ISMP List of Confused Drug Names

T his list of confused drug names, which includes look-alike and

sound-alike name pairs, consists of those name pairs that have
been published in the ISMP Medication Safety Alert!® Acute Care or
the ISMP Medication Safety Alert!® Community/Ambulatory Care
newsletters. Events involving these medications were reported to ISMP
through either the ISMP National Medication Errors Reporting Program
(ISMP MERP) or ISMP National Vaccine Errors Reporting Program (ISMP
VERP). We hope you will use this list to determine which medications
require special safeguards to reduce the risk of errors. This may include
strategies such as: using both the brand and generic names on prescrip-
tions and labels; including the purpose of the medication on prescrip-
tions; configuring computer selection screens to prevent look-alike
names from appearing consecutively; and changing the appearance of
look-alike product names to draw attention to their dissimilarities. Both
the FDA-approved and the ISMP-recommended tall man (mixed case)
letters have been included in the list below.

Updated through February 2019

Drug Name Confused Drug Name Drug Name Confused Drug Name
Abelcet amphotericin B ALPRAZolam LORazepam
Accupril Aciphex Altocor Advicor
acetaminophen acetaZOLAMIDE amantadine amiodarone
acetaZOLAMIDE acetaminophen Amaryl Reminyl
acetaZOLAMIDE acetoHEXAMIDE Ambisome amphotericin B
acetic acid for irrigation glacial acetic acid Amicar Omacor
acetoHEXAMIDE acetaZOLAMIDE Amikin Kineret
Aciphex Accupril aMILoride amLODIPine
Aciphex Aricept amiodarone amantadine
Activase Cathflo Activase amLODIPine aMILoride
Activase TNKase amphotericin B Abelcet
Actonel Actos amphotericin B Ambisome
Actos Actonel amphotericin B amphotericin B liposomal
Adacel (Tdap) Daptacel (DTaP) amphotericin B liposomal amphotericin B
Adderall Inderal Anacin Anacin-3
Adderall Adderall XR Anacin-3 Anacin
Adderall XR Adderall antacid Atacand
ado-trastuzumab emtansine trastuzumab anticoagulant citrate dextrose anticoagulant sodium citrate
Advair Advicor solution formula A solution
Advicor Advair anticoagulant sodium citrate anticoagulant citrate dextrose
Advicor Altocor solution solution formula A
Afrin (oxymetazoline) Afrin (saline) Antivert Axert
Afrin (saline) Afrin (oxymetazoline) Anzemet Avandamet
Aggrastat argatroban Apidra Spiriva
Aldara Alora Apresoline Priscoline
Alkeran Leukeran argatroban Aggrastat
Alkeran Myleran argatroban Orgaran
Allegra Anti-Itch Cream Aricept Aciphex
Allegra (fexofenadine)
(diphenhydrAMINE/allantoin) Aricept Azilect
Allegra Viagra ARIPiprazole proton pump inhibitors
Allegra Anti-Itch Cream ARIPiprazole RABEprazole
Allegra (fexofenadine)
(diphenhydrAMINE/allantoin) Arista AH (absorbable hemostatic agent) Arixtra
Alora Aldara Arixtra Arista AH (absorbable hemostatic agent)
ALPRAZolam clonazePAM Asacol Os-Cal

Note: Brand names start with an uppercase letter. Some brand names incorporate tall man letters in initial characters and may not be readily recognized as brand
names. Brand names appear in black; generic names/other products appear in red.

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ISMP List of Confused Drug Names
Drug Name Confused Drug Name Drug Name Confused Drug Name
Atacand antacid captopril carvedilol
atomoxetine atorvastatin carBAMazepine OXcarbazepine
atorvastatin atomoxetine CARBOplatin CISplatin
Atrovent Natru-Vent Cardene Cardizem
Avandamet Anzemet Cardizem Cardene
Avandia Prandin Cardura Coumadin
Avandia Coumadin carvedilol captopril
AVINza INVanz Casodex Kapidex
AVINza Evista Cathflo Activase Activase
Axert Antivert Cedax Cidex
azaCITIDine azaTHIOprine ceFAZolin cefTRIAXone
azaTHIOprine azaCITIDine cefTRIAXone ceFAZolin
Azilect Aricept cefuroxime sulfaSALAzine
B & O (belladonna and opium) Beano CeleBREX CeleXA
BabyBIG HBIG (hepatitis B immune globulin) CeleBREX Cerebyx
Bayhep-B Bayrab CeleXA CeleBREX
Bayhep-B Bayrho-D CeleXA Cerebyx
Bayrab Bayhep-B CeleXA ZyPREXA
Bayrab Bayrho-D Cerebyx CeleBREX
Bayrho-D Bayhep-B Cerebyx CeleXA
Bayrho-D Bayrab cetirizine sertraline
Beano B & O (belladonna and opium) cetirizine stavudine
Benadryl benazepril chlordiazePOXIDE chlorproMAZINE
benazepril Benadryl chlorproMAZINE chlordiazePOXIDE
Benicar Mevacor chlorproMAZINE chlorproPAMIDE
Betadine (with povidone-iodine) Betadine (without povidone-iodine) chlorproPAMIDE chlorproMAZINE
Betadine (without povidone-iodine) Betadine (with povidone-iodine) Cidex Cedax
betaine (anhydrous form) betaine HCl CISplatin CARBOplatin
betaine HCl betaine (anhydrous form) Clarispray (fluticasone propionate) Claritin (loratadine)
Bextra Zetia Claritin (loratadine) Claritin Eye (ketotifen fumarate)
Bicillin C-R Bicillin L-A Claritin (loratadine) Clarispray (fluticasone propionate)
Bicillin L-A Bicillin C-R Claritin-D Claritin-D 24
Bicitra Polycitra Claritin-D 24 Claritin-D
Bidex Videx Claritin Eye (ketotifen fumarate) Claritin (loratadine)
Brethine Methergine Clindesse Clindets
Bio-T-Gel T-Gel Clindets Clindesse
Brevibloc Brevital cloBAZam clonazePAM
Brevital Brevibloc clomiPHENE clomiPRAMINE
Brilinta Brintellix clomiPRAMINE clomiPHENE
Brintellix Brilinta clonazePAM ALPRAZolam
buprenorphine HYDROmorphone clonazePAM cloBAZam
buPROPion busPIRone clonazePAM cloNIDine
busPIRone buPROPion clonazePAM cloZAPine
Capadex [non-US product] Kapidex clonazePAM LORazepam
Capex Kapidex cloNIDine clonazePAM
Carac Kuric cloNIDine cloZAPine
Note: Brand names start with an uppercase letter. Some brand names incorporate tall man letters in initial characters and may not be readily recognized as brand
names. Brand names appear in black; generic names/other products appear in red.

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ISMP List of Confused Drug Names
Drug Name Confused Drug Name Drug Name Confused Drug Name
cloNIDine KlonoPIN Dexilant DULoxetine
cloZAPine clonazePAM dexmedetomidine dexamethasone
cloZAPine cloNIDine dexmethylphenidate dexmethylphenidate mixed salts
Clozaril Colazal dexmethylphenidate methadone
coagulation factor IX (recombinant) factor IX complex, vapor heated dexmethylphenidate mixed salts dexmethylphenidate
codeine Lodine Diabenese Diamox
Colace Cozaar Diabeta Zebeta
Colazal Clozaril Diamox Diabenese
colchicine Cortrosyn diazePAM dilTIAZem
Comvax Recombivax HB Diflucan Diprivan
Cortrosyn colchicine Dilacor XR Pilocar
Coumadin Avandia Dilaudid Dilaudid-5
Coumadin Cardura Dilaudid-5 Dilaudid
Covaryx HS Covera HS dilTIAZem diazePAM
Covera HS Covaryx HS dimenhyDRINATE diphenhydrAMINE
Cozaar Colace diphenhydrAMINE dimenhyDRINATE
Cozaar Zocor Dioval Diovan
Cubicin Cubicin RF Diovan Darvon
Cubicin RF Cubicin Diovan Dioval
cyclophosphamide cycloSPORINE Diovan Zyban
cycloSERINE cycloSPORINE Diprivan Diflucan
cycloSPORINE cyclophosphamide Diprivan Ditropan
cycloSPORINE cycloSERINE disopyramide desipramine
cycloSPORINE cycloSPORINE modified Ditropan Diprivan
cycloSPORINE modified cycloSPORINE DOBUTamine DOPamine
Cymbalta Symbyax DOCEtaxel PACLitaxel
dabigatran vigabatrin DOPamine DOBUTamine
DACTINomycin DAPTOmycin Doribax Zovirax
Daptacel (DTaP) Adacel (Tdap) Doxil Paxil
DAPTOmycin DACTINomycin DOXOrubicin DAUNOrubicin
Darvocet Percocet DOXOrubicin DOXOrubicin liposomal
Darvon Diovan DOXOrubicin IDArubicin
DAUNOrubicin DAUNOrubicin citrate liposomal DOXOrubicin liposomal DOXOrubicin
DAUNOrubicin DOXOrubicin Dramamine (dimenhyDRINATE) Dramamine (ginger root)
DAUNOrubicin IDArubicin Dramamine (dimenhyDRINATE) Dramamine (meclizine)
DAUNOrubicin citrate liposomal DAUNOrubicin Dramamine (ginger root) Dramamine (dimenhyDRINATE)
Denavir indinavir Dramamine (ginger root) Dramamine (meclizine)
Depakote Depakote ER Dramamine (meclizine) Dramamine (dimenhyDRINATE)
Depakote ER Depakote Dramamine (meclizine) Dramamine (ginger root)
DEPO-Medrol SOLU-Medrol Dulcolax (bisacodyl) Dulcolax (docusate sodium)
Depo-Provera Depo-subQ provera 104 Dulcolax (docusate sodium) Dulcolax (bisacodyl)
Depo-subQ provera 104 Depo-Provera DULoxetine Dexilant
desipramine disopyramide DULoxetine FLUoxetine
desmopressin vasopressin DULoxetine PARoxetine
Desyrel SEROquel Durasal Durezol
dexamethasone dexmedetomidine Durezol Durasal
Note: Brand names start with an uppercase letter. Some brand names incorporate tall man letters in initial characters and may not be readily recognized as brand
names. Brand names appear in black; generic names/other products appear in red.

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ISMP List of Confused Drug Names
Drug Name Confused Drug Name Drug Name Confused Drug Name
Duricef Ultracet fluPHENAZine fluvoxaMINE
Dynacin Dynacirc flumazenil influenza virus vaccine
Dynacirc Dynacin FLUoxetine DULoxetine
edetate calcium disodium edetate disodium FLUoxetine Loxitane
edetate disodium edetate calcium disodium FLUoxetine PARoxetine
Effexor Effexor XR fluvoxaMINE flavoxATE
Effexor XR Effexor fluvoxaMINE fluPHENAZine
Effexor XR Enablex Focalgin B Focalin
elvitegravir, cobicistat, emtricitabine, and elvitegravir, cobicistat, emtricitabine, and Focalin Focalgin B
tenofovir alafenamide tenofovir disoproxil fumarate Folex Foltx
elvitegravir, cobicistat, emtricitabine, and elvitegravir, cobicistat, emtricitabine, and folic acid folinic acid (leucovorin calcium)
tenofovir disoproxil fumarate tenofovir alafenamide folinic acid (leucovorin calcium) folic acid
Enablex Effexor XR Foltx Folex
Enbrel Levbid fomepizole omeprazole
Engerix-B adult Engerix-B pediatric/adolescent Foradil Fortical
Engerix-B pediatric/adolescent Engerix-B adult Foradil Toradol
Enjuvia Januvia Fortical Foradil
ePHEDrine EPINEPHrine gabapentin gemfibrozil
EPINEPHrine ePHEDrine gemfibrozil gabapentin
epiRUBicin eriBULin gentamicin gentian violet
eriBULin epiRUBicin gentian violet gentamicin
Estratest Estratest HS glacial acetic acid acetic acid for irrigation
Estratest HS Estratest glipiZIDE glyBURIDE
ethambutol Ethmozine Glucotrol Glycotrol
ethaverine [non-US name] etravirine glyBURIDE glipiZIDE
Ethmozine ethambutol Glycotrol Glucotrol
etravirine ethaverine [non-US name] Granulex Regranex
Evista AVINza guaiFENesin guanFACINE
factor IX complex, vapor heated coagulation factor IX (recombinant) guanFACINE guaiFENesin
Fanapt Xanax HBIG (hepatitis B immune globulin) BabyBIG
Farxiga Fetzima Healon Hyalgan
Fastin (phentermine) Fastin (dietary supplement) heparin Hespan
Fastin (dietary supplement) Fastin (phentermine) Hespan heparin
Femara Femhrt HMG-CoA reductase inhibitors ("statins") nystatin
Femhrt Femara HumaLOG HumuLIN
fentaNYL SUFentanil HumaLOG NovoLOG
Fetzima Farxiga HumaLOG Mix 75/25 HumuLIN 70/30
Fioricet Fiorinal Humapen Memoir (for use with HumaLOG) Humira Pen
Fiorinal Fioricet Humira Pen Humapen Memoir (for use with HumaLOG)
flavoxATE fluvoxaMINE HumuLIN HumaLOG
Flonase Flovent HumuLIN NovoLIN
Floranex Florinef HumuLIN 70/30 HumaLOG Mix 75/25
Florastor Florinef HumuLIN R U-100 HumuLIN R U-500
Florinef Floranex HumuLIN R U-500 HumuLIN R U-100
Florinef Florastor Hyalgan Healon
Flovent Flonase hydrALAZINE hydroCHLOROthiazide
Note: Brand names start with an uppercase letter. Some brand names incorporate tall man letters in initial characters and may not be readily recognized as brand
names. Brand names appear in black; generic names/other products appear in red.

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ISMP List of Confused Drug Names
Drug Name Confused Drug Name Drug Name Confused Drug Name
hydrALAZINE hydrOXYzine Kaletra Keppra
Hydrea Lyrica Kapidex Capadex [non-US product]
hydroCHLOROthiazide hydrALAZINE Kapidex Capex
hydroCHLOROthiazide hydrOXYzine Kapidex Casodex
HYDROcodone oxyCODONE Kapidex Kadian
Hydrogesic hydrOXYzine Kay Ciel Kayexalate
HYDROmorphone buprenorphine Kayexalate Kay Ciel
HYDROmorphone morphine Keflex Keppra
HYDROmorphone oxyMORphone Keppra Kaletra
hydroxychloroquine hydroxyurea Keppra Keflex
HYDROXYprogesterone medroxyPROGESTERone Ketalar ketorolac
hydroxyurea hydroxychloroquine ketorolac Ketalar
hydroxyurea hydrOXYzine ketorolac methadone
hydrOXYzine hydrALAZINE Kineret Amikin
hydrOXYzine hydroCHLOROthiazide KlonoPIN cloNIDine
hydrOXYzine Hydrogesic Kuric Carac
hydrOXYzine hydroxyurea Kwell Qwell
IDArubicin DAUNOrubicin labetalol LaMICtal
IDArubicin DOXOrubicin labetalol lamoTRIgine
IDArubicin idaruCIZUmab LaMICtal labetalol
idaruCIZUmab IDArubicin LaMICtal LamISIL
Inderal Adderall LamISIL LaMICtal
indinavir Denavir lamiVUDine lamoTRIgine
inFLIXimab riTUXimab lamoTRIgine labetalol
influenza virus vaccine flumazenil lamoTRIgine lamiVUDine
influenza virus vaccine perflutren lipid microspheres lamoTRIgine levETIRAcetam
influenza virus vaccine tuberculin purified protein derivative (PPD) lamoTRIgine levothyroxine
Inspra Spiriva Lanoxin levothyroxine
Intuniv Invega Lanoxin naloxone
INVanz AVINza lanthanum carbonate lithium carbonate
Invega Intuniv Lantus Latuda
iodine Lodine Lantus Lente
Isordil Plendil Lariam Levaquin
ISOtretinoin tretinoin Lasix Luvox
Jantoven Janumet Latuda Lantus
Jantoven Januvia Lente Lantus
Janumet Jantoven Letairis Letaris [non-US product]
Janumet Januvia Letaris [non-US product] Letairis
Janumet Sinemet leucovorin calcium Leukeran
Januvia Enjuvia leucovorin calcium LEVOleucovorin
Januvia Jantoven Leukeran Alkeran
Januvia Janumet Leukeran leucovorin calcium
K-Phos Neutral Neutra-Phos-K Leukeran Myleran
Kaopectate (bismuth subsalicylate) Kaopectate (docusate calcium) Levaquin Lariam
Kaopectate (docusate calcium) Kaopectate (bismuth subsalicylate) Levbid Enbrel
Kadian Kapidex Levemir Lovenox
Note: Brand names start with an uppercase letter. Some brand names incorporate tall man letters in initial characters and may not be readily recognized as brand
names. Brand names appear in black; generic names/other products appear in red.

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ISMP List of Confused Drug Names
Drug Name Confused Drug Name Drug Name Confused Drug Name
levETIRAcetam lamoTRIgine mefloquine Malarone
levETIRAcetam levOCARNitine memantine methadone
levETIRAcetam levoFLOXacin Menactra Menomune
levOCARNitine levETIRAcetam Menomune Menactra
levoFLOXacin levETIRAcetam Mephyton methadone
LEVOleucovorin leucovorin calcium Metadate methadone
levothyroxine lamoTRIgine Metadate CD Metadate ER
levothyroxine Lanoxin Metadate ER Metadate CD
levothyroxine liothyronine Metadate ER methadone
Lexapro Loxitane metFORMIN metroNIDAZOLE
Lexiva Pexeva methadone dexmethylphenidate
linaCLOtide linaGLIPtin methadone ketorolac
linaGLIPtin linaCLOtide methadone memantine
liothyronine levothyroxine methadone Mephyton
Lipitor Loniten methadone Metadate
Lipitor ZyrTEC methadone Metadate ER
lithium Ultram methadone methylphenidate
lithium carbonate lanthanum carbonate methadone metOLazone
Lodine codeine Methergine Brethine
Lodine iodine methazolAMIDE methIMAzole
Loniten Lipitor methazolAMIDE metOLazone
Lopressor Lyrica methIMAzole methazolAMIDE
LORazepam ALPRAZolam methIMAzole metOLazone
LORazepam clonazePAM methotrexate metOLazone
LORazepam Lovaza methotrexate MTX Patch (lidocaine and menthol)
Lotronex Protonix methylene blue VisionBlue
Lovaza LORazepam methylphenidate methadone
Lovenox Levemir methylPREDNISolone medroxyPROGESTERone
Loxitane FLUoxetine methylPREDNISolone methylTESTOSTERone
Loxitane Lexapro methylTESTOSTERone medroxyPROGESTERone
Loxitane Soriatane methylTESTOSTERone methylPREDNISolone
Lunesta Neulasta metyraPONE metyroSINE
Lupron Depot-3 Month Lupron Depot-Ped metyroSINE metyraPONE
Lupron Depot-Ped Lupron Depot-3 Month metOLazone methadone
Luvox Lasix metOLazone methazolAMIDE
Lyrica Hydrea metOLazone methIMAzole
Lyrica Lopressor metOLazone methotrexate
Maalox Maalox Total Stomach Relief metoprolol succinate metoprolol tartrate
Maalox Total Stomach Relief Maalox metoprolol tartrate metoprolol succinate
Malarone mefloquine metroNIDAZOLE metFORMIN
Matulane Materna Mevacor Benicar
Materna Matulane Micronase Microzide
Maxzide Microzide Microzide Maxzide
medroxyPROGESTERone HYDROXYprogesterone Microzide Micronase
medroxyPROGESTERone methylPREDNISolone midodrine Midrin
medroxyPROGESTERone methylTESTOSTERone Midrin midodrine
Note: Brand names start with an uppercase letter. Some brand names incorporate tall man letters in initial characters and may not be readily recognized as brand
names. Brand names appear in black; generic names/other products appear in red.

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ISMP List of Confused Drug Names
Drug Name Confused Drug Name Drug Name Confused Drug Name
miFEPRIStone miSOPROStol niCARdipine niMODipine
migalastat miglustat NIFEdipine niCARdipine
miglustat migalastat NIFEdipine niMODipine
Miralax Mirapex nilotinib neratinib
Mirapex Miralax nilotinib niraparib
miSOPROStol miFEPRIStone niMODipine niCARdipine
mitoMYcin mitoXANTRONE niMODipine NIFEdipine
mitoXANTRONE mitoMYcin niraparib neratinib
mitoXANTRONE MTX Patch (lidocaine and menthol) niraparib nilotinib
morphine HYDROmorphone Norcuron Narcan
morphine - non-concentrated oral liquid morphine - oral liquid concentrate Normodyne Norpramin
morphine - oral liquid concentrate morphine - non-concentrated oral liquid Noroxin Neurontin
Motrin Neurontin Norpramin Normodyne
MS Contin OxyCONTIN Norvasc Navane
MTX Patch (lidocaine and menthol) methotrexate NovoLIN HumuLIN
MTX Patch (lidocaine and menthol) mitoXANTRONE NovoLIN NovoLOG
Mucinex (guaiFENesin) Mucinex Allergy (fexofenadine) NovoLIN 70/30 NovoLOG Mix 70/30
Mucinex Mucomyst NovoLOG HumaLOG
Mucinex Allergy (fexofenadine) Mucinex (guaiFENesin) NovoLOG NovoLIN
Mucinex D Mucinex DM NovoLOG Flexpen NovoLOG Mix 70/30 Flexpen
Mucinex DM Mucinex D NovoLOG Mix 70/30 Flexpen NovoLOG Flexpen
Mucomyst Mucinex NovoLOG Mix 70/30 NovoLIN 70/30
Myleran Alkeran Nuedexta Neulasta
Myleran Leukeran nystatin HMG-CoA reductase inhibitors ("statins")
nalbuphine naloxone Occlusal-HP Ocuflox
naloxone Lanoxin Ocuflox Occlusal-HP
naloxone nalbuphine OLANZapine QUEtiapine
Narcan Norcuron Omacor Amicar
Natru-Vent Atrovent omeprazole fomepizole
Navane Norvasc opium tincture paregoric (camphorated tincture of opium)
Neo-Synephrine (oxymetazoline) Neo-Synephrine (phenylephrine) Oracea Orencia
Neo-Synephrine (phenylephrine) Neo-Synephrine (oxymetazoline) Orencia Oracea
neratinib nilotinib Orgaran argatroban
neratinib niraparib Ortho Tri-Cyclen Ortho Tri-Cyclen LO
Neulasta Lunesta Ortho Tri-Cyclen LO Ortho Tri-Cyclen
Neulasta Nuedexta Os-Cal Asacol
Neulasta Neumega oxaprozin OXcarbazepine
Neumega Neulasta OXcarbazepine carBAMazepine
Neumega Neupogen OXcarbazepine oxaprozin
Neupogen Neumega oxybutynin oxyCODONE
Neurontin Motrin oxyCODONE HYDROcodone
Neurontin Noroxin oxyCODONE oxybutynin
Neutra-Phos-K K-Phos Neutral oxyCODONE OxyCONTIN
NexAVAR NexIUM oxyCODONE oxyMORphone
NexIUM NexAVAR OxyCONTIN MS Contin
niCARdipine NIFEdipine OxyCONTIN oxyCODONE
Note: Brand names start with an uppercase letter. Some brand names incorporate tall man letters in initial characters and may not be readily recognized as brand
names. Brand names appear in black; generic names/other products appear in red.

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ISMP List of Confused Drug Names
Drug Name Confused Drug Name Drug Name Confused Drug Name
OxyCONTIN oxyMORphone Prandin Avandia
oxyMORphone HYDROmorphone Precare Precose
oxyMORphone oxyCODONE Precose Precare
oxyMORphone OxyCONTIN prednisoLONE predniSONE
PACLitaxel DOCEtaxel predniSONE prednisoLONE
PACLitaxel PACLitaxel protein-bound particles Prenexa Ranexa
PACLitaxel protein-bound particles PACLitaxel PriLOSEC Pristiq
Pamelor Panlor DC PriLOSEC PROzac
Pamelor Tambocor Priscoline Apresoline
Panlor DC Pamelor Pristiq PriLOSEC
paregoric (camphorated tincture of opium) opium tincture probenecid Procanbid
PARoxetine DULoxetine Procan SR Procanbid
PARoxetine FLUoxetine Procanbid probenecid
PARoxetine piroxicam Procanbid Procan SR
Patanol Platinol Procardia XL Protain XL
Pavulon Peptavlon Procet Percocet
Paxil Doxil Prograf Proscar
Paxil Plavix Prograf PROzac
Paxil Taxol propylene glycol polyethylene glycol
PAZOPanib PONATinib propylthiouracil Purinethol
PEMEtrexed PRALAtrexate Proscar Prograf
penicillin penicillAMINE Proscar Provera
penicillAMINE penicillin Protain XL Procardia XL
Peptavlon Pavulon protamine Protonix
Percocet Darvocet proton pump inhibitors ARIPiprazole
Percocet Procet Protonix Lotronex
perflutren lipid microspheres influenza virus vaccine Protonix protamine
Pexeva Lexiva Provera Proscar
PENTobarbital PHENobarbital Provera PROzac
PHENobarbital PENTobarbital PROzac Prograf
Pilocar Dilacor XR PROzac PriLOSEC
piroxicam PARoxetine PROzac Provera
Platinol Patanol Purinethol propylthiouracil
Plavix Paxil Pyridium pyridoxine
Plavix Pradax [Non-US Product] pyridoxine Pyridium
Plavix Pradaxa QUEtiapine OLANZapine
Plendil Isordil quiNIDine quiNINE
pneumococcal 7-valent vaccine pneumococcal polyvalent vaccine quiNINE quiNIDine
pneumococcal polyvalent vaccine pneumococcal 7-valent vaccine Qwell Kwell
Polycitra Bicitra RABEprazole ARIPiprazole
polyethylene glycol propylene glycol Ranexa Prenexa
PONATinib PAZOPanib raNITIdine riMANTAdine
potassium acetate sodium acetate Rapaflo Rapamune
PRALAtrexate PEMEtrexed Rapamune Rapaflo
Pradax [Non-US Product] Plavix rasageline repaglinide
Pradaxa Plavix Razadyne Rozerem
Note: Brand names start with an uppercase letter. Some brand names incorporate tall man letters in initial characters and may not be readily recognized as brand
names. Brand names appear in black; generic names/other products appear in red.

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ISMP List of Confused Drug Names
Drug Name Confused Drug Name Drug Name Confused Drug Name
Recombivax HB Comvax saquinavir (free base) saquinavir mesylate
Regranex Granulex saquinavir mesylate saquinavir (free base)
Reminyl Amaryl Sarafem Serophene
Reminyl Robinul sAXagliptin SITagliptin
Renagel Renvela selegiline Salagen
Renvela Renagel Serophene Sarafem
repaglinide rasageline SEROquel Desyrel
Reprexain ZyPREXA SEROquel SEROquel XR
Restoril RisperDAL SEROquel Serzone
Retrovir ritonavir SEROquel SINEquan
ribavirin riboflavin SEROquel XR SEROquel
riboflavin ribavirin sertraline cetirizine
rifabutin rifapentine sertraline Soriatane
Rifadin Rifater Serzone SEROquel
Rifamate rifAMPin silodosin sirolimus
rifAMPin Rifamate Sinemet Janumet
rifAMPin rifAXIMin SINEquan saquinavir
rifapentine rifabutin SINEquan SEROquel
Rifater Rifadin SINEquan Singulair
rifAXIMin rifAMPin SINEquan Zeniquin [veterinary drug]
riMANTAdine raNITIdine SINEquan Zonegran
RisperDAL Restoril Singulair SINEquan
RisperDAL rOPINIRole sirolimus silodosin
risperiDONE rOPINIRole SITagliptin sAXagliptin
Ritalin ritodrine SITagliptin SUMAtriptan
Ritalin LA Ritalin SR sodium acetate potassium acetate
Ritalin SR Ritalin LA Solu-CORTEF SOLU-Medrol
ritodrine Ritalin SOLU-Medrol DEPO-Medrol
ritonavir Retrovir SOLU-Medrol Solu-CORTEF
Rituxan Rituxan Hycela Sonata Soriatane
Rituxan Hycela Rituxan SORAfenib SUNItinib
riTUXimab inFLIXimab Soriatane Loxitane
Robinul Reminyl Soriatane sertraline
romiDEPsin romiPLOStim Soriatane Sonata
romiPLOStim romiDEPsin sotalol Sudafed
rOPINIRole RisperDAL Spiriva Apidra
rOPINIRole risperiDONE Spiriva Inspra
Roxanol Roxicet stavudine cetirizine
Roxanol Roxicodone Intensol Sudafed sotalol
Roxicet Roxanol Sudafed Sudafed PE
Roxicodone Intensol Roxanol Sudafed 12 Hour Sudafed 12 Hour Pressure + Pain
Rozerem Razadyne Sudafed 12 Hour Pressure + Pain Sudafed 12 Hour
Salagen selegiline Sudafed PE Sudafed
SandIMMUNE SandoSTATIN SUFentanil fentaNYL
SandoSTATIN SandIMMUNE sulfADIAZINE sulfaSALAzine
saquinavir SINEquan sulfADIAZINE sulfiSOXAZOLE
Note: Brand names start with an uppercase letter. Some brand names incorporate tall man letters in initial characters and may not be readily recognized as brand
names. Brand names appear in black; generic names/other products appear in red.

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ISMP List of Confused Drug Names
Drug Name Confused Drug Name Drug Name Confused Drug Name
sulfaSALAzine cefuroxime Toprol-XL Topamax
sulfaSALAzine sulfADIAZINE Toradol Foradil
sulfiSOXAZOLE sulfADIAZINE Toujeo Tanzeum
SUMAtriptan SITagliptin Toujeo Tradjenta
SUMAtriptan ZOLMitriptan Toujeo Tresiba
SUNItinib SORAfenib Toujeo Trulicity
Symbyax Cymbalta t-PA (Activase) TNKase
T-Gel Bio-T-Gel Tracleer Tricor
tacrolimus tamsulosin Tradjenta Tanzeum
Tambocor Pamelor Tradjenta Toujeo
tamsulosin tacrolimus Tradjenta Tresiba
Tanzeum Toujeo Tradjenta Trulicity
Tanzeum Tradjenta traMADol traZODone
Tanzeum Tresiba trastuzumab ado-trastuzumab emtansine
Tanzeum Trulicity traZODone traMADol
Tarceva Tresiba TRENtal TEGretol
Taxol Paxil Tresiba Tanzeum
Taxol Taxotere Tresiba Tarceva
Taxotere Taxol Tresiba Toujeo
TEGretol TEGretol XR Tresiba Tradjenta
TEGretol Tequin Tresiba Trulicity
TEGretol TRENtal tretinoin ISOtretinoin
TEGretol XR TEGretol Tricor Tracleer
Tenex Xanax tromethamine Trophamine
Tequin TEGretol Trophamine tromethamine
Tequin Ticlid Trulicity Tanzeum
Testoderm Testoderm TTS Trulicity Toujeo
Testoderm Testoderm with Adhesive Trulicity Tradjenta
Testoderm TTS Testoderm Trulicity Tresiba
Testoderm TTS Testoderm with Adhesive tuberculin purified protein derivative (PPD) influenza virus vaccine
Testoderm with Adhesive Testoderm tuberculin purified protein derivative (PPD) tetanus diptheria toxoid (Td)
Testoderm with Adhesive Testoderm TTS Tylenol Tylenol PM
tetanus diptheria toxoid (Td) tuberculin purified protein derivative (PPD) Tylenol PM Tylenol
Thalomid Thiamine Ultracet Duricef
Thiamine Thalomid Ultram lithium
tiaGABine tiZANidine valACYclovir valGANciclovir
Tiazac Ziac Valcyte Valtrex
Ticlid Tequin valGANciclovir valACYclovir
tiZANidine tiaGABine Valtrex Valcyte
TNKase Activase Varivax VZIG (varicella-zoster immune globulin)
TNKase t-PA (Activase) vasopressin desmopressin
Tobradex Tobrex Venofer Vfend
Tobrex Tobradex Venofer Vimpat
TOLAZamide TOLBUTamide Vesanoid Vesicare
TOLBUTamide TOLAZamide Vesicare Vesanoid
Topamax Toprol-XL Vesicare Vessel Care (nutritional supplement)
Note: Brand names start with an uppercase letter. Some brand names incorporate tall man letters in initial characters and may not be readily recognized as brand
names. Brand names appear in black; generic names/other products appear in red.

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ISMP List of Confused Drug Names
Drug Name Confused Drug Name Drug Name Confused Drug Name
Vessel Care (nutritional supplement) Vesicare Zestril Zetia
Vexol Vosol Zestril ZyPREXA
Vfend Venofer Zetia Bextra
Vfend Vimpat Zetia Zebeta
Viagra Allegra Zetia Zestril
Vicodin Visicol Ziac Tiazac
Videx Bidex Zocor Cozaar
vigabatrin dabigatran Zocor ZyrTEC
Vimpat Venofer ZOLMitriptan SUMAtriptan
Vimpat Vfend zolpidem Zyloprim
vinBLAStine vinCRIStine Zonegran SINEquan
vinCRIStine vinBLAStine Zostrix Zovirax
Viokase Viokase 8 Zovirax Doribax
Viokase 8 Viokase Zovirax Zostrix
Vioxx Zyvox Zovirax Zyvox
Viracept Viramune Zyban Diovan
Viramune Viracept Zyloprim zolpidem
Viramune (nevirapine) Viramune (herbal product) ZyPREXA CeleXA
Viramune (herbal product) Viramune (nevirapine) ZyPREXA Reprexain
Visicol Vicodin ZyPREXA Zestril
VisionBlue methylene blue ZyPREXA ZyrTEC
Volumen Voluven ZyPREXA Zydis Zelapar (Zydis formulation)
Voluven Volumen ZyrTEC Lipitor
Vosol Vexol ZyrTEC Zantac
VZIG (varicella-zoster immune globulin) Varivax ZyrTEC Zerit
Wellbutrin SR Wellbutrin XL ZyrTEC Zocor
Wellbutrin XL Wellbutrin SR ZyrTEC ZyPREXA
Xanax Fanapt ZyrTEC ZyrTEC-D
Xanax Tenex ZyrTEC Itchy Eye Drops
ZyrTEC (cetirizine)
Xanax Zantac (ketotifen fumarate)
Xeloda Xenical ZyrTEC -D ZyrTEC
Xenical Xeloda ZyrTEC Itchy Eye Drops
ZyrTEC (cetirizine)
Yasmin Yaz (ketotifen fumarate)
Yaz Yasmin Zyvox Vioxx
Zantac Xanax Zyvox Zovirax
Zantac ZyrTEC
Zavesca (escitalopram) [non-US product] Zavesca (miglustat)
Zavesca (miglustat) Zavesca (escitalopram) [non-US product]
Zebeta Diabeta
Zebeta Zetia
Zegerid Zestril
Zelapar (Zydis formulation) ZyPREXA Zydis
Zeniquin [veterinary drug] SINEquan
Zerit ZyrTEC
Zestril Zegerid
Note: Brand names start with an uppercase letter. Some brand names incorporate tall man letters in initial characters and may not be readily recognized as brand
names. Brand names appear in black; generic names/other products appear in red.

© ISMP 2019. Permission is granted to reproduce material with proper attribution for internal use within healthcare organizations. Other reproduction is prohibited
without written permission from the Institute for Safe Medication Practices (ISMP). Report actual and potential medication or vaccine errors to the ISMP National
Medication Errors Reporting Program (ISMP MERP) or ISMP National Vaccine Errors Reporting Program (ISMP VERP) at: www.ismp.org/report-medication-error.

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