What's in a (drug) name? Plenty!

Abstract

THE SIMILARITY IN THE NONPROPRIetary names of two cardiac drugs has resulted in 11 medication errors, including one death, and is compelling authorities to propose name changes. The revisions are being suggested for amrinone and amiodarone. Amrinone is a positive inotropic agent with vasodilator activity, and amiodarone is an antiarrhythmic agent. The United States Pharmacopeia (USP) and the United States Adopted Names Council, which assign generic names to drugs, are proposing changing amrinone to inamrinone—using the “in” prefix that appears intheinnovator’sbrandnameInocor,and changingamiodarone tocamiodarone— usingthe“c”prefixappearingintheinnovator’s brand name Cordarone. The USP said it hoped the name changes incorporating the letter of each innovator’s proprietary name will help health care providers associate the new nomenclature with each drug along with achieving alphabetic separation and creating different verbalization. Amrinone was given its USAN (United States Adopted Name) in 1977 and amiodarone was given its USAN in 1987. Michael Cohen, cofounder and president of the Institute for Safe Medication Practices (ISMP), said his organization has been publishing warnings about the name confusion since the beginning of the decade—before both medications became available as injectables. “This is a big problem because a switch can be fatal,” Cohen said. “They have almost the opposite pharmacological effect, and both are critical care drugs.” Diane D. Cousins, USP vice president for the Practitioner and Product Experience Division, said the USP has monitored the name situation. “A change isn’t going to happen due to a single event, more often it’s a pattern,” Cousins said. “From the early 1990s we couldn’t see a trend, although we knew something was happening and monitored it.”