Alert: Beware of Potential Confusion between Pradax and Plavix!
ISMP Canada has received reports about confusion between the Canadian brand names of 2 drugs: Pradax (generic name dabigatran etexilate) and Plavix (generic name clopidogrel). The brand names Pradax and Plavix may look very similar when written by hand. The names can also sound similar when spoken aloud.
Both Pradax and Plavix are used to prevent unwanted blood clots, but they work in different ways and are used in different circumstances. Plavix keeps platelets (blood cells that are involved in the formation of clots) from sticking together. Pradax is an anticoagulant: it blocks one of the substances that cause blood to clot. Plavix is sometimes prescribed for patients who can't take anticoagulants, so a mix-up between these drugs could be serious.
From top to bottom:
dabigatran etexilate (Pradax) 75 mg, 110 mg, and 150 mg capsules. The capsules are light blue and cream in colour.
Photo: 2011, Boehringer Ingelheim (Canada) Ltd
From top to bottom:
clopidogrel (Plavix) 75 mg and 300 mg tablets. Tablets are pink.
Photo: 2011 Compendium of Pharmaceuticals and Specialties (CPS), electronic version.
In one incident, a patient needed a procedure to treat a brain aneurysm. The patient was supposed to take Plavix with Aspirin for several days before the procedure. There was a mix-up at the community pharmacy where the patient had the prescription filled, and the patient was given Pradax instead of Plavix. The patient took the Pradax capsules, along with the Aspirin, for several days before going to the hospital for the procedure. Fortunately, the patient remembered how important it is to bring all your medicines with you any time you go to a hospital for treatment. A pharmacist reviewed the medicines when the patient was admitted to the hospital, noticed the problem, and called the community pharmacy. The community pharmacist confirmed that the order for Plavix had been misinterpreted and that Pradax had been dispensed in error. The neurosurgeon was notified, and the procedure was postponed.
Here are some tips to help consumers prevent this type of mistake:
- Whenever you get a prescription, review the details with the doctor before you leave the office. In particular, find out (and write down) both the brand name and the generic name for every medicine. If you cannot read the handwriting on the prescription form, ask your doctor to print the information.
- Be sure you understand why the doctor has prescribed the medicine for you, and make sure you understand the instructions for taking the medicine.
- Doses of medicine come in different forms (for example, tablets or capsules) and different colours. Knowing what your medicine should look like may help you prevent a mistake with your medicine. Pictures of Pradax and Plavix are shown in Figure 1 and Figure 2.
- After you have the prescription filled, check the medicine before you leave the pharmacy. Ask the pharmacist to go over the name of the drug and the detailed instructions with you. If any of the information that your pharmacist provides does not match what you were expecting to see or hear, tell the pharmacist immediately.
- Read all written information provided with your prescription before you begin to take a new medicine. If you have any questions, ask your pharmacist or your physician.
- Make a list of all your medicines. Keep the list with you at all times, and show it to any healthcare professional who is caring for you.
- If you are being admitted to hospital, or you are having any kind of medical procedure, bring all your medicines with you and review them with the healthcare professional.
For more information, read about how to take charge of your medicine.
ISMP Canada has notified the manufacturers of Pradax and Plavix, and healthcare professionals, about the potential for confusion between these products.