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Fda Video: Medication Errors with Multiple Brand Names


The Institute for Safe Medication Practices (ISMP) recently highlighted medication errors that can occur when a drug is marketed under more than one brand name, especially when one of those names is well established. ISMP describes a case where a female patient went to the emergency department with ischemic chest pain and ECG changes. One of her medications was Revatio, which had been prescribed to treat her pulmonary arterial hypertension. The ED physician reviewed the patient's medication list but did not recognize that Revatio contains sildenafil, the active ingredient in Viagra. The patient was given aspirin and sublingual nitroglycerin, and later was started on an IV nitroglycerin infusion for continued chest pain and elevated troponin-T. Using organic nitrates in any form, at any time, with sildenafil and similar erectile dysfunction drugs is contraindicated. Fortunately, this patient did not experience adverse effects or blood pressure changes because an internist quickly recognized the problem and stopped the infusion.