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Reporting a Medication Error

Mix-ups between five different inhalers that all include “Ellipta” as part of their brand names

Published June 4, 2018

The name of a unique inhaler device included in five different brand name medicines has led to multiple mix-ups, not only by consumers but by doctors, pharmacists, and nurses as well. In 2013, the global drug company, GlaxoSmithKline, introduced Ellipta, a new type of inhaler device. It is circular in shape, about the size of a hockey puck, and can combine several different medicines together. The company has packaged combinations of one, two, or three of the medicines listed below using this unique inhaler device. The five brand name products that include the Ellipta device name are:

  • Breo Ellipta (fluticasone and vilanterol), which is used to treat asthma and chronic obstructive pulmonary disease (COPD)
  • Arnuity Ellipta (fluticasone), which is used to treat asthma
  • Anoro Ellipta (umeclidinium and vilanterol), which is used to treat COPD
  • Incruse Ellipta (umeclidinium), which is used to treat COPD
  • Trelegy Ellipta (fluticasone, umeclidinium, and vilanterol),which is used to treat COPD

In early 2017, we first alerted healthcare providers to these mix-ups. One of the events that triggered that alert involved a community pharmacist who mistakenly dispensed Breo Ellipta to a consumer who had been prescribed Incruse Ellipta. The pharmacist was only familiar with Breo Ellipta and had never heard of Incruse Ellipta. He therefore misread the prescription for “Incruse” Ellipta as “Increase”  Ellipta. Since this was a new medicine for the consumer, the pharmacist called the doctor to clarify the “increased” dose of what he thought was a prescription for Breo Ellipta. Not recognizing the pharmacist’s confusion, the doctor simply confirmed the starting dose for a patient taking Breo Ellipta. This error was finally identified a month later when the consumer was hospitalized for an unrelated surgery. A hospital pharmacist asked the consumer about medicines he took at home and became suspicious when he learned the consumer was using both Breo Ellipta and another inhaler product that contained the same corticosteroid, fluticasone.

Figure 1. Image from website for Breo Ellipta (left) compared to the actual product (right).

Since then, ISMP has reviewed a year’s worth of adverse drug event reports submitted to the US Food and Drug Administration (FDA) between October 2016 and September 2017. We found 557 error reports indicating that consumers and healthcare providers had confused these inhaler products. Compared to all other drugs we examined during this period, 557 was a very large number of error reports for one product. Most of the errors involved Breo Ellipta and Anoro Ellipta. While the names Breo and Anoro are unique, the two products are easily confused because of their common Ellipta name and nearly identical packaging. The other reports identified only a few mix-ups between Arnuity Ellipta and Anoro Ellipta. But those names are similar enough to make mix-ups likely as the two brands become more popular.

Also, if consumers visit the product websites to learn how to use the new Ellipta type of inhaler, they are exposed to erroneous and misleading images of the product. For example, on the company website the image of the Breo Ellipta inhaler looks different from the actual product. The web version features only the “Breo” brand name; “Ellipta” is missing, as are the generic names of the medicine, the strength, and other important label information (Figure 1). The online picture does not resemble the actual Breo Ellipta label except in color. Worse yet, an instructional video that was on the company website about how to use the Breo Ellipta inhaler portrays the device with a label that only reads “Ellipta” (Figure 2). This furthers confusion between the various products using the Ellipta inhaler name. Or, it could make consumers who watch the video believe the pharmacy has dispensed the wrong product. 

Figure 2. An image from the Breo Ellipta video instructions only includes the device name on the product label.

Here’s what you can do: If your doctor prescribes an inhaled medicine that uses the Ellipta inhaler device, be sure you know exactly which product is intended before you leave the doctor’s office. When you fill your prescription, verify that the intended product has been dispensed before you leave the pharmacy. Make sure your pharmacist knows whether you have been prescribed the inhaled medicine to treat asthma or COPD. Knowing why the medicine has been prescribed might help the pharmacist be sure you get the right product. Talk to your pharmacist if you have any questions about how to use the inhaler. If you visit the product website to watch the instructional video, be aware that your inhaled medicine product will look different than portrayed on the website.

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