Sad confusion of look-alike tablets.

A 61-year-old female was prescribed Tablet Methotrexate and folic acid for her psoriatic arthropathy. Incidentally her daughter-in-law was also prescribed Tablet folic acid during her antenatal check-up for the same. Unfortunately, the pregnant lady ingested a tablet of Methotrexate erroneously since the tablet Methotrexate and tablet folic acid were lying in the same cover at home. Subsequently on realization of their mistake, they were referred to a geneticist and a fetal scan done did not reveal any abnormalities. However, exactly a month later she felt loss of foetal movements and patient also aborted.

A closer look at the packets of Tablets Folic acid and Methotrexate [Figure 1 and 2] revealed them to be identical as far as the tablet size, colour and packing of the tablet is concerned. However, a mistake of this nature could be disastrous as one of the tablet (methotrexate) is highly teratogenic.

Figure 1

Picture showing names of the tablets

Figure 2

Picture showing front of the tablet strips that look identical

This case report is an attempt to highlight certain issues which are very important but often ignored in our clinical practice. Over two-third of our population lives in rural areas. Many of our patients are ignorant about diseases and medications due to lack of literacy in English. Wrong dispensing of medicines, dispensing medicines without prescriptions and other practices unimaginable in the West occur in this country, especially in rural aras. Thus it is not uncommon to encounter patients who nonchalantly reveal a carefully folded strip of steroid drug which they have been taking for months, or even methotrexate which they have been taking for long periods of time without the supervision of a dermatologist and of course without any follow-up investigations.[1] Considering that many of our patients are uneducated, it is my feeling that many such incidents might have happened without being noticed or reported.

Keeping this incident in mind, the following suggestions are made:

The clinician should personally see that the medicines are correctly dispensed and the dosages are explained to the patients with the medicines in hand physically. The WHO has provided certain aids to improve patient adherence to treatment in the form of patient leaflets (either written or pictorial), day calendars, drug passport, dosage box, etc.[2] This can be used as a guide for our clinical practice.

It is recommended that some of the highly teratogenic drugs should be packed in an entirely different unique packing (e.g., red-coloured packs), so that the medicines can be identified by the people readily as being highly dangerous if taken without proper advice. Such unforeseen and unfortunate incidents as mentioned above can be prevented in the future.

Further, we should learn to be proactive in our practice by bringing these issues at various forums repeatedly and thus force the Government to formulate suitable laws in the interest of the common man.