Hazard Alert! Sinequan® (doxepin)

From the April 11, 1996 issue of MSA Acute Care Edition Newsletter

Yesterday’s ISMP Medication Safety Alert! (April 10, 1996) described a medication error which involved confusion between one of the new protease inhibitors, ritonavir, and Retrovir® (zidovudine), an established antiretroviral.

This is a special alert about a second reported error which involves one of the other protease inhibitors. We have just been informed of an incident in which a patient with human immunodeficiency virus (HIV) was supposed to receive saquinavir 600 mg tid. A community pharmacist misread the handwritten prescription and dispensed Sinequan® (doxepin), a tricyclic antidepressant. The patient developed toxicity from the Sinequan ® and has been hospitalized.

The protease inhibitors are an important class of medications that have demonstrated dramatic efficacy in reducing the level of HIV in patients. Because of their importance, approval was granted by FDA for the three currently marketed products under an accelerated process:

• ritonavir (Norvir®) - Abbott Laboratories
• saquinavir (Invirase®) - Hoffman La Roche Laboratories
• indinavir (Crixivan®) - Merck In addition to the marketed protease inhibitors, at least two more are under investigation:
• nelfinavir (Viracept®) - Agouron Pharmaceuticals
• VX478 (nonproprietary and brand names not yet assigned) - Vertex/Glaxo Wellcome

In many cases, the drugs are being prescribed before staff has had adequate time to familiarize themselves with the drugs and nomenclature. In order to prevent additional errors, it is important that physicians, nurses, and pharmacists be aware of the new products. We recommend that hospitals alert appropriate staff through memos or newsletters. Further, until these drugs become well established, we also recommend that prescribers use both brand and generic names for orders and that the names be printed.

The April 27th issue of ISMP Medication Safety Alert! will include an article on the nomenclature of antiviral medications used in patients with HIV.