Sunday , October 22 2017
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Avandia, Not Coumadin — Coumadin, Not Avandia

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)….

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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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