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Potential confusion with AMARYL (glimepiride)
and REMINYL (galantamine)
From the September 9, 2004 issue
Diabetes or Alzheimers? We've had several reports of
mix-ups in which the antidiabetic agent AMARYL (glimepiride)
had been dispensed to geriatric patients instead of the Alzheimer's
medication REMINYL (galantamine). Each drug is available
in a 4 mg tablet, although other tablet strengths are also available
for each. In one case, a 78-year-old woman with a history of
Alzheimer's disease was admitted to the hospital with hypoglycemia
(blood glucose on admission 27 mg/dL). A review of the medications
she was taking at home revealed that her pharmacist dispensed
Amaryl 4 mg, which she took BID instead of Reminyl 4 mg BID.
In another case, an 89-year-old female received Amaryl instead
of Reminyl for 3 days, eventually requiring hospitalization
for treatment of severe hypoglycemia. A third patient received
Amaryl instead of Reminyl while in the hospital, leading to
severe hypoglycemia. All patients recovered with treatment.
These events have been linked to poor prescriber handwriting
and sound-alike, look-alike names (figure appears in PDF version
of newsletter). It's possible that prescriptions for Amaryl
are more commonly encountered than those for Reminyl. Thus,
confirmation bias (seeing that which is most familiar, while
overlooking any disconfirming evidence) may lead pharmacists
or nurses into "automatically" believing a Reminyl
prescription is for Amaryl. Obviously, accidental administration
of Amaryl poses great danger to any patient, especially an older
patient, who may be more sensitive to its hypoglycemic effects.
Practitioners should be alerted to the potential for confusion
between Amaryl and Reminyl. Prescribers should be reminded to
indicate the medication's purpose on prescriptions. Consider
building alerts about potential confusion into computer order
entry systems and/or adding reminder labels to pharmacy containers.
Patients (or caregivers) should be educated about all of their
medications, so they are familiar with each product's name,
purpose, and expected appearance. Most importantly, pharmacists
and nurses should confirm that patients are diabetic before
dispensing or administering any antidiabetic medication. FDA,
Aventis (Amaryl), and Janssen (Reminyl) are aware of these reports
and are contemplating efforts to help reduce the potential for
errors. |
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