What’s in a generic name?Clues about the drug’s use and possible adverse effects

Many healthcare professionals, particularly pharmacists, know that a drug’sgeneric name can often help position it among other drugs in the sametherapeutic class by recognizing drug name stems, a collection of short

name fragments, that have been embedded in the generic drug names. Becausedrugs in each of these therapeutic classes work on similar sites in the body andhave similar effects and side effects, the generic name can help healthcare profes-sionals understand how the drug might be used clinically and alert them to possibleadverse effects often seen with drugs within the specific class of medications.However, not all healthcare professionals realize that generic drug names providethese very important clues.

USAN naming processSince 1961, the United States Adopted Names (USAN) Council has been responsiblefor selecting simple, informative, and unique generic (nonproprietary) drug namesbased on pharmacologic and/or chemical relationships.1,2 For pharmaceutical com-panies, obtaining a generic name is required before bringing a new drug to themarket. Today, there are 5 members of the USAN Council, including the AmericanMedical Association (AMA), United States Pharmacopeia (USP), American Phar-macists Association (APhA), US Food and Drug Administration (FDA), and a memberat large. ISMP also has an important role with USAN by identifying medication er-rors that have been tied to generic drug names.

At the crux of the USAN naming process is the collection of standard stems usedas prefixes, suffixes, and infixes to identify the pharmacologic property and/orchemical structure of the medication, or both. Sometimes, the standard name

stems used for generic drugnames can lead to name similari-ties that cause mix-ups among thevarious drugs with the same stem.However, the stem helps positionan unfamiliar drug with others ina class and provides clues as to itsuse and effects. For example,drugs ending in the stem -olol be-long to the class of drugs knownas beta blockers. Some examplesof beta blockers available in the

US include atenolol, bisoprolol, esmolol, metoprolol, and propranolol. While thisclass of drugs may be used to treat a variety of conditions, in general, a drug withan -olol stem in its generic name is often used to treat heart failure, cardiac ar-rhythmias, and hypertension, and shares similar adverse effects, like bradycardiaand hypotension.

Another example is the group of drugs ending with the stem -oxetine used for an-tidepressants (FLUoxetine type). Examples of drugs with this name stem include

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Chlorhexidine mixed up with lido-caine oral solution. The ISMP NationalMedication Errors Reporting Program(ISMP MERP) database contains 14 re-ports of confusion between Hi-Tech Phar-macal’s look-alike containers of chlorhex-idine gluconate oral rinse 0.12% andlidocaine hydrochloride oral topical solu-tion 2% (Figure 1). The light teal text color,small font size, and prominent barcodeson these labels contribute to visual simi-larity. If topical lidocaine is administered

instead of the chlorhexidine rinse, anes-thesia of the oropharyngeal area may oc-cur, which can affect the gag reflex thatprotects the airway when swallowing.

In a report we recently received, chlorhex-idine 0.12% was administered and ingestedby a patient instead of lidocaine solution.No serious outcome was reported.

Most of the reported mix-ups have in-volved pharmacy dispensing and storageerrors. (Similar packaging and mix-ups be-tween unit dose cups of lidocaine oral so-lution and sulfamethoxazole and trimetho-prim oral suspension from Hi-TechPharmacal have also been reported, andthe company may offer other productswith this look-alike packaging.)

Also, the US Food and Drug Administra-tion (FDA) recently released a statementabout rare but serious allergic reactions

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Supported by educational grants from Baxter, Novartis, and Fresenius Kabi

Figure 1. Look-alike containers of Hi-Tech Pharma-cal’s chlorhexidine rinse and lidocaine oral solution.

USAN INN

acetaminophen paracetamol

albuterol salbutamol

glyBURIDE glibenclamide

meperidine pethidine

rifAMPin rifampicin

torsemide torasemide

Table 1. Examples of differences between USAN and INNnonproprietary drug names8

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vortioxetine (TRINTELLIX), FLUoxetine (PROZAC), and PARoxetine (PAXIL).These drugs are selective serotonin reuptake inhibitors (SSRI). They work by in-creasing levels of the neurotransmitter serotonin in the brain by blocking their re-absorption or reuptake. They are used to treat various psychiatric disorders suchas depression, anxiety, and obsessive-compulsive disorder. They also share manyof the same side effects.

Once the generic names are built using the appropriate stem and other conventions,occasionally the pharmaceutical company supplies a syllable or two that may bemeaningful to the drug development process. For example, the multiple myelomadrug carfilzomib (KYPROLIS) includes the stem -zomib reserved for proteasomeinhibitors and is also named after molecular biologist Philip Whitcome and hiswife, Carla, who both died from cancer (“fil” instead of “phil” was used for Phillipto make the drug name globally compatible).3 Dasatinib (SPRYCEL) includes thestem -tinib reserved for tyrosine kinase inhibitors and is also named after researchfellow Jagabandhu Das.3

Coordination of generic drug namesThe USAN Council seeks to coordinate generic drug names with the World HealthOrganization (WHO) International Nonproprietary Names (INN) Program so that asingle, acceptable worldwide generic name is used when communicating drugnames. The single generic name also facilitates communication in global profes-sional journals and research. The INN system began operating earlier than USANin 1950, when the first list of INN for pharmaceutical substances was published.4

With few exceptions (Table 1, on page 1), generic drug names used in the US arethe same as those adopted for use by the INN outside the US.

Overlooked clues in generic drug namesUnderstanding the clues found in generic drug names is much like learning Englishvocabulary by studying Greek and Latin roots—learn what the stem means andyou will have clues to help understand what the drug does and how it affects thebody.3 Unfortunately, not all healthcare professionals involved in the medication-use process have been taught to recognize drug name stems. Generic names maybe a mystery requiring brute memorization, and these healthcare professionalsmay not associate the drug with potential adverse effects within a certain class ofdrugs. Some healthcare professionals may have received extensive education dur-ing academic and clinical training regarding medications, including pharmacology,therapeutic uses, possible adverse effects, and potential interactions, but the drugnaming system and importance of stems may not have been emphasized.

Despite this lack of training, it is more than likely that healthcare professionals havelearned, through experience, that drugs with generic names that end in -cillin areantibiotics in the penicillin family; drugs with names that end in -pressin are vaso-constrictors; drugs with names that end in -prazole are proton pump inhibitors(antiulcer drugs); drugs with names that end in -parin are heparin derivatives; andso on. However, if healthcare practitioners have not been explicitly taught to rec-ognize the stems in generic names, it may be difficult to classify drugs into cate-gories so that much of the general mechanism of action, intended indication, andpossible adverse effects can be recognized simply from the drug name.

Please note, there are some exceptions to this rule. For example, the drug ARIP-iprazole has the -prazole drug stem, which is affiliated with the proton pump in-hibitor drug class as mentioned above. However, ARIPiprazole is actually an an-tipsychotic medication. So, we must emphasize that although drug stems maygive important clues about the drug, it is imperative that all healthcare practitioners

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after the use of topical chlorhexidine(www.ismp.org/sc?id=2863), which canalso occur if chlorhexidine rinse is usedin the oral cavity. FDA noted that otherprescription chlorhexidine gluconateproducts such as mouthwashes and oralchips already contain a label warningabout the possibility of serious allergic re-actions.

Normally, we would recommend purchas-ing one of these items from a differentsupplier, but it appears that Hi-Tech Phar-macal is currently the only supplier ofthese items in unit dose cups. We havecontacted Hi-Tech Pharmacal, which isnow owned by Akorn, and asked the com-pany to take steps to reduce the risk ofmix-ups between these drugs in unit dosecups. If you have these items in stock, werecommend taking steps to avoid mix-ups.Work with your pharmacy and ask themto add auxiliary labels to trays or cups thatprominently list the drug names. Phar-macy may also consider purchasing bulkcontainers of one of the products andrepackaging it in unit doses before dis-pensing, or have a contract packager pre-pare individual unit doses. The use of bar-code scanning technology during stockingand administration is also recommended.

IVFE confused with IV iron (IVFe). TheAmerican Society for Parenteral and En-teral Nutrition (ASPEN) recently reportedthat IVFE, an abbreviation used for IV fatemulsion, has been confused with IV iron(IVFe), risking medication errors. Reportsof confusion also appear in the ISMP Na-tional Medication Errors Reporting Pro-gram (ISMP MERP) database. ASPEN pre-viously chose to use IVFE as anabbreviation for IV fat emulsion in its doc-uments, as it was the term the US Foodand Drug Administration (FDA) used todescribe oil-in-water emulsions for intra-venous (IV) administration. The FDA haschanged the terminology from IV fat emul-sion to the US Pharmacopeia term, lipidinjectable emulsion; therefore, ASPEN isno longer using IV fat emulsion or its ab-breviation, IVFE, in documents. The termlipid injectable emulsion is now used. Youmay see the official abbreviation in articlesand standard documents (ILE since LIE

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look up and review drug information on any medications they are unfamiliar withbefore they prescribe, dispense, or administer them to patients.

How ISMP can helpThere are hundreds of drug name stems and subgroups of these stems used byUSAN and INN. For example, the general stem -cept refers to receptor molecules,and the subgroups define the targets (e.g., -farcept for interferon receptors, -virceptfor antiviral receptors). New stems are constantly being created for novel pharma-cologic categories of medications.5 Exhaustive lists of the stems for healthcareprofessionals may not be helpful, nor are lists that describe the meaning of drugname stems in terms that may not be understandable to all healthcare professionalswithout extensive training in pharmacotherapy (e.g., phosphodiesterase-5 enzymeinhibitors for -afil [e.g., tadalafil]).

Instead, healthcare professionals should be provided with information about thestems associated with the most common drugs prescribed or administered, alongwith the stems for drugs used to treat common chronic conditions. Short educa-tional programs covering a few stems at a time related to a specific class of med-ications are recommended. This should be accompanied by information regardingthe clinical effects and common or dangerous adverse effects found within eachclass of drugs.

To this end, ISMP plans to begin a regular series of short features in this newsletterhighlighting common drug name stems to promote their recognition. ISMP is bor-rowing the idea from an outstanding effort that is already underway in the Frenchpublication, Prescrire International, a journal that provides reliable, independentinformation that enables fully informed decision-making about medications.6 Thejournal, which has long advocated the use of the INN as an important tool in theappropriate use of medications, also offers a free Independent Drug & HealthcareNewsletter.7 Look for the first ISMP feature about common drug name stems inthe June 2017 issue and then about every other month thereafter.

ReferencesAmerican Medical Association. USAN Council. January 13, 2017. Accessed on March 6, 2017, at:1)www.ismp.org/sc?id=2873. American Medical Association. Procedure for USAN name selection. 2016. Accessed on March 6,2)2017, at: www.ismp.org/sc?id=2875.  Drahl C. Where drug names come from. Behind every generic name lies a specific process. J Amer3)Chem Soc. 2012;90(3):36-7. World Health Organization. International Nonproprietary Names. 2017. Accessed on March 6, 2017,4)at: www.ismp.org/sc?id=2876.  American Medical Association. United States Adopted Names approved stems. 2017. Accessed on5)March 6, 2017, at: www.ismp.org/sc?id=2879. Prescrire. Welcome to the Prescrire in English website. Accessed on March 6, 2017, at: http://english.pre6)scrire.org. Prescrire. Sign up to receive the newsletter. Accessed on March 6, 2017, at: www.ismp.org/sc?id=2877. 7)Aronson JK. “Where name and image meet”—the argument for “adrenaline.” BMJ.8)2000;320(7233):506-9.

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did not seem appropriate), however, re-ferring to the full term, lipid injectable emul-sion, rather than using an abbreviation, isthe safest course of action in hospitals.Healthcare professionals should avoid us-ing the abbreviation IVFE entirely.

FentaNYL diversion alert. A pharmacistcontacted us to let us know about a di-version and tampering incident that hadoccurred at his hospital, which was feltto be related to the labeling style of theWest-Ward Pharmaceuticals fentaNYL50 mcg/mL, 2 mL vial. The paper labeling

extends to the topof the flip-top cap(Figure 1). This hadbeen carefully pull-ed back, and theflip-top cap hadbeen removed.Then, the fentaNYLmedication hadbeen withdrawnfrom the vial andreplaced with ster-ile water for injec-tion. The flip-topcap was then re-placed and held inplace by the label,which had enoughadhesive to keep itin place, disguisingthe tampering and

diversion. In fact, the label has enoughglue to cause the vials to stick together inthe 25-vial carton, sometimes resulting intorn or crinkled labels on vials that havenot been tampered with. We contactedWest-Ward but have not yet heardwhether any changes are planned.

Educate fluorouracil home infusionpatients about accidental overinfu-sion. We recently received a call from afamily member of a patient with cancerwho was to receive a 7-day infusion offluorouracil at home via an ambulatoryelastomeric infusion pump. For an un-known reason, the entire infusion ran inover 4 days. The patient was very sleepyfor the next 2 days and had “terrible diar-rhea.” Even though the infusion wasempty, they waited until the patient’s

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Newsletter also partially supported by an educational grant from

Possible reason for hyperglycemia in patients using an insulin pen

Individuals who teach patients with diabetes about insulin, particularly how to useinsulin pens, need to be aware of an unusual situation that can happen once patientsbecome familiar with the NovoFine Autocover disposable safety needle system thatis used in many hospitals. With this needle system (Figure 1, on page 4), the userholds the outer cover of the needle system while it is screwed onto the insulin pen.

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Figure 1. The fentaNYLlabel that extends abovethe flip-top cap wascarefully peeled away,the medication wasremoved and replacedwith sterile water, thecap was replaced, andthen the label waspulled up around the capto hide any signs oftampering.

April 2017 Volume 15 Issue 4 Page 4

ISMP Nurse AdviseERR(ISSN 1550-6304) © 2017Institute for Safe Medica-tion Practices (ISMP).Subscribers are granted

permission to redistribute the newsletter or repro-duce its contents within their practice site or facil-ity only. Other reproduction, including posting ona public-access website, is prohibited without writ-ten permission from ISMP. This is a peer reviewedpublication.

Report medication and vaccine errors toISMP: Please call 1-800-FAIL-SAF(E), or visitwww.ismp.org/MERP or www.ismp.org/VERP.ISMP guarantees the confidentiality of informationreceived and respects the reporters’ wishes re-garding the level of detail included in publications.

To subscribe: www.ismp.org/sc?id=384

Editors: Ann Shastay, MSN, RN, AOCN; Judy Smet-zer, BSN, RN, FISMP; Michael Cohen, RPh, MS, ScD(hon), DPS (hon); Russell Jenkins, MD; Ronald S. Lit-man, DO. ISMP, 200 Lakeside Drive, Suite 200, Hor-sham, PA 19044. Email: ismpinfo@ismp.org; Tel:215-947-7797; Fax: 215-914-1492.

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The outer cover is then removed, exposing a plastic needle shield that covers theneedle. As the device is held against the skin, the needle shield slides back, allowingthe skin to be punctured, and the insulin is injected once the button is pressed. Afterthe injection is complete, the shield slides back over the needle as it is removed fromthe skin and locks in place so the needle cannot be used again. It is a safety needle.

The Autocover safety needle is quite differ-ent than standard insulin pen needles thatpatients typically purchase at their phar-macy. Insulin pen needles for home use areusually not safety needle and do not employa needle shield. However, these two needlesystems can look similar, and patients maynot recognize the difference. Both the Auto-cover safety needles and standard needlesystems have an outer cover that, when re-moved, exposes either a retractable needleshield (Autocover safety needle, Figure 1)or a needle cap (standard needle, Figure 2).The Autocover needle shield is not intendedto be removed prior to injection, but the nee-dle cap on the standard needle must be re-moved before the injection to allow admin-istration of insulin.

Recently, a hospitalized patient was re-ceiving new insulin therapy with aNovoFine Autocover safety needle at-tached to the pen. Prior to being dis-charged, nurses and a certified diabeteseducator (CDE) taught the patient how touse the insulin pen at home using thesafety needle and instructed the patient to perform blood glucose testing four timesa day. The hospital conducted home visits after discharge, and the patient reportedelevated blood glucose levels to the nurse during a visit. When the nurse investigated,she realized the patient was not removing the cap from the pen needle because shethought it was the same safety needle used during her hospitalization. Consequently,she was not receiving any insulin since the needle never punctured the skin.

We first published an alert about this in our May 2009 newsletter. With the latestcase, it is clear that the problem continues to exist, so the issue is Worth repeating.Patients who use Autocover safety needles in the hospital and are then switched tostandard pen needles at home must be advised that there are two types of needlesystems for pens. If they are using standard needles, they need to know to removeboth caps. The hospital that reported the latest event has changed to non-safetyneedles when training patients to make sure they know how to administer insulinwith the pen and needle they will use at home. All hospitals should verify whichneedle the patient will be using upon discharge and tailor the training to that needlewhenever possible.

If blood glucose levels are elevated after injection, the patient should be remindedto consult a diabetes educator, pharmacist, or physician, who should review injectiontechnique with the patient. Community pharmacists dispensing pen supplies shouldalso educate patients regarding their proper use, and patients should question if theinsulin pen needle is not what they expect.

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Figure 1. NovoFine Autocover has outer coverthat must be removed, but the plastic needleshield slides back during injection.

Figure 2. BD Ultra-Fine III, a standard non-safetyneedle for patients that use insulin pens at home,has clear outer cover and gray needle cap. Eachmust be removed prior to injection.

Outer Cover

Needle Shield

Outer Cover

Needle Cover

scheduled appointment 4 days later to re-port the mishap. The doctor hospitalizedthe patient and treated her with IV hydra-tion. It’s unclear why the antidote uridinetriacetate was not administered, but thesafety and efficacy of uridine triacetateinitiated more than 96 hours following theend of fluorouracil or capecitabine ad-ministration has not been established. Thepatient was discharged after 7 days ofhospitalization.

We are learning more about the pump is-sue that occurred, but this incident pointsto the need to educate patients with am-bulatory infusion pumps about specificdetails in regards to how the pump works,what to expect over the course of thetreatment, infusion rates, how long the in-fusion should last, how much should beleft in the container each day, and theneed to immediately report any incidentto their care team should the containerempty sooner than anticipated.

Dangerous delays have been known tooccur because patients are often asymp-tomatic in the first few hours and days.But rapid identification of a fluorouraciloverdose allows prompt treatment withthe antidote to minimize serious side ef-fects and the risk of a harmful or fatal out-come. Patients need to be educated aboutrapidly reporting events to their health-care team.

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