March 2007: ALERT: Zytram XL Name Looks and Sounds Like Zyban
ISMP Canada has received a report of concern about a newly marketed product with the brand name Zytram XL. Zytram XL is the brand name for tramadol hydrochloride controlled release tablet. Zytram XL looks and sounds like a brand name for buproprion hydrochloride, Zyban. Zytram XL is an opioid analgesic, whereas Zyban is a smoking cessation aid. With both products available in 150 mg tablets (Zytram XL is also available in 200 mg, 300 mg, and 400 mg controlled release tablets), the reporter expressed concerns about the possibility of an inadvertent mix-up. Subsequently, ISMP Canada received a second report in which a prescription for “Zytram XL 150 mg po once daily” was processed as “Zyban 150 mg po once daily”. ISMP Canada has notified Health Canada and Purdue Pharma, and both organizations are following up on these reports.The following strategies are suggested as interim measures to reduce the risk of a mix-up: use the generic name (in addition to the brand name where applicable), clarify the indication of the drug with the patient and the prescriber if necessary, clearly distinguish the two drugs in the product selection screen of pharmacy order entry systems, and avoid stocking these items in close proximity in the pharmacy.
