Wrong Medication Dispensed by Pharmacist – Whom to Blame?
On taking history, patient informed that she had visited a gynecologist at a different hospital for heavy menstrual bleeding. She was found to have uterine fibroid and endometrial polyp on USG . She was advised medication for that to be used for 10 days from Day 15 to Day 25 of her menstrual cycle. First month showed some response. Patient again had similar complaints and re consultation with the same doctor was taken. She asked her to repeat the same dose.
During the 3rd month patient took the same course on her own by buying medication from a local medical shop and she landed with us with the above mentioned complaints. On going through her medication- the sheet she was using was Tab Methotrexate 10 mg 2 times daily- a medication that is used in Rhematoid arthritis, connective tissue disorders for immunosuppression.
The ER physician informed the same to me and we started treating her as Methotrexate toxicity. We were really lost as we did not find any indication for Methotrexate in Menorrhagia anywhere in the literature. We let the night go with supportive treatment.
Next day I sat with the attendants to take proper details. I asked them to show me the gynaecologist’s prescription and the medication that they used. Luckily she was carrying both. The prescription very clearly read as Tab Meprate 10 mg twice daily. This Meprate contains Medroxyprogesterone which is a hormonal therapy given for over bleeding during menses. The medicine that she was using was Tab Methotrexate which is a immunosuppressant. The patient had consulted a doctor at a different hospital and had gone to a generic medical shop for the purchase of medications.
It was the fault of the dispensing pharmacist who just went with the rhyming of the medicine name- Meprate and Methotrexate.
Take home messages:
1. Please ensure that the medication taken is with proper prescription.
2. Do not buy over the counter medication saying that we used it previously and it helped.
3. Once the medicine is dispensed , please recheck if medication prescribed and bought are the same.
4. If the trade name is confusing , please check the name on the Internet and confirm or ask your doctor to verify.
5. Please be more cautious to avoid such dangerous complications.
Dr Kiranmayi Pagadala MBBS. DNB Gen . Med
