Lamisil (Terbinafine) and Lamictal (Lamotrigine) Name Confusion
October 8, 2009
Prescription dispensing errors have occurred when Lamictal (lamotrigine) was dispensed instead of Lamisil (terbinafine) and vice versa. Lamictal is an anticonvulsant medication used in a number of neuropsychiatric disorders. It comes in 25 mg, 100 mg, 150 mg, and 200 mg tablets. Lamictal is generally dosed twice daily and is titrated to effect. In comparison, Lamisil is an antifungal medication most commonly used for nail fungal infections. It is supplied as 250 mg tablets, cream, or topical spray. The tablets are dosed once daily and are not titrated to effect. Serious consequences of error include precipitating a seizure or bipolar episode from failure to take Lamictal and increasing the risk of serious rash such as Stevens-Johnson’s syndrome. Things that can be done to lessen the chance of an error include:
- Pharmacies – Store the medications in separate places in the pharmacy.
- Prescribers – Write both the brand and generic names on all prescriptions along with indication.
- Pharmacy staff – Verify the brand and generic names with the prescriber whenever possible.
- Patients – Tell your pharmacist why you are taking these medications and report any changes in medication appearance.
The following links are available for additional information and helpful ideas.
- FDA MedWatch safety alert:
- GlaxoSmithKline Lamictal website with tablet pictures:
- ISMP Confused Drug Names list:
October 8, 2009; August 4, 2006; University of Utah, Drug Information Service. Copyright 2009, Drug Information Service, University of Utah, Salt Lake City, UT.