Warning from FDA:

In the wake of two recent patient deaths in the UK, the Institute for Safe Medication Practices (ISMP) is again warning healthcare professionals about potentially fatal mixups between various formulations of amphotericin B, which is used intravenously to treat serious fungal infections. The problem occurs when the lipid-based or liposomal formulations of the drug are accidentally substituted for the conventional form, and vice versa.

Lipid-based and liposomal formulations of amphotericin B are prescribed at higher doses than conventional amphotericin B. If the conventional form is given at the dose used for the lipid-based or liposomal formulations, serious and possibly fatal overdosing can occur. Conversely, if the lipid-based or liposomal forms are given at dose appropriate for the conventional drug, underdosing and ineffective treatment can occur.

Here are some of ISMP's recommendations to avoid these errors:

-- Ask prescribers to communicate orders using both the brand name and the full generic name. For example, "Ambisome, amphotericin B liposomal."

-- With conventional amphotericin B deoxycholate, don't exceed a dose of 1.5 mg/kg daily. And consider establishing dose alerts in computer systems.

-- Restrict the preparation and dispensing of amphotericin B products to the pharmacy.

-- Store the different forms of the drugs separately, and use cautionary labels to highlight the difference.

-- Include lipid-based and liposomal amphotericin B on your list of high-alert medications.

-- Require an independent double-check before amphotericin B products are administered.

Additional Information:

• ISMP Medication Safety Alert! Worth Repeating: Preventing Mix-ups Between Various Formulations of Amphotericin B. Volume 12, Issue 18. September 6, 2007.

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