Original Article www.jpgmonline.com Confusing brand names: Nightmare of medical profession

Rataboli PV, Garg A

Department of Pharma- ABSTRACT cology and Therapeutics, Objective: has more than 20,000 registered pharmaceutical manufacturers. Consequently, there is a Goa Medical College, Bambolim, Goa 403202, flood of brand names to choose from. We conducted this study to analyse and sort out the multitudinous India brand names thronging the Indian market, and identified those that could create a possible confusion. Materials and Methods: Recent issues of formularies like Indian Drug Review, Drug Index, and Monthly Correspondence: Index of Medical Specialities-India were checked and all the brand names given were included. Some other Amit Garg, MD brand names that are available with the pharmacists but are not included in these indexes were also included E-mail: [email protected] 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 Received : 09-08-04 role of prescribing doctors, dispensing pharmacists, consumer patients, and the manufacturing companies to Review completed : 30-09-04 prevent “wrong prescribing” due to similarities in brand names. Accepted : 22-12-04 PubMed ID : 15793332 J Postgrad Med 2005;51:13-6 KEY WORDS: Identical; look-alike; sound-alike; confusing; brand names

rescribing with their brand name is an essential the patients, doctors, pharmacists, and the drug manufacturers were P part of medical practice. The recent issues of the In assessed. dian Drug Review (IDR) lists more than 8000 brand names of drugs.[1] Many additional brand names not listed by drug for- Observations mularies like IDR, Monthly Index of Medical Specialities Confusing brand names according to the category are listed in Ta- (MIMS)-India, or Drug Index are also available. This plethora bles 1-12. The confusing brand names were broadly divided into three groups: identical, orthographic, and phonological. These of branded formulations has the potential for creating confu- groups were then reclassified into twelve categories based on the sion amongs the practising doctors, pharmacists and patients. nature of the drug group, dosage forms, and the drug manufactur- Many brand names have been confused due to illegible hand- ing companies. writing, poor pronunciation and other factors. Numerous case reports and studies have thrown light on the confusion over Discussion similar drug names.[2-9] Considering this confusion, we under- took a study to categorise the available confusing brand names in the Indian market with an aim to inform the medical pro- The twelve categories of confusing brand names listed above fession. present a bird’s eye view of the difficulties posed by the pre- scribers and dispensers due to exactly identical, look-alike and Materials and Methods sound-alike names. Needless to say, the names mentioned above are just the ‘tip of the iceberg’ and there could be many Recent issues of commonly used drug formularies i.e. Indian Drug more confusing brand names available in the Indian and the Review (IDR) (May-June, 2004) and Monthly Index of Medical Spe- world drug market. cialities (MIMS)- India (June 2004) were referred to and the brand names included in them were analysed. Some other brand names Categories I, II, IV, VII, VIII, and XII pose a very high danger available with the pharmacists but not included in these two formu- to the prescribing doctors, pharmacists, and patients. A slight laries were also checked. Same name (identical), similar-looking (or- thographic), and similar-sounding (phonological) names that could deviation of legibility on the part of the prescribing doctor or cause confusion among the prescribing doctors and dispensing phar- lack of observation and careless attitude of the dispensing phar- macists were sorted out.[10] They were then divided into twelve cat- macists can cause serious damage or injury to the patient. Dis- egories and the risk-benefits of wrong prescribing and dispensing to pensing Celin (vitamin C) instead of Celib (celecoxib) to a

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Table 1: Look-alike brand names, different generic names, Table 4: Sound-alike brand names, different generic names, different manufacturer (Category I) different manufacturers (Category IV) Brand names Generic names Manufacturer Brand names Generic names Manufacturer Tibitol Ethambutol PCI Abzole Albendazole Euphoric Pharm Pvt. Ltd. Tobitil Tenoxicam Ranbaxy Lab Ltd. Abzorb Clotrimazole Crosslands Research Labs. Trip Nortriptyline Ltd. Edegra Sildenafil Sun Pharm India Ltd. Triz Cetrizine Indoco Remedies Ltd. Allegra Fexofenadine Hoechst Marion Roussel Pronim Nimesulide Unichem Lab Ltd. Hemsi Ferrous fumarate Serum International Pronil Fluoxetine PIL Pharmacia India Ltd. Hemsyl Ethamsylate Indoco Remedies Farizym Enzymes Infar Maladine Mepacrine Unicure Remedies Pvt Ltd. Fasigyn Tinidazole Pfizer Ltd. Mala-D OCP - Celib Celecoxib Unichem Lab Ltd. Allerzine Cetirizine Jenburkt Pharm Ltd. Celin Vitamin C Glaxo Smithkline Alergin Ephedrine + Theophylline Cipla Ltd. Dan Diclofenac Unison Pharm. Xental 400 Pentoxiphylline Targof Pure Drugs Ltd. Dax Cefadroxil DWD Pharm. Zentel 400 Albendazole Glaxo Smithkline Eltocin Erythromycin IPCA Lab Ltd. Lyser-D Diclofenac + Comed Chem Pvt. Ltd. Eltroxin Thyroxine Glaxo Smithkline Serratiopeptidase Glyred Gliclazide Nizer-D Nimesulide + U.S.V. Ltd. Glyrep Metformin Emcure Pharm Ltd. Pseudoephedrine Azoo Azithromycin Group Pharmaceuticals Oceph Cefixime Emcure Pharm Ltd. Azox Alprazolam Aarpik Remedies Ocef Cephalexin Osper Acein Enalapril Targof Pure Drugs Ltd. Enzide Enalapril Cadila Pharm Ltd. Acem Clarithromycin Emcure Pharm Ltd. N-Side Nimesulide Citadel Five Pvt Ltd. Normace Enalapril Unisearch Normax Norfloxacin IPCA Table 2: Look-alike brand names, different generic names, same manufacturer (Category II) Table 5: Look-alike or sound-alike brand names, different Brand names Generic names Manufacturer generic names, different manufacturers, different dosage forms PD-Mox Amoxycillin Parenteral (Category V) PD-Rox Roxithromycin Parenteral Brand names Generic names Manufacturer Clomine Clomipramine PIL Clozine Chlorpromazine PIL Betanate (ointment) Clobetasol Cosme Healthcare Bioclox Clarithromycin Biochem Betanase (tablet) Glibenclamide Zydus Medica Biodoxi Doxycycline Biochem Piplar (drops) Pipenzolate Lark Lab. Ltd. Zyrof Rofecoxib Zydus Ciplar (tablet) Propranolol Cipla Ltd. Zyrop Erythropoietin Zydus Adiflox (ointment) Ciprofloxacin Intas Pharm Pvt. Ltd. Adilox (capsule) Ampicillin + Cloxacillin Albert David Ltd.

Table 3: Look-alike brand names, same generic name, different manufacturers (Category III) Table 6: Identical brand names, one with an additional letter different generic names, same manufacturer, different dosage Brand names Generic names Manufacturer forms (Category VI) Ceftrion Ceftriaxone Claris Life Brand names Generic names Manufacturer Ceftron Ceftriaxone Inga Lab. Pvt. Ltd. Ena Enalapril Menarini Raunak Ph. Ltd. Vorth (tablet) Valdecoxib Gracewell Enam Enalapril Dr.Reddy’s Lab Ltd. Vorth-P (injection) Parecoxib Gracewell Diclofen Diclofenac Biochem Taxim (injection) Cefotaxime Alkem Lab Ltd. Diklofen Diclofenac Stadmed Pvt. Ltd. Taxim-O (tablet) Cefixime Alkem Lab Ltd. Taxim-O Cefixime Alkem Lab Ltd. Axim-O Cefixime Kee Pharm Ltd. Table 7: Identical brand names, one with additional letter Oflex Ofloxacin Finecure different generic names, same manufacturer, same dosage form Oflox Ofloxacin Protec (Category VII) Aflox Ofloxacin Anikem Lab Brand names Generic names Manufacturer patient with arthritis or taking Tobitil (tenoxicam) in place of Acnesol (gel) Erythromycin Systopic Lab Ltd. Tibitol (ethambutol) can not only cause failure of treatment Acnesol-CL (gel) Clarithromycin Systopic Lab Ltd. but can cause aggravation of disease and often serious toxicity. though the names are look-alike or sound-alike, there is less Although Category III listed above appears harmless to the likelihood of ‘prescription-dispensing error’ as the drug dos- consuming patients, it is of definite concern to the practition- age forms of the two preparations are different. ers and manufacturers. A new manufacturing company often competes with a reputed brand by giving a similar name to its Category IX will do no harm if the names are interchanged in drug. Categories V, X, and XI are interesting but harmless. Al- topical preparations like Acnesol (erythromycin) and Acnesol-

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Table 8: Identical brand names, one with an additional letter, reports to USP’s MER Program.[11] different generic names, different manufacturers (Category VIII) Practitioners and pharmacists often report confusion between Brand names Generic names Manufacturer look-alike and sound-alike brand names, between similar ge- Clomin Dicyclomine + Core Health Care neric names, and between similar brand and generic names. Clomine Clomipramine PIL To add to this, doctors’ illegible handwriting, incomplete Vizol Multivitamin Maan Pharm Ltd. knowledge of drug names, newly available products, and simi- Vizole Levamisole M. M. Labs lar packing and labelling of drugs marketed by the same com- pany contribute largely to wrong prescribing and dispensing. Table 9: Identical brand names, one with an additional letter, same generic name in different combination, same Various recommendations have come forth to do away with manufacturer (Category IX) the confusion regarding similar drug names.[2,3,7,8,12] To sum up a few of them: Brand names Generic names Manufacturer • Licensing authorities and regulatory agencies should exer- Acnesol Erythromycin Systopic Lab Ltd. cise more control over the naming of a new formulation. Acnesol-T Erythromycin + Tretinoin Systopic Lab Ltd. • Non-proprietary and new proprietary names should be in- Novolid Nimesulide Brown and Burk Pharm Ltd. ternationalised. Novolid-S Nimesulide + Brown and Burk Pharm Ltd. Serratiopeptidase • Pharmaceutical regulatory processes should be streamlined Aamin Amlodipine Targof Pure Drugs Ltd. and improved. Aamin-A Amlodipine + Atenolol Targof Pure Drugs Ltd. • Over the counter (OTC) drugs should be given unique names. Table 10: Identical brand names, different generic names, • Non-proprietary names should be used as far as possible in different manufacturers, different dosage forms (Category X) prescriptions. • Regulatory authorities should be willing to change the Brand names Generic names Manufacturer names if cross occurs. Vizol (capsules) Multivitamins Maan Pharm Ltd. • There should be good communication among those who Vizol (eye drops) Methyl cellulose D’zwon Remedies prescribe, supply and administer medicines and those who take them. Table 11: Identical brand names, same generic name, different manufacturers, different dosage forms (Category XI) Most of these recommendations are quite far-fetched and re- mote and may take time before they are actually put into prac- Brand names Generic names Manufacturer tice. Therefore, considering the Indian scene, we propose a few Ofloren (tablets) Ofloxacin Indoco Remedies Ltd. simple and immediate steps to prevent brand name confu- Ofloren (eye drops) Ofloxacin Warren Pharm Pvt. Ltd. sion:

Table 12: Identical brand names, different generic names, same 1. The practitioner: Doctors should be well-versed with phar- manufacturer, different dosage forms (Category XII) macological (generic) names and the brand names that are Brand names Generic names Manufacturer available in their local setting. We should try to write drugs Oceph (capsules) Cefdinir Emcure Pharm Ltd. in legible handwriting. Although ‘legibility’ is something Oceph (tablets) Cefixime Emcure Pharm Ltd. ‘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, T (erythromycin + tretinoin) or oral preparations like Novolid this will make us write clearly paying due attention to the (nimesulide) and Novolid-S (nimesulide + serratiopeptidase). spellings. It could be even more appropriate to write the However, in antihypertensive preparations, substitutions of a generic names below the brand names in parentheses to combination product like Aamin-A (amlodipine + atenolol) avoid any confusion. Abbreviations should be strictly in place of a single drug product like Aamin (amlodipine) can avoided. The doses should be mentioned without fail, as induce hypotension and cause harm to the patient. Secondly, this would settle the conflict most of the time. We should the combination may not be indicated in some patient or may also avoid giving prescriptions over the phone. In case it is even be contraindicated. the need of the hour, the drug name should be clearly spelt out and the patient should be asked to repeat it for confir- The problem of confusing brand names is commonplace all mation. Finally, if we feel that two drugs have confusing over the world. In 2001, the U.S. Pharmacopoeia released ‘Use brand names then it should be reported to the medical caution, avoid confusion’, an updated list highlighting con- representatives of the companies involved and they should fusing brand name sets and identified more than 750 unique be asked to consider revising their product names. drug names that have been reported to the USP Medication 2. The dispenser/pharmacist: The pharmacists should be Errors Reporting (MER) Program. Similar drug names, either wholly convinced about the nature of the brand they are in writing or in speaking, account for approximately 15% of all dispensing. If there is any doubt about the name, they

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should not hesitate to consult the prescribing doctor be- call and all those concerned should get themselves together to fore dispensing. It is always desirable for the pharmacist to solve this gigantic problem. We should not forget that the have knowledge of the doses of commonly used drugs. It is unfortunate patient, for whom all the brand names are made, observed that many times they dispense the brands avail- is ultimately at the receiving end of this confusion. We hope able at their shop rather than what is written in the pre- that this study serves as a base to have a cautionary approach scription. This practice should stop. and to make practitioners aware of these potential hazards. 3. The patient: A literate patient can himself check if the dispensed product is ‘exactly the same’ as per the doctor’s References prescription. He should bring to the notice of the pharma- cist in case of any doubt and refuse to accept any varia- 1. Indian Drug Review, New Delhi: Mediworld Publication; 2004. 2. Hazra A. Confusing brand names. Indian J Pharmacol 2002;34:367-8. tions being handed over. Illiterate patients should make it 3. Aronson JK. Medication errors resulting from the confusion of drug names. Expert a habit to verify the dispensed drug with the doctor or any Opin Drug Saf 2004;3:167-72. 4. Lambert BL, Chang KY, Lin SJ. Effect of orthographic and phonological similarity literate person at home or in the neighbourhood. on false recognition of drug names. Soc Sci Med 2001;52:1843-57. 4. The manufacturer: Now is the time when the manufactur- 5. Kurth MC, Langston JW, Tetrud JW. “Stelazine” versus “selegiline”- A hazard in prescription writing. N Engl J Med 1990;323:1776. ing companies should also join hands in the battle against 6. Huminer D, Dux S, Rosenfeld JB, Pitlik SD. Inadvertent sulfonylurea-induced this common enemy. They should do a thorough check hypoglycemia. A dangerous, but preventable condition. Arch Intern Med 1989;149:1890-2. about the available brand names before naming their prod- 7. Lambert BL, Lin SJ, Chang KY, Gandhi SK. Similarity as a risk factor in drug-name confusion errors: The look-alike (orthographic) and sound-alike (phonetic) model. uct. Any reports of confusing brand names should be taken Med Care 1999;37:1214-25. seriously and renaming their product should be considered. 8. Hoffman JM, Proulx SM. Medication errors caused by confusion of drug names. Drug Saf 2003;26:445-52. 9. Gogtay NJ, Jakhere SG, Waingankar SP, Dalvi SS, Kshirsagar NA.Therapeutic drug In conclusion, look-alike and sound-alike brand names of vari- monitoring as a tool to identify medication errors. Drug Saf 2004;27:143-4. 10. Lambert BL. Predicting look-alike and sound-alike medication errors. Am J Health ous drugs are here to stay. As new products are made available, Syst Pharm 1997;54:1161-71. additional confusion is bound to occur. Numerous errors have 11. “Use caution, avoid confusion.” USP Quality Review; No. 76, March 2001. http:// www.usp.org/pdf/patientSafety/qr762001-03-01.pdf. Accessed on June 2, 2004. occurred in the past due to misinterpretation of written or spo- 12. Aronson JK. Confusion over similar drug names MIMS?. Problems and solutions. ken names. Thus, it is the need of the hour to give a wake-up Drug Saf 1995;12:155-60.

Symposia for 2005

Journal of Postgraduate Medicine will be publishing symposia on important public health issues such as Leptospirosis, Telemedicine and Disaster Medicine. Watch out for the articles from the experts in the field. Health Issues of Disasters

• Disasters as complex medical emergencies - F. M. Burkle Jr • Planning in the warning phase of disaster - R. W. Perry • Pre-hospital response for disaster: the role of information communication technology - J. L. Arnold • Preparing for the man-made disasters: Bioterrorism - D. A. Alexander • Medical management of disasters - V. Kvetan • The post-disaster effects: The psychological impact - D. Silove

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