These drug names are too close for comfort

Look-alike and sound-alike similarity between the names of two different medications used in epilepsy might be putting children in jeopardy of getting the wrong medication. The drugs are clobazam and clonazepam.

Children with a rare and severe form of childhood onset epilepsy known as Lennox-Gastaut Syndrome (LGS) are most vulnerable to this error. Clobazam was approved by FDA in October 2011, specifically for this condition. LGS is characterized by frequent seizures and different seizure types, often accompanied by developmental delay and psychological and behavioral problems. Its onset is generally between the ages of 4 to 6.

Mix-ups between these two medications have been reported to us, both by hospitals and community pharmacies, and the potential for confusion is unmistakable.

Last month we heard from a pharmacist who made this error. He told us that the mother noticed the mix-up when she got home. She came back to the pharmacy and exchanged the medicine. Three other close calls have been sent to our error reporting program.

Both clobazam and clonazepam are members of a class of drugs known as benzodiazepines, which are mostly used for panic anxiety, panic attacks and sedation and sleep. But they can also be used in epilepsy. Other related drugs are Xanax, Valium and Ativan.  Clobazam and clonazepam have about a 10-fold difference in strength; Clobazam is said to be less sedating that clonazepam, which is helpful for kids.

Besides the name similarity, part of the problem is that it takes a long time for a new drug to penetrate the medical community. So some pharmacists and nurses still might not be familiar with clobazam. On the other hand, clonazepam, which can also be used in LGS, has been around for many years, has a much wider array of uses and is familiar to almost all health professionals. With such similar spelling, pharmacists and nurses familiar with clonazepam but not clobazam may inadvertently see the much more familiar drug name when reading a prescription.

Probably the best way to prevent mix-ups is for doctors to order clobazam by its brand name, Onfi. Clonazepam is also known as Klonopin but it’s also available as a generic. Parents of children with LGS should be aware of the potential problem since they are the ones most likely to be prescribed clobazam.

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