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Reporting a Medication Error

Drug brand name may not have same ingredient in another country

68497d6cb194485d2759fde9466457b7 MAn American man who took Dilacor XR (diltiazem extended-release) ran out of medicine while traveling to Serbia. A Serbian pharmacist refilled the prescription with a brand name medicine called Dilacor. But in Serbia, Dilacor is the brand name for digoxin, a totally different medicine than diltiazem.


Digoxin slows the heartbeat while diltiazem lowers blood pressure. The man did not notice the mistake and continued to take the medicine after returning home. He also took an extra tablet each day because he felt his blood pressure medicine was not working. By the third day, he began vomiting and developed headaches and chest pain, all signs of taking too much digoxin. He went to an emergency room where a doctor discovered the error. He was then admitted to the hospital and given a medicine called Digibind (digoxin immune FAB), which stops digoxin from working in the body.

If you travel outside of the United States (US), or buy medicines from another country, the brand name of your medicine may be used for a totally different medicine. The table below lists just a few examples of brand name medicines that have different ingredients in other countries. Some of these medicines are used to treat the same condition, but the doses are different because they contain different ingredients.

When you travel, always carry enough medicine for the entire trip plus a few days extra. Also take a list of your medicines that includes both generic and brand names (if you take a brand-name medicine). If you should unexpectedly need a refill while away, the generic name of the medicine will help the pharmacist dispense the correct product. As another safeguard, always tell the pharmacist the reason you are taking the medicine.

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