Clomipramine, clomiphene, and generic drug-dispensing errors.

Sir,

Brand names may show similarities between neuropsychiatric drugs and drugs belonging to other medical specializations. For example, in 2015, the USA Food and Drug Administration issued a warning about prescribing and dispensing errors resulting from brand name confusion between the antidepressant drug Brintellix (vortioxetine) and the antiplatelet drug Brilinta (ticagrelor).[1] Brand names show similarities even within the neuropsychiatric domain. This is understandable when the pharmacological content is the same, but can result in potentially serious dispensing errors when the pharmacological content is different.[23]

Physicians in India are exhorted to prescribe drugs by their generic name rather than by a brand name; or, more specifically, by their chemical name rather than by a brand name (the distinction is subtle but important; most Indian brands are actually generic because the original brands are out of patent). Here, we report how even generic prescriptions can result in dispensing errors.

A 35-year-old male with obsessive-compulsive disorder was prescribed clomipramine 100 mg/day in divided doses. There was no improvement; so, at a 1-month follow-up, the dose was increased to 150 mg/day. Two months later, there was still no improvement. An examination of the pill strips in his possession showed that he was actually taking six tablets of clomiphene citrate (25 mg, each) daily, and not clomipramine, as advised. He was referred to an endocrinologist; fortunately, there were no adverse consequences associated with 3 months of daily clomiphene use.

Our report illustrates how dispensing errors can arise from generic prescriptions; thus, the problem is not with similar-sounding brands, alone. Similar concerns have been reported by other authors, and computer-assisted alerts are suggested to flag possible errors.[4] Such alerts are not possible in India, given the current health-care standards. Therefore, there are several take-home messages for medical practice in India. Clinicians should write legibly. Patients should be asked to confirm that they have been dispensed with the same drug as that advised; if necessary, they should return to check with the prescriber. Finally, patients should be asked to always bring their medication strips along at follow-up so that compliance to the right drug, dose, and schedule can be checked. This is especially important when patients fail to show the expected response, and more so when unexpected adverse effects develop.

As a parting note, clomiphene is fortunately safe during long-term use. Whereas it is used for inducing ovulation in infertile women, it can also be used in men for the treatment of hypogonadism and infertility in doses such as 25–50 mg on alternate days for months to years.[5]

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Conflicts of interest

There are no conflicts of interest.