Being Alive, Los Angeles; May 1998

A letter from these doctors in the February 5 issue of the New England Journal of Medicine describes two HIV+ patients seen at their hospital within a two-week period who encountered this problem.

The first patient received a prescription for nelfinavir. He had the prescription filled at his pharmacy, and later noted that the name printed directly on the bottle was different from the name on the prescription label. The pharmacy had mislabeled a bottle of nevirapine as nelfinavir. Fortunately, this error was detected before the patient took any of the drug.

The second patient was not so lucky. She had been prescribed d4T, 3TC and nelfinavir. Shortly after beginning this drug regimen she developed severe fatigue, excessive sleeping and nausea. The symptoms stopped when the drugs were discontinued. It was subsequently discovered that she had been given nevirapine instead of nelfinavir.

The authors caution physicians and pharmacists to be "particularly careful when prescribing, transcribing prescriptions for, and dispensing nevirapine and nelfinavir, in order to prevent potentially serious adverse drug reactions or subtherapeutic dosing."

In a comment to the New England Journal, Dr. Kirk V. Shepard of Roxane Laboratories replied that these two medication errors were unfortunate, but that while the names may be confused, there are distinctive differences in the product labels, the appearance of the tablets and the packaging. "Regardless of the steps taken to reduce medication errors, dispensing mistakes do occur," he said.

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