Prescribing, dispensing errors seen with Brintellix, Brilinta

August 3, 2015

FDA issued a drug safety warning that there have been 50 reports of medication errors because of confusion between the antidepressant Brintellix (vortioxetine) and the antiplatelet agent Brilinta (ticagrelor).

FDA issued a drug safety warning that there have been 50 reports of medication errors because of confusion between the antidepressant Brintellix (vortioxetine) and the antiplatelet agent Brilinta (ticagrelor). Fortunately, no patient ingested the wrong medication despite the prescribing and dispensing errors.

Since June 2015, the wrong drug was dispensed in 12 cases. In half of cases, the error occurred when prescribing the medication, and in the other six cases, the error occurred during the dispensing of the drug.

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In one case, a pharmacist did not dispense Brintellix, as it was misinterpreted as Brilinta and that patient had a contraindication to antiplatelet therapy. Therefore, the patient’s antidepressant therapy was not dispensed and the patient was not treated for the psychiatric condition for a period of time.

Name confusion is the culprit

Problems associated with name confusion occurred because the two brand names have the same first three letters, so they look and sound similar. In addition, both brand names appear in the computerized physician order entry system, when the physician needs to select medications.

“To reduce the risk of name confusion when prescribing Brintellix or Brilinta, include both the brand (proprietary) and generic (established) names, the indication, and the correct medication dose, and directions for use,” FDA warned.