1. Shastay, Ann MSN, RN, AOCN

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ACIPHEX SPRINKLE (RABEprazole sodium) delayed-release capsules are used to treat gastroesophageal reflux disease in children 1 to 11 years for up to 12 weeks. Although the product is a capsule, it must NOT be swallowed whole or chewed, nor should the granules be crushed. Patients or caregivers should open the capsule and sprinkle the granule contents on a spoonful of soft food or liquid, and take the entire mixture within 15 minutes of preparation. AcipHex delayed-release tablets for adults should be swallowed whole, not crushed or chewed. AcipHex Sprinkle is the only capsule formulation proton pump inhibitor (PPI) that cannot be swallowed whole. All other PPI capsules, such as omeprazole, esomeprazole, and lansoprazole, can be swallowed whole, although patients who have difficulty swallowing can also open these capsules and sprinkle the pellets over a tablespoon of applesauce. Other sprinkle capsules, such as topiramate sprinkle capsules, divalproex sodium delayed-release sprinkle capsules, and KLOR-CON sprinkle capsules (potassium chloride extended-release), can be swallowed whole or opened and sprinkled over soft food.


Some of the auxiliary labels that automatically print with pharmacy labels for AcipHex Sprinkle capsules may be interpreted to mean that the capsules can be swallowed whole (Figure 1). If applied to the prescription bottle, the labels can cause confusion and increase the risk of incorrect administration if older children try to swallow the capsules.

Figure 1 - Click to enlarge in new windowFigure 1. Auxiliary labels printed with AcipHex Sprinkles prescription label are confusing. AcipHex Sprinkles delayed-release capsules should NOT be swallowed whole.

Retail pharmacies should evaluate the medical information pamphlet and auxiliary labels programmed to print with AcipHex Sprinkle prescriptions to be sure they reflect the correct administration method. Nurses need to be aware of the correct administration either through built-in administration instructions in the electronic medical record or other drug information resources. We also contacted all major drug information vendors so they can make any necessary changes to auxiliary warnings they provide in their content for pharmacies.


Please, no more teaspoon dosing. Some community or ambulatory care pharmacists mistakenly believe it is helpful to "translate" prescription liquid dosing instructions for patients from metric (e.g., milliliters [mL]) to household measures (e.g., teaspoon). When they receive a prescription with dosing in mL, they change it to teaspoon dosing or list both teaspoons and mL (in parentheses) on the label, believing most consumers are more familiar with household measures than metric dosing.


Unfortunately, pharmacy staff have inadvertently typed the number of mL in the teaspoons field, sometimes resulting in patient hospitalization. A close call occurred when AUGMENTIN ES-600 (amoxicillin and clavulanate) suspension was prescribed for a child with otitis media. When the child's mother picked up the medication, a pharmacist provided counseling about how often to give each dose, to discard the medication in 10 days, and that it may cause diarrhea. However, the actual volume required for each dose was not discussed. Later, when the child's parent read the label at home, it said, "Give 5 teaspoons by mouth twice daily for 10 days." Wondering if this was accurate, she logged into an electronic patient portal to view a summary of her child's office visit and saw that the dose should have been 5 mL, not 5 teaspoons.


Mix-ups between mL and teaspoon have been a longstanding problem. In recent years, there has been considerable movement toward the use of the metric system for all over-the-counter (OTC) and prescription liquid medications. Most oral dosing devices now display an mL scale, some exclusively. Thus, "translating" mL doses to teaspoons, or listing both teaspoons and mL on labels, should cease, as it is not helpful to patients and creates confusion. The National Council for Prescription Drug Programs published Recommendations and Guidance for Standardizing the Dosing Designations on Prescription Container Labels of Oral Liquid Medications in 2014, calling upon stakeholders, particularly pharmacy leadership, to adopt mL dosing as the standard. This is needed for all patient instructions on pharmacy labels and in computer systems. Also, always provide an appropriate metric dosing device, and ensure that patients or caregivers know how to measure the dose in mL, using "teach back" to confirm understanding.


Dramamine umbrella name confusing. The brand name DRAMAMINE is the latest example of a well-known, successful, OTC drug name being recycled for use in products that contain a different active ingredient or ingredients that differ from those in the original product. The original Dramamine contains 50 mg of dimenhydrinate (Figure 2), which is also available in a chewable form, along with a children's formulation containing 25 mg. But there is now a Dramamine that contains meclizine 25 mg per tablet (Figure 3), and another formulation that only contains ginger root-Dramamine Non-Drowsy Naturals, a supplement (Figure 4). Packaging for all these products highlights the Dramamine name. When an "umbrella name" (brand-name extension) is used for products with varying ingredients, there is bound to be confusion regarding the product's ingredients, strength, and concentration. The wrong product or dose may be taken or the product may be used when contraindicated. Misleading product names can also cause confusion when treating side effects or accidental ingestion of these products. Although full ingredients are listed in the product's Drug Facts or supplement panel, this information may be overlooked due to confirmation bias.

Figure 2-4. Dimenhyd... - Click to enlarge in new windowFigure 2-4. Dimenhydrinate (1), meclizine (2), and ginger (3) are all "Dramamine" products.