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Cohen and Smetzer

strength increases the risk of an error. It is also possible that
the odd 123-mg strength of migalastat may be viewed as a
dosing mistake.
To prevent errors, neither medication should be prescribed,
dispensed, or refilled without verifying the proper patient
diagnosis. If you have both medications in your organization,
consider adding an alert during order processing to warn about
possible mix-ups or require a hard stop to verify the patient's
diagnosis. Also refer to these medications using brand names
when possible. Barcode scanning should be employed during
product selection and administration, and we recommend storing the medications apart from one another. We are considering tall man letters (e.g., migALAstat and migLUstat) to help
differentiate these drugs on computer screens and in other presentations. We will inform you if we add this drug name pair
to our list of drug names with tall man letters.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
Figure 1. Although these vials are somewhat different in
overall appearance, the light blue cap color contributed to the
medication mix-up.

Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.

References

Figure 2. This label color is the standard American Society for
Testing and Materials (ASTM) color for opioids.

normally breaks down certain fatty substances that can build
up in some organs and cause problems in the liver, spleen,
bone, and blood. Both drugs are associated with enzymes
and fat disorders.
In addition to name similarity, migalastat and miglustat
are both only available in a capsule dosage form; migalastat
comes as a 123-mg capsule and miglustat as a 100-mg capsule. Because only 1 strength is available for either medication, the strength may be omitted when ordering the drug in
some circumstances. With similarities in names, single
strengths, and oral capsule formulations, omitting the

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Hospital Pharmacy - June 2019

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