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MHRA urges vigilance when dispensing similar-sounding drugs

Practice The MHRA has warned pharmacists to take care when dispensing certain drugs with similar names, following reports of patients being given the wrong medicine.

The MHRA has warned pharmacists to take care when dispensing certain drugs with similar names, following reports of patients being given the wrong medicine.


Patients have been supplied a leukaemia drug instead of treatment for nephropathic cystinosis and a Parkinson's drug instead of treatment for schizophrenia because of similar sounding names, the MHRA reported in its drug-safety update last month.


The MHRA urged pharmacists who had any doubt about the medicine they were meant to dispense to contact the prescriber first because these errors could result in life-threatening conditions.

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Pharmacists should report any suspected adverse drug reactions, including those arising from medication errors, to the MHRA through its yellow card scheme, the medicines watchdog said.


In 2010, the MHRA issued a similar warning after a nine-month-old child was accidentally prescribed mercatopurine instead of mercaptamine by their GP. The child was admitted to hospital with pancytopenia after a month of receiving the wrong treatment, before making a full recovery.


The MHRA has received reports of the following drugs being confused:

● Mercaptamine, for the treatment of nephropathic cystinosis

● Mercaptopurine, for the treatment of acute leukaemia


● Risperidone, for the treatment of schizophrenia

● Ropinirole, for the treatment of Parkinson's


● Sulfadiazine, for the prevention of rheumatic fever

● Sulfasalazine, for the treatment of mild to severe ulcerative colitis, Crohn's disease and rheumatoid arthritis


● Zuclopenthixol acetate, for the treatment of schizophrenia and other psychoses

● Zuclopenthixol decanoate, for the treatment of schizophrenia



How often have you spotted similar mix-ups in your practice?

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