What’s In A Name?

What’s In A Name?

I was a medical student when I made my first medication error.  Most doctors wait until they’re out of training and can actually write prescriptions and give orders before they screw things up.  Not me.

It was the very first clinical rotation of my third year and we had admitted a lady to our service who had chest pain and high blood pressure.  All of the testing had come back normal and it was looking less likely that she was actually experiencing a heart attack or aortic dissection (much to the dismay of us medical students, who desperately wanted to witness our first real medical disaster).  While looking through her records I hit upon the idea that this lady might be suffering a panic attack and suggested to the attending physician that we try treating her for this.  He gave my suggestion a moment’s consideration and shooed me away by telling me to ask the intern write for the sedative Klonopin.

Somehow, as the message spun through my cerebral cortex on its way to being translated into a request for the team’s intern, I got a little confused and passed on the wrong bit of information.  “The attending wants you to try some clonidine.”  The intern dutifully wrote the order and the nurse administered the medication.

In the end the patient faired just fine despite my error.  Clonidine—the somewhat homophonous counterpart to Klonopin—is actually a blood pressure pill and was a reasonable addition to her medication regimen.

It was then that I became conscious of the multiple layers of difficulty surrounding the names of drugs.  Clonidine and Klonopin.  Zantac and Xanax.  Inderal and Adderall.  Take one look at the complete list of “sound-alike” drugs and you’ll begin to understand how a young medical student could make such an error.

To make matters worse, every drug has to have not one, but two separate names.  Clonidine is also Catapres and Klonopin is also clonazepam (you’ll notice that I stick with the convention of capitalizing the trade name of the compound).  Some have even more: diltiazem can be Cardizem, Cartia, Dilacor, Diltiaz, Tiazac, Viazem, Dilzem, and Dilatrate.  This sort of chaos would be appropriate only if diltiazem treated multiple personality disorder rather than hypertension.

We study drugs for hours and hours in medical school but don’t even come close to learning all the different names for them until we have to start dispensing them as interns and residents.  I’m pretty sure I wasn’t passably fluent in drug nomenclature until I graduated internal medicine residency, a full seven years after I started med school.

I bring all this up as a preface for the subject of this week’s blog post: “Drug names are confusing” with subtitle “How can you expect an eighty-year-old patient to know his entire medication list if his own doctor struggles with it?” with sub-subtitle “The drug naming system is a clever plot by a vast pharmaceutical conspiracy to enslave the human race in mindless confusion” with sub-sub-subtitle “How I learned to stop worrying and love the bomb.”  Sorry, wrong subtitle.

Here are my gripes (and for the purpose of my argument I’ll stick mainly to the drugs I know best):

1. All drugs have at least two names (as outlined above).  Some are similar (digoxin and Lanoxin, niacin and Niaspan) and others not (verapamil and Calan), but all are confusing.  Why not just stick with just one name (say, Zocor) and add the suffix “generic” or “branded” as indicated?  Is it really necessary that patients learn both Zocor and simvastatin?
2. Drug names are rarely descriptive.  Here’s a game: take out your copy of the PDR (you know, the one you keep on your bedstand), scan the list of medications and just try to guess what each drug is meant for based on the name.  Ranexa, Inspra, Keppra, Zyprexa, Celexa.  Meaningless, all of them.  At least car companies come close to conveying some sense of meaning with their names (Viper, Cobra, Firebird, Pacer).  Years ago we had drugs like Hytrin and Minipress—with monikers that invoked some blood pressure-ishness—until we discovered that they’re actually lousy blood pressure pills and relegated them to the domain of the prostate.  Lopressor alone remains a blood pressure pill that actually sounds like one.You’ve got the diabetic drug Januvia that sounds like a new-age face cream (“Eliminate unsightly wrinkles with Januvia”); the antiarrhythmic Tambocor that sounds like something from band camp (“My son’s singing with so off-key that his music teacher made him play the Tambocor”); and Exubera, the insulin formulation that sounds like a street name for speed (“Dude, where can I score some of that Exubera?”).
3. Drug names are often unpronounceable.  I remember when the clot-busting drug ReoPro came out, with the alphabetically-random generic abciximab.  It took me weeks before I could spit that one out without giving my tongue a hernia.Then there are some simple ones that just beg to be pronounced incorrectly.  Write down the following names and hand them one of your patients: atenolol, diltiazem, simvastatin, lisinopril, and amiodarone.Odds are pretty good that what you’ll hear will be something like this: AT-en-all, DILT-i-zem, sim-VAST-in, LIS-prel, and AM-a-RI-dee-an.Even the medical professionals can’t get Cardizem right.  The makers of this drug came up with a fiendishly slick way to get us all messed up on this one.  The generic, diltiazem, has the “ia” sound in the middle, but they conveniently left that out when they came up with the trade version, Cardizem.  Hence, half the time you hear someone refer to this medication they’ll call it car-DEE-a-zem rather than CAR-di-zem.
4. Drug names are often unspellable. Need something to control your rhythm?  Try Rythmol (but where did the “rh” go?).  What was that new med my doctor put me on?  Multack, Multak, Multaque?  No, Multaq.  Why do half of all new drugs have to start with X or Z?  And what’s with the fixation on using the letter Y as a vowel (Zyrtec, Lyrica, Zyvox, Bystolic)?  What ever happened to “a, e, i, o, u and sometimes (only sometimes) y”?  The name Xyzal (levocetirizine) looks more like an algebra equation than an allergy drug.  Taking the cake in this category has got to be Pristiq (generic desvenlafaxine): it’s unspellable in both brand and generic, unpronounceable, and has a trade name that in no way relates to its purpose (antidepressant).  The only way it could be worse is if they had spelled it Prystyq.

Can you really blame the medical student who can’t tell the difference between a sedative and an antihypertensive whose names are separated by a solitary consonant?  Or the geriatric patient who stares at you in confusion when you tell him you’re putting him on Zaroxolyn (metolazone) or hydrochlorothiazide?

All I know is I want first dibs on the naming of the next batch of high blood pressure medications that come on the market.  You’ll love them: Normopress*, High-no-more, and Strokeblocker—catchy names, without resorting to a single X, Y, or Z.

* Note: I thought I was being pretty clever when I came up with the fictional name “normopress.”  Just as I was about to submit this post to my hardcore and unforgiving editors I decided to Google the name.  It turns out that Normopress is the trade name for methyldopa in South Africa, atenolol/indapemide in Europe, and losartan in Pakistan—all blood pressure pills.  Guess I’m not the only one eager to prescribe medications that sound more intuitive than Ranexa and Exforge.