Inadvertent substitution of acetohexamide for acetozolamide.
Hargett N A, Ritch R, Mardirossian J, Kass M A, Podos S M
AI Summary
Accidental substitution of diabetes drug acetohexamide for glaucoma drug acetazolamide occurred due to similar names/appearance, causing serious hypoglycemic reactions. Clinicians must be vigilant for this dangerous medication error.
Abstract
In three cases acetohexamide (Dymelor), an oral hypoglycemic agent, was mistakenly given to patients instead of acetazolamide (Diamox), which had been prescribed for their glaucoma. A number of similarities, including the fact that both medications are 250-mg white tablets, with similar generic and brand names which are generically repackaged medications juxtaposed on the pharmacist's shelf, predispose to the inadvertent substitution of one medication for the other. In one instance a systemic hypoglycemic reaction resulting in head trauma and confusion ended in an emegency hospital admission following the substitution of acetohexamide for acetazolamide.
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