Drug nomenclature: suggestions for change he problems inherent in our present system of drug nomenclature are created by the large number of names for individual drugs. Each prescription drug has at least two names, a generic and a trade name. If the drug is popular many companies may distribute it, each using its own trade name. Moreover, the drug may have a different generic name in another country; for example, Tylenol is acetaminophen in Canada but paracetamol in Britain. More serious than the inconvenience of needing to look up unfamiliar names is the fact that drugs with similar names may have very different properties. It is all too easy to confuse Reverin, an antibiotic, with Revimine, a heart drug. A medication error involving these two drugs could have serious consequences. Clearly an international conference on drug nomenclature should be held, because the problem is not restricted to one country. Here are my suggestions. * In all countries drugs should have the same name, which should be decided by the originating manufacturer. So that brand-name and generic drugs can be distinguished, the brand-name drug should be listed in capital letters, with the manufacturer's name capitalized in parenthesis for example, VALIUM (ROCHE). The generic drug should be listed in lower-case letters instead, with the manufacturer's name in parenthesis but only the first letter capitalized - for example, valium (Homer). * Compound drugs present a problem, but a solution could be to name the drug in the following manner: Tylenol No. 1 (McNeil), a compound of TYLENOL 300 mg, caffeine 15 mg and codeine phosphate 8 mg. The capitalized 1422
CAN MED ASSOC J 1992; 147 (10)
TYLENOL indicates that McNeil is the original manufacturer of that drug but not of the other components of the compound. If another company made the same compound it would have to list "tylenol" in lower-case letters, since it did not develop the drug. As the originating manufacturer McNeil would have the choice of using the name TYLENOL or ACETAMINOPHEN, and all other manufacturers would have to follow suit. 0 A standard naming system could be used to indicate what family the drug belongs to and what it is used for. To some extent this occurs already. A statement on a prescription bottle that a drug is a $-blocker and intended for migraine prophylaxis would be useful information for another physician. If enforced internationally such a system would make it possible for a physician to find out something about foreign drugs, even if they were not available in the physician's own country. Most of us have had problems because of the present system of drug nomenclature but have considered the system to be fixed in stone. Perhaps we should think about correcting its deficiencies.
more errors than would occur if there were only one name per drug. Second, physicians, particularly those in training or newly qualified, have to burden their already overloaded minds with unnecessary information. The amount of drug knowledge required of a practitioner has probably doubled in the last 5 years, and with 30 or more new products on the market monthly, the knowledge requirement will be tremendous in 10 years. The solution is easy. Manufacturers of existing drugs should use only the generic name for each, adding a trade-name prefix with a hyphen (e.g., Novo-amoxicillin). Manufacturers discovering new drugs should give each a generic name, then add a prefix and a hyphen. With luck, the CPS could then be small enough to be carried in the pocket of one's white coat. If we continue with the current drug-naming procedure and with international travel so common, we will have to deal with so many foreign names and dispensing difficulties that we will all need portable computers to prescribe for even the simplest of ailments. Philip Rutter, MD St. Albert, Alta.
Harry F.L. Pollett, MD, FRCPC East Bay, NS
In these days of government officials wanting to control everything medical, why don't they control the naming of drugs? Currently, every drug has at least two names, and some have three or more. The proof is in the green pages of the Canadian Pharmaceutical Association's Compendium of Pharmaceuticals and Specialties (CPS). This leads to two very important problems. First, because many trade names are close to the generic names of other drugs, dispensing drugs from prescriptions in imperfect handwriting leads to
Medical training in the United States I n my previous letter (Can Med Assoc J 1992; 146: 99) I discussed the problems faced by Canadians wishing to remain in the United States after their medical training. Specifically, the J-1 (exchange visitor) visa precludes easy immigration because of the requirement that a trainee return to Canada for 2 years before seeking an immigration visa. The H-i visa, though temporary LE 15 NOVEMBRE 1992
in nature also, does not have a similar requirement. Up to now the H-I visa has been available not for postgraduate medical education involving direct patient care but, rather, for "teaching and research only." This phrase was inadvertently left out of the Immigration Act of 1990 as passed by the United States Congress. Congress then passed the Miscellaneous and Technical Immigration and Naturalization Amendments of 1991 specifying that alien physicians can obtain H-I B visas provided that they have passed the Federal Licensing Exam (FLEX) "or an equivalent examination as determined by the Secretary of Health and Human Services." It remains to be seen whether examination by the Medical Council of Canada will be designated as equivalent to the FLEX for the H-i B visa; it does have reciprocal licensure value in most states. An H- l B visa can now be obtained instead of a J-1 visa by medical school graduates who wish to enter residency training in the United States; considerable personal hardship would thus be avoided if the physician wanted to stay in the country after training was completed. The H- I B visa also opens the door for those who want to practise in the United States but for whom obtaining permanent residency (the "green card") would add unnecessary delay. According to guidelines published by Alex Barrowcliff in the first issue of Physicians Classified
Journal (July/August 1992) an offer of employment must first be secured. The employer files a Labor Certificate Application with the US Labor Department to obtain permission to file an H-IB (turnaround time 14 to 30 days). The physician applies for and receives licensure in the state of intended employment (turnaround time 1 to 5 months). The employer then files the H-i1B ap-
plication with the US ImmigraWe replicated the methods of tion and Naturalization Service McGuigan's study by examining along with a copy of the medical the Ontario provincial coroner's licence (turnaround time about 30 records for the years 1988 and days). 1989. Twelve cases of death due This procedure requires that to salicylate poisoning alone were the applicant qualify for licensure. reported; six of the patients were This may be a problem for those pronounced dead at home or on who have not completed an in- arrival at a hospital. The clinical ternship year. It is also a problem records of the six remaining pain those states (New York, for tients indicated recognition of the example) that require US citizen- severity of the intoxication, apship or permanent residency be- propriate treatment and consultafore licensure. tion in five cases. The sixth patient was treated for a different Leslie L. Citrome, MD, FRCPC intoxication, and a diagnosis of Middletown, NY salicylate poisoning was made on the basis of postmortem toxicologic analysis. To assess if underreporting to the provincial coroner's office Salicylate poisoning could account for the reduction in reported number of fatalities we Six years ago McGuigan' re- reviewed the records in the two ported on seven patients, adult teaching hospitals in the Ottreated in Ontario hospitals, tawa referral region for all deaths who died as a result of salicylate resulting from drug overdose durpoisoning. The cases were a subset ing 1988. These hospitals provide of 27 deaths in adults due to adult tertiary care and in combisalicylate ingestion alone that nation are the only source of hewere reported to the provincial modialysis to approximately onetenth of the adult population of coroner's office in 1984. All the patients were alert at Ontario. No cases of fatal salicythe time of presentation in the late poisoning that had not been emergency department, and cor- reported to the provincial cororect diagnoses were made. Howev- ner's office were identified. The number of deaths due er, management was clearly deficient. The clinical records con- to salicylate poisoning alone in tained no estimates of the poten- Ontario declined from 51 in tial severity of intoxication in mil- 1983-843 to 12 in 1988-89. This ligrams per kilogram or references marked decrease is not solely atto the Done nomogram, the stan- tributable to a decline in the fredard reference for estimating po- quency of salicylate overdoses. In tential toxicity.2 In only two of the a review of all cases of drug intoxseven cases was activated charcoal ication (excluding ethanol alone) administered to reduce absorp- in which the patient had presenttion, and only four of the patients ed to the emergency department received sodium bicarbonate to of the Ottawa General Hospital enhance excretion and reduce during the years 1986 to 1988, penetration into the central ner- salicylate ingestion ranked fifth in vous system. None of the patients frequency.4 Of 1001 patients 15% was referred for or treated with had taken salicylates, and of all hemodialysis. In no case was a the drugs ingested (65% of the regional poison-control centre or patients had taken two or more clinical toxicologist consulted. substances) 7% were salicylates. The patients died an average of 18 Salicylates were involved in 3 of hours after arrival at the hospital. the 10 deaths.
CAN MED ASSOC J 1992; 147 (10)
LE 15 NOVEMBRE 1992
1426
CAN MED ASSOC J 1992; 147 (10)
TYLENOL indicates that McNeil is the original manufacturer of that drug but not of the other components of the compound. If another company made the same compound it would have to list "tylenol" in lower-case letters, since it did not develop the drug. As the originating manufacturer McNeil would have the choice of using the name TYLENOL or ACETAMINOPHEN, and all other manufacturers would have to follow suit. 0 A standard naming system could be used to indicate what family the drug belongs to and what it is used for. To some extent this occurs already. A statement on a prescription bottle that a drug is a $-blocker and intended for migraine prophylaxis would be useful information for another physician. If enforced internationally such a system would make it possible for a physician to find out something about foreign drugs, even if they were not available in the physician's own country. Most of us have had problems because of the present system of drug nomenclature but have considered the system to be fixed in stone. Perhaps we should think about correcting its deficiencies.
more errors than would occur if there were only one name per drug. Second, physicians, particularly those in training or newly qualified, have to burden their already overloaded minds with unnecessary information. The amount of drug knowledge required of a practitioner has probably doubled in the last 5 years, and with 30 or more new products on the market monthly, the knowledge requirement will be tremendous in 10 years. The solution is easy. Manufacturers of existing drugs should use only the generic name for each, adding a trade-name prefix with a hyphen (e.g., Novo-amoxicillin). Manufacturers discovering new drugs should give each a generic name, then add a prefix and a hyphen. With luck, the CPS could then be small enough to be carried in the pocket of one's white coat. If we continue with the current drug-naming procedure and with international travel so common, we will have to deal with so many foreign names and dispensing difficulties that we will all need portable computers to prescribe for even the simplest of ailments. Philip Rutter, MD St. Albert, Alta.
Harry F.L. Pollett, MD, FRCPC East Bay, NS
In these days of government officials wanting to control everything medical, why don't they control the naming of drugs? Currently, every drug has at least two names, and some have three or more. The proof is in the green pages of the Canadian Pharmaceutical Association's Compendium of Pharmaceuticals and Specialties (CPS). This leads to two very important problems. First, because many trade names are close to the generic names of other drugs, dispensing drugs from prescriptions in imperfect handwriting leads to
Medical training in the United States I n my previous letter (Can Med Assoc J 1992; 146: 99) I discussed the problems faced by Canadians wishing to remain in the United States after their medical training. Specifically, the J-1 (exchange visitor) visa precludes easy immigration because of the requirement that a trainee return to Canada for 2 years before seeking an immigration visa. The H-i visa, though temporary LE 15 NOVEMBRE 1992
in nature also, does not have a similar requirement. Up to now the H-I visa has been available not for postgraduate medical education involving direct patient care but, rather, for "teaching and research only." This phrase was inadvertently left out of the Immigration Act of 1990 as passed by the United States Congress. Congress then passed the Miscellaneous and Technical Immigration and Naturalization Amendments of 1991 specifying that alien physicians can obtain H-I B visas provided that they have passed the Federal Licensing Exam (FLEX) "or an equivalent examination as determined by the Secretary of Health and Human Services." It remains to be seen whether examination by the Medical Council of Canada will be designated as equivalent to the FLEX for the H-i B visa; it does have reciprocal licensure value in most states. An H- l B visa can now be obtained instead of a J-1 visa by medical school graduates who wish to enter residency training in the United States; considerable personal hardship would thus be avoided if the physician wanted to stay in the country after training was completed. The H- I B visa also opens the door for those who want to practise in the United States but for whom obtaining permanent residency (the "green card") would add unnecessary delay. According to guidelines published by Alex Barrowcliff in the first issue of Physicians Classified
Journal (July/August 1992) an offer of employment must first be secured. The employer files a Labor Certificate Application with the US Labor Department to obtain permission to file an H-IB (turnaround time 14 to 30 days). The physician applies for and receives licensure in the state of intended employment (turnaround time 1 to 5 months). The employer then files the H-i1B ap-
plication with the US ImmigraWe replicated the methods of tion and Naturalization Service McGuigan's study by examining along with a copy of the medical the Ontario provincial coroner's licence (turnaround time about 30 records for the years 1988 and days). 1989. Twelve cases of death due This procedure requires that to salicylate poisoning alone were the applicant qualify for licensure. reported; six of the patients were This may be a problem for those pronounced dead at home or on who have not completed an in- arrival at a hospital. The clinical ternship year. It is also a problem records of the six remaining pain those states (New York, for tients indicated recognition of the example) that require US citizen- severity of the intoxication, apship or permanent residency be- propriate treatment and consultafore licensure. tion in five cases. The sixth patient was treated for a different Leslie L. Citrome, MD, FRCPC intoxication, and a diagnosis of Middletown, NY salicylate poisoning was made on the basis of postmortem toxicologic analysis. To assess if underreporting to the provincial coroner's office Salicylate poisoning could account for the reduction in reported number of fatalities we Six years ago McGuigan' re- reviewed the records in the two ported on seven patients, adult teaching hospitals in the Ottreated in Ontario hospitals, tawa referral region for all deaths who died as a result of salicylate resulting from drug overdose durpoisoning. The cases were a subset ing 1988. These hospitals provide of 27 deaths in adults due to adult tertiary care and in combisalicylate ingestion alone that nation are the only source of hewere reported to the provincial modialysis to approximately onetenth of the adult population of coroner's office in 1984. All the patients were alert at Ontario. No cases of fatal salicythe time of presentation in the late poisoning that had not been emergency department, and cor- reported to the provincial cororect diagnoses were made. Howev- ner's office were identified. The number of deaths due er, management was clearly deficient. The clinical records con- to salicylate poisoning alone in tained no estimates of the poten- Ontario declined from 51 in tial severity of intoxication in mil- 1983-843 to 12 in 1988-89. This ligrams per kilogram or references marked decrease is not solely atto the Done nomogram, the stan- tributable to a decline in the fredard reference for estimating po- quency of salicylate overdoses. In tential toxicity.2 In only two of the a review of all cases of drug intoxseven cases was activated charcoal ication (excluding ethanol alone) administered to reduce absorp- in which the patient had presenttion, and only four of the patients ed to the emergency department received sodium bicarbonate to of the Ottawa General Hospital enhance excretion and reduce during the years 1986 to 1988, penetration into the central ner- salicylate ingestion ranked fifth in vous system. None of the patients frequency.4 Of 1001 patients 15% was referred for or treated with had taken salicylates, and of all hemodialysis. In no case was a the drugs ingested (65% of the regional poison-control centre or patients had taken two or more clinical toxicologist consulted. substances) 7% were salicylates. The patients died an average of 18 Salicylates were involved in 3 of hours after arrival at the hospital. the 10 deaths.
CAN MED ASSOC J 1992; 147 (10)
LE 15 NOVEMBRE 1992
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