ISMP List of Confused Drug Names

This list of confused drug names, which includes look-alike including the purpose of the medication on prescriptions;
and sound-alike name pairs, consists of those name pairs configuring computer systems to require a minimum of the
that have been published in the ISMP Medication Safety first five letters of a drug name during product searches
Alert!® Acute Care, the ISMP Medication Safety Alert!® to limit similar names from appearing together on the
Community/Ambulatory Care, and the FDA and ISMP Lists same screen; and changing the appearance of look-alike
of Look-Alike Drug Names with Recommended Tall Man product names to draw attention to their differences. Both
Letters. We hope you will use this list to determine which the US Food and Drug Administration (FDA)-approved and
medications require special safeguards to reduce the risk the ISMP-recommended tall man (mixed case) letters have
of errors. This may include strategies such as: using both been included in this list.
the brand and generic names on prescriptions and labels;
Updated through February 2023
Drug Name Confused Drug Name Drug Name Confused Drug Name
Abelcet amphotericin B ALfentanil* SUFentanil*
Accupril Aciphex Alkeran Leukeran
acetaminophen acetaZOLAMIDE Alkeran Myleran
acetaZOLAMIDE acetaminophen Allegra Viagra
acetaZOLAMIDE acetoHEXAMIDE Allegra Anti-Itch Cream
Allegra (fexofenadine)
acetic acid for irrigation glacial acetic acid (diphenhydrAMINE/allantoin)
acetoHEXAMIDE acetaZOLAMIDE Allegra Anti-Itch Cream
Allegra (fexofenadine)
Aciphex Accupril (diphenhydrAMINE/allantoin)
Aciphex Aricept Alora Aldara
Activase Cathflo Activase ALPRAZolam clonazePAM
Activase TNKase ALPRAZolam LORazepam
Actonel Actos Altocor Advicor
Actos Actonel amantadine amiodarone
Adacel (Tdap) Daptacel (DTaP) Amaryl Reminyl
Adderall Adderall XR Ambien* ambrisentan*
Adderall Inderal Ambisome amphotericin B
Adderall XR Adderall ambrisentan* Ambien*
ado-trastuzumab emtansine trastuzumab Amicar Omacor
Advair Advicor Amikin Kineret
Advicor Advair aMILoride amLODIPine
Advicor Altocor amiodarone amantadine
Afrin (oxymetazoline) Afrin (saline) amLODIPine aMILoride
Afrin (saline) Afrin (oxymetazoline) amphotericin B Abelcet
Aggrastat argatroban amphotericin B Ambisome
Aldara Alora amphotericin B amphotericin B liposomal
ALfentanil* fentaNYL* amphotericin B liposomal amphotericin B

Note: Brand names start with uppercase letter. Some brand names incorporate tall man letters in initital characters and may not be readily recognized as
brand names. Brand names appear in black; generic names/other products appear in red. Name pairs marked with an asterisk (*) are newly added.

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ISMP List of Confused Drug Names
Drug Name Confused Drug Name Drug Name Confused Drug Name
Anacin Anacin-3 Bayrab Bayrho-D
Anacin-3 Anacin Bayrho-D Bayhep-B
antacid Atacand Bayrho-D Bayrab
Anticoagulant Citrate Dextrose Anticoagulant Sodium Citrate Beano B & O (belladonna and opium)
Solution Formula A Solution belimumab* bamlanivimab*
Anticoagulant Sodium Citrate Anticoagulant Citrate Dextrose Benadryl benazepril
Solution Solution Formula A benazepril Benadryl
Antivert Axert Benicar Mevacor
Anzemet Avandamet Betadine (with providone- Betadine (without providone-
Apidra Spiriva iodine) iodine)
apixaban* axitinib* Betadine (without providone- Betadine (with providone-
Apresoline Priscoline iodine) iodine)
argatroban Aggrastat betaine (anhydrous form) betaine HCl
argatroban Orgaran betaine HCl betaine (anhydrous form)
Aricept Aciphex Bextra Zetia
Aricept Azilect Bicillin C-R Bicillin L-A
ARIPiprazole proton pump inhibitors Bicillin L-A Bicillin C-R
ARIPiprazole RABEprazole Bicitra Polycitra
Arista AH (absorbable Bidex Videx
Arixtra
hemostatic agent) Bio-T-Gel T-Gel
Arista AH (absorbable Brethine Methergine
Arixtra
hemostatic agent) Brevibloc Brevital
Asacol Os-Cal Brevital Brevibloc
Atacand antacid Brilinta Brintellix
atomoxetine atorvastatin Brilinta* Briviact*
atorvastatin atomoxetine Brintellix Brilinta
Atrovent Natru-Vent Briviact* Brilinta*
Avandamet Anzemet BUPivacaine* ROPivacaine*
Avandia Coumadin buprenorphine HYDROmorphone
Avandia Prandin buPROPion busPIRone
Avinza Evista busPIRone buPROPion
Avinza Invanz Capadex [non-US product] Kapidex
Axert Antivert Capex Kapidex
axitinib* apixaban* captopril carvedilol
azaCITIDine azaTHIOprine Carac Kuric
azaTHIOprine azaCITIDine carBAMazepine OXcarbazepine
Azilect Aricept CARBOplatin CISplatin
B & O (belladonna and opium) Beano Cardene Cardizem
HBIG (hepatitis B immune Cardizem Cardene
BabyBIG
globulin) Cardura Coumadin
bamlanivimab* belimumab* carvedilol captopril
Bayhep-B Bayrab Casodex Kapidex
Bayhep-B Bayrho-D Cathflo Activase Activase
Bayrab Bayhep-B Cedax Cidex

Note: Brand names start with uppercase letter. Some brand names incorporate tall man letters in initital characters and may not be readily recognized as
brand names. Brand names appear in black; generic names/other products appear in red. Name pairs marked with an asterisk (*) are newly added.

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©2023 ISMP. All Rights Reserved.
ISMP List of Confused Drug Names
Drug Name Confused Drug Name Drug Name Confused Drug Name
ceFAZolin* cefoTEtan* Claritin-D 24 Claritin-D
ceFAZolin* cefOXitin* Clindesse Clindets
ceFAZolin* cefTAZidime* Clindets Clindesse
ceFAZolin cefTRIAXone cloBAZam clonazePAM
cefoTEtan* ceFAZolin* clomiPHENE clomiPRAMINE
cefoTEtan* cefOXitin* clomiPRAMINE clomiPHENE
cefoTEtan* cefTAZidime* clonazePAM ALPRAZolam
cefoTEtan* cefTRIAXone* clonazePAM cloBAZam
cefOXitin* ceFAZolin* clonazePAM cloNIDine
cefOXitin* cefoTEtan* clonazePAM cloZAPine
cefOXitin* cefTAZidime* clonazePAM LORazepam
cefOXitin* cefTRIAXone* cloNIDine clonazePAM
cefTAZidime* ceFAZolin* cloNIDine cloZAPine
cefTAZidime* cefoTEtan* cloNIDine KlonoPIN
cefTAZidime* cefOXitin* cloZAPine clonazePAM
cefTAZidime* cefTRIAXone* cloZAPine cloNIDine
cefTRIAXone ceFAZolin Clozaril Colazal
cefTRIAXone* cefoTEtan* coagulation factor IX
factor IX complex, vapor heated
cefTRIAXone* cefOXitin* (recombinant)
cefTRIAXone* cefTAZidime* codeine Lodine
cefuroxime sulfaSALAzine coenzyme Q10 (CoQ10)* Cometriq*
CeleBREX CeleXA Colace Cozaar
CeleBREX Cerebyx Colazal Clozaril
CeleXA CeleBREX colchicine Cortrosyn
CeleXA Cerebyx Comvax Recombivax HB
CeleXA ZyPREXA Cometriq* coenzyme Q10 (CoQ10)*
Cerebyx CeleBREX Cortrosyn colchicine
Cerebyx CeleXA Coumadin Avandia
cetirizine sertraline Coumadin Cardura
cetirizine stavudine Covaryx HS Covera HS
chlordiazePOXIDE chlorproMAZINE Covera HS Covaryx HS
chlorproMAZINE chlordiazePOXIDE Cozaar Colace
chlorproMAZINE chlorproPAMIDE Cozaar Zocor
chlorproPAMIDE chlorproMAZINE Cubicin Cubicin RF
Cidex Cedax Cubicin RF Cubicin
CISplatin CARBOplatin cycloPHOSphamide* cycloSERINE*
citalopram* escitalopram* cycloPHOSphamide cycloSPORINE
Clarispray (fluticasone cycloSERINE* cycloPHOSphamide*
Claritin (loratadine)
propionate) cycloSERINE cycloSPORINE
Clarispray (fluticasone cycloSPORINE cycloPHOSphamide
Claritin (loratadine)
propionate) cycloSPORINE cycloSERINE
Claritin (loratadine) Claritin Eye (ketotifen fumarate) cycloSPORINE cycloSPORINE modified
Claritin Eye (ketotifen fumarate) Claritin (loratadine) cycloSPORINE modified cycloSPORINE
Claritin-D Claritin-D 24 Cymbalta Symbyax

Note: Brand names start with uppercase letter. Some brand names incorporate tall man letters in initital characters and may not be readily recognized as
brand names. Brand names appear in black; generic names/other products appear in red. Name pairs marked with an asterisk (*) are newly added.

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©2023 ISMP. All Rights Reserved.
ISMP List of Confused Drug Names
Drug Name Confused Drug Name Drug Name Confused Drug Name
dabigatran vigabatrin disopyramide desipramine
DACTINomycin DAPTOmycin Ditropan Diprivan
Daptacel (DTaP) Adacel (Tdap) DOBUTamine DOPamine
DAPTOmycin DACTINomycin DOCEtaxel PACLitaxel
Darvocet Percocet DOPamine DOBUTamine
Darvon Diovan Doribax Zovirax
DAUNOrubicin DAUNOrubicin liposomal Doxil Paxil
DAUNOrubicin DOXOrubicin DOXOrubicin DAUNOrubicin
DAUNOrubicin IDArubicin DOXOrubicin DOXOrubicin liposomal
DAUNOrubicin liposomal DAUNOrubicin DOXOrubicin IDArubicin
Denavir indinavir DOXOrubicin liposomal DOXOrubicin
Depakote Depakote ER Dramamine (dimenhyDRINATE) Dramamine (ginger root)
Depakote ER Depakote Dramamine (dimenhyDRINATE) Dramamine (meclizine)
DEPO-Medrol SOLU-Medrol Dramamine (ginger root) Dramamine (dimenhyDRINATE)
Depo-Provera Depo-subQ provera 104 Dramamine (ginger root) Dramamine (meclizine)
Depo-subQ provera 104 Depo-Provera Dramamine (meclizine) Dramamine (dimenhyDRINATE)
desipramine disopyramide Dramamine (meclizine) Dramamine (ginger root)
desmopressin vasopressin droNABinol* droPERidol*
Desyrel Seroquel droPERidol* droNABinol*
dexAMETHasone dexmedeTOMIDine Dulcolax (bisacodyl) Dulcolax (docusate sodium)
Dexilant DULoxetine Dulcolax (docusate sodium) Dulcolax (bisacodyl)
dexmedeTOMIDine dexAMETHasone DULoxetine Dexilant
dexmethylphenidate mixed DULoxetine FLUoxetine
dexmethylphenidate
salts DULoxetine PARoxetine
dexmethylphenidate methadone Durasal Durezol
dexmethylphenidate mixed Durezol Durasal
dexmethylphenidate
salts
Duricef Ultracet
Diabenese Diamox
Dynacin Dynacirc
Diabeta Zebeta
Dynacirc Dynacin
Diamox Diabenese
edetate calcium disodium edetate disodium
diazePAM dilTIAZem
edetate disodium edetate calcium disodium
Diflucan Diprivan
Effexor Effexor XR
Dilacor XR Pilocar
Effexor XR Effexor
Dilaudid Dilaudid-5
Effexor XR Enablex
Dilaudid-5 Dilaudid
elvitegravir, cobicistat, elvitegravir, cobicistat,
dilTIAZem diazePAM emtricitabine, and tenofovir emtricitabine, and tenofovir
alafenamide disoproxil fumarate
dimenhyDRINATE diphenhydrAMINE
elvitegravir, cobicistat, elvitegravir, cobicistat,
Dioval Diovan
emtricitabine, and tenofovir emtricitabine, and tenofovir
Diovan Darvon disoproxil fumarate alafenamide
Diovan Dioval Enablex Effexor XR
Diovan Zyban Enbrel Levbid
diphenhydrAMINE dimenhyDRINATE Engerix-B adult Engerix-B pediatric/adolescent
Diprivan Diflucan Engerix-B pediatric/adolescent Engerix-B adult
Diprivan Ditropan Enjuvia Januvia

Note: Brand names start with uppercase letter. Some brand names incorporate tall man letters in initital characters and may not be readily recognized as
brand names. Brand names appear in black; generic names/other products appear in red. Name pairs marked with an asterisk (*) are newly added.

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©2023 ISMP. All Rights Reserved.
ISMP List of Confused Drug Names
Drug Name Confused Drug Name Drug Name Confused Drug Name
ePHEDrine EPINEPHrine Focalin Focalgin B
EPINEPHrine ePHEDrine Folex Foltx
epiRUBicin eriBULin folic acid folinic acid (leucovorin calcium)
eriBULin epiRUBicin folinic acid (leucovorin calcium) folic acid
escitalopram* citalopram* Foltx Folex
Estratest Estratest HS fomepizole omeprazole
Estratest HS Estratest Foradil Fortical
ethambutol Ethmozine Foradil Toradol
ethaverine [non-US name] etravirine Fortical Foradil
Ethmozine ethambutol gabapentin gemfibrozil
etravirine ethaverine [non-US name] gemfibrozil gabapentin
Evista AVINza gentamicin gentian violet
coagulation factor IX gentian violet gentamicin
factor IX complex, vapor heated
(recombinant) glacial acetic acid acetic acid for irrigation
Fanapt Xanax glipiZIDE glyBURIDE
Farxiga Fetzima Glucotrol Glycotrol
Fastin (dietary supplement) Fastin (phentermine) glyBURIDE glipiZIDE
Fastin (phentermine) Fastin (dietary supplement) Glycotrol Glucotrol
Femara Femhrt Granulex Regranex
Femhrt Femara guaiFENesin guanFACINE
fentaNYL* ALfentanil* guanFACINE guaiFENesin
fentaNYL SUFentanil HBIG (hepatitis B immune
BabyBIG
Fetzima Farxiga globulin)
Fioricet Fiorinal Healon Hyalgan
Fiorinal Fioricet heparin Hespan
flavoxATE fluvoxaMINE Hespan heparin
Flonase Flovent HMG-CoA reductase inhibitors
nystatin
Floranex Florinef (“statins”)
Florastor Florinef HumaLOG HumuLIN
Florinef Floranex HumaLOG NovoLOG
Florinef Florastor HumaLOG Mix 75/25 HumuLIN 70/30
Flovent Flonase Humapen Memoir (for use with
Humira Pen
flumazenil influenza virus vaccine HumaLOG)
FLUoxetine DULoxetine Humapen Memoir (for use with
Humira Pen
FLUoxetine Loxitane HumaLOG)
FLUoxetine PARoxetine HumuLIN HumaLOG
fluPHENAZine fluvoxaMINE HumuLIN NovoLIN
fluvoxaMINE flavoxATE HumuLIN 70/30 HumaLOG Mix 75/25
fluvoxaMINE fluPHENAZine HumuLIN R U-100 HumuLIN R U-500
Fluzone High-Dose HumuLIN R U-500 HumuLIN R U-100
Fluzone Quadrivalent*
Quadrivalent* Hyalgan Healon
Fluzone High-Dose hydrALAZINE hydroCHLOROthiazide
Fluzone Quadrivalent*
Quadrivalent* hydrALAZINE* HYDROmorphone*
Focalgin B Focalin hydrALAZINE hydrOXYzine

Note: Brand names start with uppercase letter. Some brand names incorporate tall man letters in initital characters and may not be readily recognized as
brand names. Brand names appear in black; generic names/other products appear in red. Name pairs marked with an asterisk (*) are newly added.

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©2023 ISMP. All Rights Reserved.
ISMP List of Confused Drug Names
Drug Name Confused Drug Name Drug Name Confused Drug Name
Hydrea Lyrica Jantoven Januvia
hydroCHLOROthiazide hydrALAZINE Janumet Jantoven
hydroCHLOROthiazide hydrOXYzine Janumet Januvia
hydroCHLOROthiazide* hydroxychloroquine* Janumet Sinemet
HYDROcodone oxyCODONE Januvia Enjuvia
Hydrogesic hydrOXYzine Januvia Jantoven
HYDROmorphone buprenorphine Januvia Janumet
HYDROmorphone* hydrALAZINE* Kadian Kapidex
HYDROmorphone* hydrOXYzine* Kaletra Keppra
HYDROmorphone morphine Kaopectate (bismuth
Kaopectate (docusate calcium)
HYDROmorphone oxyMORphone subsalcylate)
hydroxychloroquine hydroxyurea Kaopectate (bismuth
Kaopectate (docusate calcium)
hydroxychloroquine* hydroCHLOROthiazide* subsalcylate)
HYDROXYprogesterone medroxyPROGESTERone Kapidex Capadex [non-US product]
hydroxyurea hydroxychloroquine Kapidex Capex
hydroxyurea hydrOXYzine Kapidex Casodex
Ure-Na Kapidex Kadian
hydroxyurea*
(palatable form of oral urea)* Kay Ciel Kayexalate
hydrOXYzine hydrALAZINE Kayexalate Kay Ciel
hydrOXYzine hydroCHLOROthiazide Keflex Keppra
hydrOXYzine Hydrogesic Keppra Kaletra
hydrOXYzine* HYDROmorphone* Keppra Keflex
hydrOXYzine hydroxyurea Ketalar ketorolac
IDArubicin DAUNOrubicin ketamine* ketorolac*
IDArubicin DOXOrubicin ketorolac Ketalar
IDArubicin idaruCIZUmab ketorolac* ketamine*
idaruCIZUmab IDArubicin ketorolac methadone
Ilaris* Ilumya* Kineret Amikin
Ilumya* Ilaris* KlonoPIN cloNIDine
Inderal Adderall K-Phos Neutral Neutra-Phos-K
indinavir Denavir Kuric Carac
inFLIXimab riTUXimab Kwell Qwell
influenza virus vaccine flumazenil labetalol LaMICtal
influenza virus vaccine perflutren lipid microspheres labetalol lamoTRIgine
tuberculin purified protein LaMICtal labetalol
influenza virus vaccine
derivative (PPD) LaMICtal LamISIL
Inspra Spiriva LamISIL LaMICtal
Intuniv Invega lamiVUDine lamoTRIgine
Invanz Avinza lamoTRIgine lamiVUDine
Invega Intuniv lamoTRIgine levETIRAcetam
iodine Lodine lamoTRIgine levothyroxine
Isordil Plendil lamoTRIgine labetalol
ISOtretinoin tretinoin Lanoxin levothyroxine
Jantoven Janumet Lanoxin naloxone

Note: Brand names start with uppercase letter. Some brand names incorporate tall man letters in initital characters and may not be readily recognized as
brand names. Brand names appear in black; generic names/other products appear in red. Name pairs marked with an asterisk (*) are newly added.

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©2023 ISMP. All Rights Reserved.
ISMP List of Confused Drug Names
Drug Name Confused Drug Name Drug Name Confused Drug Name
lanthanum carbonate lithium carbonate Lovaza LORazepam
Lantus Latuda Lovenox Levemir
Lantus Lente Loxitane FLUoxetine
Lariam Levaquin Loxitane Lexapro
Lasix Luvox Loxitane Soriatane
Lasix* Wakix* Lunesta Neulasta
Latuda Lantus Lupron Depot-3 Month Lupron Depot-Ped
Lente Lantus Lupron Depot-Ped Lupron Depot-3 Month
Letairis Letaris [non-US product] Luvox Lasix
Letaris [non-US product] Letairis Lyrica Hydrea
leucovorin calcium Leukeran Lyrica Lopressor
leucovorin calcium LEVOleucovorin Maalox Maalox Total Stomach Relief
Leukeran Alkeran Maalox Total Stomach Relief Maalox
Leukeran leucovorin calcium Malarone mefloquine
Leukeran Myleran Materna Matulane
Levaquin Lariam Matulane Materna
Levbid Enbrel Maxzide Microzide
Levemir Lovenox medroxyPROGESTERone HYDROXYprogesterone
levETIRAcetam lamoTRIgine medroxyPROGESTERone methylPREDNISolone
levETIRAcetam levOCARNitine medroxyPROGESTERone methylTESTOSTERone
levETIRAcetam levoFLOXacin mefloquine Malarone
levOCARNitine levETIRAcetam memantine methadone
levoFLOXacin levETIRAcetam Menactra Menomune
LEVOleucovorin leucovorin calcium Menomune Menactra
levothyroxine lamoTRIgine Mephyton methadone
levothyroxine Lanoxin Metadate methadone
levothyroxine liothyronine Metadate CD Metadate ER
Lexapro Loxitane Metadate ER Metadate CD
Lexiva Pexeva Metadate ER methadone
linaCLOtide linaGLIPtin metFORMIN metroNIDAZOLE
linaGLIPtin linaCLOtide methadone dexmethylphenidate
liothyronine levothyroxine methadone ketorolac
Lipitor Loniten methadone memantine
Lipitor ZyrTEC methadone Mephyton
lithium Ultram methadone Metadate
lithium carbonate lanthanum carbonate methadone Metadate ER
Lodine codeine methadone methylphenidate
Lodine iodine methadone metOLazone
Loniten Lipitor methazolAMIDE methIMAzole
Lopressor Lyrica methazolAMIDE metOLazone
LORazepam ALPRAZolam Methergine Brethine
LORazepam clonazePAM methIMAzole methazolAMIDE
LORazepam Lovaza methIMAzole metOLazone
Lotronex Protonix methotrexate metOLazone

Note: Brand names start with uppercase letter. Some brand names incorporate tall man letters in initital characters and may not be readily recognized as
brand names. Brand names appear in black; generic names/other products appear in red. Name pairs marked with an asterisk (*) are newly added.

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©2023 ISMP. All Rights Reserved.
ISMP List of Confused Drug Names
Drug Name Confused Drug Name Drug Name Confused Drug Name
MTX Patch (lidocaine and Mucinex Mucomyst
methotrexate
menthol) Mucinex (guaiFENesin) Mucinex Allergy (fexofenadine)
methylene blue VisionBlue Mucinex Allergy (fexofenadine) Mucinex (guaiFENesin)
methylphenidate methadone Mucinex D Mucinex DM
methylPREDNISolone medroxyPROGESTERone Mucinex DM Mucinex D
methylPREDNISolone methylTESTOSTERone Mucomyst Mucinex
methylTESTOSTERone medroxyPROGESTERone Myleran Alkeran
methylTESTOSTERone methylPREDNISolone Myleran Leukeran
metOLazone methadone nalbuphine naloxone
metOLazone methazolAMIDE naloxone Lanoxin
metOLazone methIMAzole naloxone nalbuphine
metOLazone methotrexate Narcan Norcuron
metoprolol succinate metoprolol tartrate Natru-Vent Atrovent
metoprolol tartrate metoprolol succinate Navane Norvasc
metroNIDAZOLE metFORMIN Neo-Synephrine Neo-Synephrine
metyraPONE metyroSINE (oxymetazoline) (phenylephrine)
metyroSINE metyraPONE Neo-Synephrine Neo-Synephrine
Mevacor Benicar (phenylephrine) (oxymetazoline)
Micronase Microzide neratinib nilotinib
Microzide Maxzide neratinib niraparib
Microzide Micronase Neulasta Lunesta
midodrine Midrin Neulasta Neumega
Midrin midodrine Neulasta Nuedexta
miFEPRIStone miSOPROStol Neumega Neulasta
migALAstat migLUstat Neumega Neupogen
migLUstat migALAstat Neupogen Neumega
Miralax Mirapex Neurontin Motrin
Mirapex Miralax Neurontin Noroxin
miSOPROStol miFEPRIStone Neutra-Phos-K K-Phos Neutral
mitoMYcin mitoXANTRONE NexAVAR NexIUM
mitoXANTRONE mitoMYcin NexIUM NexAVAR
MTX Patch (lidocaine and niCARdipine NIFEdipine
mitoXANTRONE
menthol) niCARdipine niMODipine
morphine HYDROmorphone NIFEdipine niCARdipine
morphine - non-concentrated morphine - oral liquid NIFEdipine niMODipine
oral liquid concentrate nilotinib neratinib
morphine - oral liquid morphine - non-concentrated nilotinib niraparib
concentrate oral liquid niMODipine niCARdipine
Motrin Neurontin niMODipine NIFEdipine
MS Contin OxyCONTIN niraparib neratinib
MTX Patch (lidocaine and niraparib nilotinib
methotrexate
menthol) nizatidine* tiZANidine*
MTX Patch (lidocaine and Norcuron Narcan
mitoXANTRONE
menthol) Normodyne Norpramin

Note: Brand names start with uppercase letter. Some brand names incorporate tall man letters in initital characters and may not be readily recognized as
brand names. Brand names appear in black; generic names/other products appear in red. Name pairs marked with an asterisk (*) are newly added.

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©2023 ISMP. All Rights Reserved.
ISMP List of Confused Drug Names
Drug Name Confused Drug Name Drug Name Confused Drug Name
Noroxin Neurontin oxyMORphone* oxyBUTYnin*
Norpramin Normodyne oxyMORphone oxyCODONE
Norvasc Navane oxyMORphone OxyCONTIN
NovoLIN HumuLIN oxytocin* OxyCONTIN*
NovoLIN NovoLOG PACLitaxel DOCEtaxel
NovoLIN 70/30 NovoLOG Mix 70/30 PACLitaxel protein-bound
PACLitaxel
NovoLOG HumaLOG particles
NovoLOG NovoLIN PACLitaxel protein-bound
PACLitaxel
NovoLOG Flexpen NovoLOG Mix 70/30 Flexpen particles
NovoLOG Mix 70/30 NovoLIN 70/30 Pamelor Panlor DC
NovoLOG Mix 70/30 Flexpen NovoLOG Flexpen Pamelor Tambocor
Nuedexta Neulasta Panlor DC Pamelor
HMG-CoA reductase inhibitors paregoric (camphorated
nystatin opium tincture
(“statins”) tincture of opium)
Occlusal-HP Ocuflox PARoxetine DULoxetine
Ocuflox Occlusal-HP PARoxetine FLUoxetine
OLANZapine QUEtiapine PARoxetine piroxicam
Omacor Amicar Patanol Platinol
omeprazole fomepizole Pavulon Peptavlon
paregoric (camphorated Paxil Doxil
opium tincture
tincture of opium) Paxil Plavix
Oracea Orencia Paxil Taxol
Orencia Oracea Paxil* Trexall*
Orgaran argatroban PAZOPanib PONATinib
Ortho Tri-Cyclen Ortho Tri-Cyclen LO PEMEtrexed PRALAtrexate
Ortho Tri-Cyclen LO Ortho Tri-Cyclen penicillAMINE penicillin
Os-Cal Asacol penicillin penicillAMINE
oxaprozin OXcarbazepine PENTobarbital PHENobarbital
OXcarbazepine carBAMazepine Peptavlon Pavulon
OXcarbazepine oxaprozin Percocet Darvocet
oxyBUTYnin oxyCODONE Percocet Procet
oxyBUTYnin* OxyCONTIN* perflutren lipid microspheres influenza virus vaccine
oxyBUTYnin* oxyMORphone* Pexeva Lexiva
oxyCODONE HYDROcodone PHENobarbital PENTobarbital
oxyCODONE oxybutynin PHYSostigmine* pyRIDostigminee*
oxyCODONE OxyCONTIN Pilocar Dilacor XR
oxyCODONE oxyMORphone piroxicam PARoxetine
OxyCONTIN MS Contin Pitocin* Pitressin*
OxyCONTIN* oxyBUTYnin* Pitressin* Pitocin*
OxyCONTIN oxyCODONE Platinol Patanol
OxyCONTIN oxyMORphone Plavix Paxil
OxyCONTIN* oxytocin* Plavix Pradax [Non-US Product]
oxyMORphone HYDROmorphone Plavix Pradaxa

Note: Brand names start with uppercase letter. Some brand names incorporate tall man letters in initital characters and may not be readily recognized as
brand names. Brand names appear in black; generic names/other products appear in red. Name pairs marked with an asterisk (*) are newly added.

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©2023 ISMP. All Rights Reserved.
ISMP List of Confused Drug Names
Drug Name Confused Drug Name Drug Name Confused Drug Name
Plendil Isordil PROzac Provera
pneumococcal polyvalent Purinethol propylthiouracil
pneumococcal 7-valent vaccine
vaccine Pyridium pyridoxine
pneumococcal polyvalent pyRIDostigmine* PHYSostigmine*
pneumococcal 7-valent vaccine
vaccine pyRIDostigmine* pyridoxine*
Polycitra Bicitra pyridoxine Pyridium
polyethylene glycol propylene glycol pyridoxine* pralidoxime*
PONATinib PAZOPanib pyridoxine* pyridostigmine*
potassium acetate sodium acetate QUEtiapine OLANZapine
Pradax [Non-US Product] Plavix quiNIDine quiNINE
Pradaxa Plavix quiNINE quiNIDine
PRALAtrexate PEMEtrexed Qwell Kwell
pralidoxime* pyridoxine* RABEprazole ARIPiprazole
Prandin Avandia Ranexa Prenexa
Precare Precose raNITIdine riMANTAdine
Precose Precare Rapaflo Rapamune
prednisoLONE predniSONE Rapamune Rapaflo
predniSONE prednisoLONE rasageline repaglinide
Prenexa Ranexa Razadyne Rozerem
PriLOSEC Pristiq Recombivax HB Comvax
PriLOSEC PROzac Regranex Granulex
Priscoline Apresoline Remeron* Rozerem*
Pristiq PriLOSEC Reminyl Amaryl
probenecid Procanbid Reminyl Robinul
Procan SR Procanbid Renagel Renvela
Procanbid probenecid Renvela Renagel
Procanbid Procan SR repaglinide rasageline
Procardia XL Protain XL Reprexain ZyPREXA
Procet Percocet Restoril RisperDAL
Prograf Proscar Retrovir ritonavir
Prograf PROzac ribavirin riboflavin
propylene glycol polyethylene glycol riboflavin ribavirin
propylthiouracil Purinethol rifabutin rifapentine
Proscar Prograf Rifadin Rifater
Proscar Provera Rifamate rifAMPin
Protain XL Procardia XL rifAMPin Rifamate
protamine Protonix rifAMPin rifAXIMin
proton pump inhibitors ARIPiprazole rifapentine rifabutin
Protonix Lotronex Rifater Rifadin
Protonix protamine rifAXIMin rifAMPin
Provera Proscar riMANTAdine raNITIdine
Provera PROzac RisperDAL Restoril
PROzac PriLOSEC RisperDAL rOPINIRole
PROzac Prograf risperiDONE rOPINIRole

Note: Brand names start with uppercase letter. Some brand names incorporate tall man letters in initital characters and may not be readily recognized as
brand names. Brand names appear in black; generic names/other products appear in red. Name pairs marked with an asterisk (*) are newly added.

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©2023 ISMP. All Rights Reserved.
ISMP List of Confused Drug Names
Drug Name Confused Drug Name Drug Name Confused Drug Name
Ritalin ritodrine Sinequan Singulair
Ritalin LA Ritalin SR Sinequan Zeniquin [veterinary drug]
Ritalin SR Ritalin LA Sinequan Zonegran
ritodrine Ritalin Singulair Sinequan
ritonavir Retrovir sirolimus silodosin
Rituxan Rituxan Hycela SITagliptin sAXagliptin
Rituxan Hycela Rituxan SITagliptin SUMAtriptan
riTUXimab inFLIXimab Slynd* Syeda*
Robinul Reminyl sodium acetate potassium acetate
rocuronium* Romazicon* Solu-CORTEF SOLU-Medrol
Romazicon* rocuronium* SOLU-Medrol DEPO-Medrol
romiDEPsin romiPLOStim SOLU-Medrol Solu-CORTEF
romiPLOStim romiDEPsin Sonata Soriatane
rOPINIRole RisperDAL SORAfenib SUNItinib
rOPINIRole risperiDONE Soriatane Loxitane
ROPivacaine* BUPivacaine* Soriatane sertraline
Roxanol Roxicet Soriatane Sonata
Roxanol Roxicodone Intensol sotalol Sudafed
Roxicet Roxanol Spiriva Apidra
Roxicodone Intensol Roxanol Spiriva Inspra
Rozerem Razadyne Spravato* Steglatro*
Rozerem* Remeron* stavudine cetirizine
Salagen selegiline Steglatro* Spravato*
SandIMMUNE SandoSTATIN Sudafed sotalol
SandoSTATIN SandIMMUNE Sudafed Sudafed PE
saquinavir Sinequan Sudafed 12 Hour Pressure +
Sudafed 12 Hour
saquinavir (free base) saquinavir mesylate Pain
saquinavir mesylate saquinavir (free base) Sudafed 12 Hour Pressure +
Sudafed 12 Hour
Sarafem Serophene Pain
sAXagliptin SITagliptin Sudafed PE Sudafed
selegiline Salagen SUFentanil* ALfentanil*
Serophene Sarafem SUFentanil fentaNYL
Seroquel Desyrel sulfADIAZINE sulfaSALAzine
Seroquel Seroquel XR sulfADIAZINE sulfiSOXAZOLE
Seroquel Serzone sulfaSALAzine cefuroxime
Seroquel Sinequan sulfaSALAzine sulfADIAZINE
Seroquel XR Seroquel sulfiSOXAZOLE sulfADIAZINE
sertraline cetirizine SUMAtriptan SITagliptin
sertraline Soriatane SUMAtriptan ZOLMitriptan
Serzone Seroquel SUNItinib SORAfenib
silodosin sirolimus Syeda* Slynd*
Sinemet Janumet Symbyax Cymbalta
Sinequan saquinavir tacrolimus tamsulosin
Sinequan Seroquel Tambocor Pamelor

Note: Brand names start with uppercase letter. Some brand names incorporate tall man letters in initital characters and may not be readily recognized as
brand names. Brand names appear in black; generic names/other products appear in red. Name pairs marked with an asterisk (*) are newly added.

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©2023 ISMP. All Rights Reserved.
ISMP List of Confused Drug Names
Drug Name Confused Drug Name Drug Name Confused Drug Name
tamsulosin tacrolimus Toprol-XL Topamax
Tanzeum Toujeo Toradol Foradil
Tanzeum Tradjenta Toujeo Tanzeum
Tanzeum Tresiba Toujeo Tradjenta
Tanzeum Trulicity Toujeo Tresiba
Tarceva Tresiba Toujeo Trulicity
Taxol Paxil t-PA TNKase
Taxol Taxotere Tracleer Tricor
Taxotere Taxol Tradjenta Tanzeum
Tegretol Tegretol XR Tradjenta Toujeo
Tegretol Tequin Tradjenta Tresiba
Tegretol Trental Tradjenta Trulicity
Tegretol XR Tegretol traMADol traZODone
Tenex Xanax trastuzumab ado-trastuzumab emtansine
Tequin Tegretol traZODone traMADol
Tequin Ticlid Trental Tegretol
Testoderm Testoderm TTS Tresiba Tanzeum
Testoderm Testoderm with Adhesive Tresiba Tarceva
Testoderm TTS Testoderm Tresiba Toujeo
Testoderm TTS Testoderm with Adhesive Tresiba Tradjenta
Testoderm with Adhesive Testoderm Tresiba Trulicity
Testoderm with Adhesive Testoderm TTS tretinoin ISOtretinoin
tuberculin purified protein Trexall* Paxil*
tetanus diptheria toxoid (Td)
derivative (PPD) Tricor Tracleer
T-Gel Bio-T-Gel tromethamine Trophamine
Thalomid Thiamine Trophamine tromethamine
Thiamine Thalomid Trulicity Tanzeum
thrombin topical Trulicity Toujeo
Thrombate III*
(recombinant)* Trulicity Tradjenta
thrombin topical Trulicity Tresiba
Thrombate III*
(recombinant)*
tuberculin purified protein
influenza virus vaccine
tiaGABine tiZANidine derivative (PPD)
Tiazac Ziac tuberculin purified protein
tetanus diptheria toxoid (Td)
Ticlid Tequin derivative (PPD)
tiZANidine tiaGABine Tylenol Tylenol PM
tiZANidine* nizatidine* Tylenol PM Tylenol
TNKase Activase Ultracet Duricef
TNKase t-PA Ultram lithium
Tobradex Tobrex Ure-Na
hydroxyurea*
Tobrex Tobradex (palatable form of oral urea)*
TOLAZamide TOLBUTamide valACYclovir valGANciclovir
TOLBUTamide TOLAZamide Valcyte Valtrex
Topamax Toprol-XL valGANciclovir valACYclovir

Note: Brand names start with uppercase letter. Some brand names incorporate tall man letters in initital characters and may not be readily recognized as
brand names. Brand names appear in black; generic names/other products appear in red. Name pairs marked with an asterisk (*) are newly added.

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©2023 ISMP. All Rights Reserved.
ISMP List of Confused Drug Names
Drug Name Confused Drug Name Drug Name Confused Drug Name
Valtrex Valcyte Xenical Xeloda
VZIG (varicella-zoster immune Yasmin Yaz
Varivax
globulin) Yaz Yasmin
vasopressin desmopressin Zantac Xanax
Venofer Vfend Zantac (raNITIdine)
Zantac 360° (famotidine)*
Venofer Vimpat [no longer marketed in US]*
Vesanoid Vesicare Zantac ZyrTEC
Vesicare Vesanoid Zantac (raNITIdine)
Zantac 360° (famotidine)*
[no longer marketed in US]*
Vessel Care (nutritional
Vesicare
supplement)
Zavesca (escitalopram) [non-US
Zavesca (miglustat)
product]
Vessel Care (nutritional
Vesicare
supplement)
Zavesca (escitalopram) [non-US
Zavesca (miglustat)
Vexol Vosol product]
Vfend Venofer Zebeta Diabeta
Vfend Vimpat Zebeta Zetia
Viagra Allegra Zegerid Zestril
Vicodin Visicol Zelapar (Zydis formulation) ZyPREXA Zydis
Videx Bidex Zemplar* Zemuron*
vigabatrin dabigatran Zemuron* Zemplar*
Vimpat Venofer Zeniquin [veterinary drug] Sinequan
Vimpat Vfend Zerit ZyrTEC
vinBLAStine vinCRIStine Zestril Zetia
vinCRIStine vinBLAStine Zestril ZyPREXA
Viokase Viokase 8 Zestril Zegerid
Viokase 8 Viokase Zetia Bextra
Vioxx Zyvox Zetia Zestril
Viracept Viramune Zetia Zebeta
Viramune Viracept Ziac Tiazac
Viramune (herbal product) Viramune (nevirapine) Zocor Cozaar
Viramune (nevirapine) Viramune (herbal product) Zocor ZyrTEC
Visicol Vicodin ZOLMitriptan SUMAtriptan
VisionBlue methylene blue zolpidem Zyloprim
Volumen Voluven Zonegran Sinequan
Voluven Volumen Zostrix Zovirax
Vosol Vexol Zovirax Doribax
VZIG (varicella-zoster immune Zovirax Zostrix
Varivax
globulin) Zovirax Zyvox
Wakix* Lasix* Zyban Diovan
Wellbutrin SR Wellbutrin XL Zyloprim zolpidem
Wellbutrin XL Wellbutrin SR ZyPREXA CeleXA
Xanax Fanapt ZyPREXA Reprexain
Xanax Tenex ZyPREXA Zestril
Xanax Zantac ZyPREXA ZyrTEC
Xeloda Xenical ZyPREXA Zydis Zelapar (Zydis formulation)

Note: Brand names start with uppercase letter. Some brand names incorporate tall man letters in initital characters and may not be readily recognized as
brand names. Brand names appear in black; generic names/other products appear in red. Name pairs marked with an asterisk (*) are newly added.

www.ismp.org | 13
©2023 ISMP. All Rights Reserved.
ISMP List of Confused Drug Names
Drug Name Confused Drug Name Drug Name Confused Drug Name
ZyrTEC Lipitor ZyrTEC Itchy Eye Drops
ZyrTEC (cetirizine)
(ketotifen fumarate)
ZyrTEC Zantac
ZyrTEC-D ZyrTEC
ZyrTEC Zerit
Zyvox Vioxx
ZyrTEC Zocor
Zyvox Zovirax
ZyrTEC ZyPREXA
ZyrTEC ZyrTEC-D
ZyrTEC Itchy Eye Drops
ZyrTEC (cetirizine)
(ketotifen fumarate)

Note: Brand names start with uppercase letter. Some brand names incorporate tall man letters in initital characters and may not be readily recognized as
brand names. Brand names appear in black; generic names/other products appear in red.
Name pairs marked with an asterisk (*) are newly added.

©ISMP 2023. Permission is granted to reproduce material with proper attribution for internal use within healthcare organizations. Other repro-
duction 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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