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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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