Method Pharmaceutical Federation (FIP)3 and the A brief online survey was designed International Union of Basic and Clinical comprising ten statements related to Pharmacology (IUPHAR)4. the familiarization and usage of INN. The survey questions were available in Participants were invited to respond to each both English and French. Participants statement on a 5-point Likert Scale (Strongly were requested to answer a single set of the disagree / Disagree / Somewhat disagree, questions offered in either language. The somewhat agree / Agree / Strongly agree), survey was open for one month during and there was also an “I do not know” March 2016. Thereafter the data were option. collated and analyzed. The following institutions and organizations were selected for Respondents recruitment of survey participants: A total of 1 074 respondents from universities, the user community of 68 countries participated in the the WHO MedNet platform for INN1, survey (Table 1), including 432 (40%) men La Revue Prescrire2, the International and 642 (60%) women. The majority of 1 http://mednet.who.int – password required 2 French: http://www.prescrire.org/fr/Summary.aspx; 3 http://www.fip.org/ English: http://english.prescrire.org/en/Summary.aspx 4 http://www.iuphar.org/

Respondents’ characteristics Table 1: Countries of residence Table 2: Occupation Country English French Total Occupation Number (%) response response Students (including 47% 652 (61%) South Africa 65 1 66 pharmacy students and 21% Singapore 57 57 medical students) Professionals Italy 46 1 47 Pharmacists 117 (11%) USA 33 33 Physicians 43 (4%) Spain 23 2 25 Scientists/researchers 72 (7%) France 20 633 653 (excluding professors) Germany 20 20 Academics (professors) 67 (6%) Switzerland 18 18 Other professionals 123 (11%) 17 17 Total 1 074 (100%) China 10 10 Table 3: Age (years) Japan 10 10 English French All Others* 116 2 118 Range 19–76 16–72 16–76 Total 435 639 1 074 Mode 22 18 18 40.5% 59.5% 100% Average 40.5 24.7 31.1 * Table 1, Others: (Responses in English) – Canada, Croatia, Australia, , Russian Federation, Finland, Ireland, New Zealand, Peru, Portugal, Brazil, Costa Rica, Netherlands, Norway, Austria, Belgium, Chile, Colombia, Czech Republic, Denmark, Iceland, , Mexico, Nigeria, Poland, Republic of Serbia, Sweden, Argentina, Bangladesh, Bulgaria, Cote d’Ivoire, Cuba, El Salvador, Hungary, Indonesia, , Kyrgyzstan, Latvia, Libyan Arab Jamahiriya, Malawi, Malaysia, Mongolia, Namibia, Philippines, Qatar, Republic of Korea, Romania, Rwanda, Saudi, Arabia, Slovenia, Thailand, Turkey, Uganda, Uruguay, Venezuela, Vietnam. (Responses in French) – Algeria.

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Survey about International Nonproprietary Names the respondents were students and the agreement included 69% of the students remainder were professionals (Table 2). and 81% of the professionals, indicating The students were mostly enrolled in life that the latter are more familiar with this sciences courses, 44% of them were first-year situation. Thirteen percent disagreed with students. The working experience of the the statement, while 9% answered that they professionals ranged from 1 to 50 years. The did not know. mean age of the respondents was 31 years; the participants who responded in French 4. INN stems were younger on average than those who Seventy-one percent of all respondents (68% responded in English (Table 3). of the professionals and 73% of the students) agreed that pharmaceutical substances Summary of results belonging to the same therapeutic or An overview of results is provided in chemical class share the same stem in their Figure 1. For the purpose of the summaries INN.5 Only 6% of the respondents disagreed, shown below, responses of “Agree” and but 14% of all respondents answered that “Strongly agree” were added together, as they did not know, meaning that in total were responses of “Disagree” and “Strongly 20% of respondents were unaware of the disagree”. function of INN stems and the remaining The examples given in the footnotes are 9% were unsure (“Somewhat disagree, included in this article for illustration, but somewhat agree”). were not provided in the survey. 5. “-mab” stem 1. Acronym Three quarters (76%) of the participants Eighty-five percent of all respondents were aware that the “-mab” suffix in an INN knew that the acronym INN stands for designates a substance belonging to the International Nonproprietary Names; 7% class of immunological agents known as answered that they did not know, and the monoclonal antibodies,6 whereas 17% (19% remaining 8% thought that this was not the of the students and 16% of the professionals) case. responded that they did not know and the remaining 7% disagreed wholly or partially 2. INN versus generic names with this statement. Sixty-five percent of the respondents agreed that the INN of a medicine is the same as the 6. How INN are assigned generic name, 25% disagreed, and 11% did Sixty-seven percent of the respondents not know. were aware that WHO in collaboration with INN experts and national nomenclature 3. INN versus brand names committees assigns INN, while 25% of the Almost three quarters (74%) of all participants (28% of the students and 21% respondents agreed that different of the professionals) did not know, and the manufacturers may give their products others disagreed or partly disagreed. different trade names although the active 5 ingredient has the same INN. Those in Example : the stem « -conazole” denotes triazole- or imidazole systemic antifungal agents: miconazole, ketoconazole, fluconazole, itraconazole, voriconazole, posaconazole, isavuconazole.(1) 6 Examples: rituximab, trastuzumab, gemtuzumab.(2)

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Survey about International Nonproprietary Names

Figure 1: Overview of survey statements and responses (n = 1 074)

Majority response: Agree or strongly agree Disagree or strongly disagree Agree/disagree, or don’t know

0% 50% 100%

1) I am aware that INN stands for International Nonproprietary Name for pharmaceutical substances.

2) The International Nonproprietary Name of a pharmaceutical substance is also known as the generic name.

3) The International Nonproprietary Name of a pharmaceutical substance may appear in several brand names that come from different manufacturers.

4) Pharmaceutical substances belonging to the same therapeutic or chemical class share the same stem in the International Nonproprietary Name.

5) The stem in the name “trastuzumab” is “mab”, indicating that the substance is a monoclonal antibody.

6) WHO collaborates with INN experts and national nomenclature committees to select a single name of worldwide acceptability for each active pharmaceutical ingredient

7) The name “acetaminophen” is an US Adopted Name while “” is the Int’l Nonproprietary Name.

8) At the university I attended, health sciences programmes Professionals Students use only brand names of drugs in the instruction.

9) In my country, when physicians prescribe medications they always use International Nonproprietary Name.

10) When a pharmaceutical substance is converted to a salt or an ester, a modified International Nonproprietary Name is given.

7. Acetaminophen, paracetamol universities where they studied, the health Just over half (51%) of all respondents, sciences programmes use only brand names including 71% of the professionals and 38% in teaching. This suggests that health science of the students, agreed that acetaminophen students across various countries may is an US Adopted Name (USAN) while learn about medicines using INN or names paracetamol is the INN of the same commonly used in their continent, such medicine. This leaves a surprisingly as USAN, British approved names (BAN), high proportion (29%) of professional other nationally approved non-brand names. respondents who were not aware that this Interestingly, 83% of the students but very common medicine has two names. only 56% of the professionals answered that brand names are not the only medicine 8. Use of INN in teaching names they learned during their courses. Seventy-two percent of all respondents This suggests that the use of non-brand disagreed with the statement that at the names in tertiary education has increased.

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Survey about International Nonproprietary Names

This is indeed encouraging; however, the are more experienced and may be better learning may be further enhanced if students informed about the nomenclature of learn more about the rules and principles medicines than students. However, the according to which INN are constructed. responses suggest that professionals are still not familiar with certain aspects of the INN 9. Use of INN in prescribing nomenclature system. Fifty-five percent of all respondents Generally, the respondents knew about disagreed that physicians always use the INN for pharmaceutical substances; INN when prescribing medicines. Only however, they were less familiar with certain 13% agreed, 25% somewhat agreed specific aspects, such as how INN are and somewhat disagreed, and 7% said constructed and what the components in a they didn’t know. The wording of the name mean. This is not unexpected as most statement (“... always use INN...”) may of the respondents were students, who may have discouraged some respondents from have had limited exposure to the concept of agreeing. Nevertheless this is an interesting INN. The survey responses further suggested finding: the responses to the previous that although INN (or generic names) are question indicated that students learn about increasingly used in teaching, in practice medicines using not only brand names, and many physicians still prefer to prescribe yet in practice the use of brand names still using brand names. appears to be prevalent. Based on the survey findings it is recommended that practitioners should 10. Modified INN be encouraged to use INN for prescription Only 29% agreed to the statement that a salt and dispensing to harmonize medicine or ester of a pharmaceutical substance is names around the world. It is further given a modified INN,7 8% somewhat agreed recommended that the principles of how and somewhat disagreed. Close to half (46%) INN are constructed and assigned should be of all respondents answered that they did not more widely included in tertiary education. know, and 17% disagreed, adding up to 63% This would make learning about medicines of all respondents (54% among professionals more meaningful and less of rote learning, and 69% among students) who were not and would facilitate a better understanding aware that INN are modified to designate a of certain aspects of pharmacology. salt or ester form of a medicine. References Conclusions and recommendations 1 WHO. The use of stems in the selection of The survey was taken by a cross-section of International Nonproprietary Names (INN) professionals and students. The majority of for pharmaceutical substances. WHO/EMP/ RHT/TSN/2013.1. Geneva: World Health the respondents were students, accounting Organization; 2013. for 61% of all participants. 2 WHO. Revised monoclonal antibody (mAb) It was found that students and nomenclature scheme. Geneva, 26 May 2017. professionals responded differently to most 3 WHO. International Nonproprietary Names of the statements. This is not unexpected, Modified. INN Working Document 05.167/3. as it can be assumed that professionals å

7 Example: The INN “clindamycin phosphate” denotes the phosphate salt form of clindamycin.(3)

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