Summary

Dr. Padma L, with the help of a case, emphasises the importance of writing drug names legibly and mentioning generic names on prescriptions too. Some drugs may have similar names and may look alike as well. In such cases, a tiny error in interpretation can prove to be a grave mistake.

A 40-year old lady was admitted for cardiac arrhythmias. She was prescribed Isoptin (verapamil). However, it was later noted that the patient's heart rate was not coming down and instead, she had severe tachycardia. When the medication was checked, it was found that the patient was receiving Isoprin (Isoprenaline) and not Isoptin.

What was the problem?

1. Isoptin is a drug which reduces heart rate. The generic name is verapamil. The drug is used to protect the ventricles from atrial tachyarrhythmias as it can depress AV conduction.
2. Isoprin, that is isoprenaline is a non-selective beta stimulant so it increases heart rate.

In this case, the pharmacist might not have understood the legibility of the prescription Hence the drug was interchanged and the mishap might have taken place.

Practice points

This particular situation arose because of 'look alike and sound alike drugs'. The prescription should have been written legibly and the generic name should have been mentioned as well. The pharmacist should have observed the generic name, manufacture date, expiry date, and colour of the ingredient.

What is the suggested OPD treatment for the resulting Paroxysmal supraventricular tachycardia (PSVT) in this case?

1. Verapamil, diltiazem, and bepridil are drugs that depress the AV node conduction and prolong the recovery of the Ca+ channels.
2. Beta blockers like metoprolol can also be prescribed.
3. Digoxin should be rarely used.

Disclaimer- The views and opinions expressed in this article are those of the author's and do not necessarily reflect the official policy or position of M3 India.

The writer, Dr. Padma L is a Professor of Pharmacology.