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Avandia, Not Coumadin — Coumadin, Not Avandia

Dec 8, 2013

From our partners at ISMP (Institute for Safe Medication Practices) – Last week the US Food and Drug Administration (FDA) notified health professionals about their determination that recent data for rosiglitazone-containing drugs, such as Avandia, combination products (Avandaryl [rosiglitazone and glimepiride] and Avandamet [rosiglitazone and metformin]), and generics, do not show an increased risk of heart attack compared to the standard type 2 diabetes medicines metformin and sulfonylureas (i.e., glimepiride, glipizide, glyburide). As a result, FDA is lifting some of the restrictions previously in place since 2010. The mention of Avandia brings to mind one of the most commonly reported serious drug name mix-ups in the past — confusing handwritten Avandia orders for Coumadin and vice versa (Figure 1)….


Figure 1. This order for Avandia 8 mg daily was misread as Coumadin 8 mg daily.

Whether or not prescribers will go back to adding Avandia to oral regimens for patients with type 2 diabetes is unknown.

Hopefully, the fact that most physician practices and many hospitals are now utilizing electronic prescribing systems will preclude us from receiving these types of reports again.

If the use of Avandia is being contemplated in the future, the potential for drug name mix-ups with handwritten prescriptions should be considered.

As reported by ISMP.org  (Institute for Safe Medication Practice)


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Diabetes in Control is partnered with the Institute for Safe Medication Practices (ISMP) to help ensure errors and near-miss events get reported and shared with millions of health care practitioners. The ISMP is a Patient Safety Organization obligated by law to maintain the anonymity of anyone involved, as well as omitting or changing contextual details for that purpose. Help save lives and protect patients and colleagues by confidentially reporting errors to the ISMP.



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