"Where name and image meet"—the argument for "adrenaline"

British Medical Journal, Feb 19, 2000 by Jeffrey K Aronson

Summary points

A European Commission directive requiring member states to use recommended international non-proprietary names for all drugs is soon to be implemented

For most drug names there will be little or no change

For around two dozen drugs the changes are more important; these will be dual labelled during the five year changeover period

It is intended that adrenaline (British approved name) will be changed to epinephrine (recommended international non-proprietary name)

The strong arguments for persuading the European Union to resist this particular change are based on usage, history, etymology, and, most importantly, risk of clinical errors

Their white epinephrin, my crimes Aldous Huxley, Island

Assuming that you don't want to call it dihydroxyphenylmethylaminoethanol, which name should you use--adrenaline or epinephrine? All the arguments and evidence suggest that you should prefer adrenaline.

Naming names

All drugs have at least three different names.[1]

* The chemical name-whose form generally follows the rules issued by the International Union of Pure and Applied Chemistry--for example, (R)-1-(3,4-dihydroxyphenyl)-2-methylaminoethanol.

* The approved (official or generic) name--which is usually the World Health Organisation's recommended international non-proprietary name (rINN). However, it may be some locally approved name--for example, the British approved name (BAN), denomination commune francaise (DCF),Japanese accepted name (JAN), or United States adopted name (USAN). The monster substance mentioned above is better known as adrenaline (British approved name) or epinephrine (recommended international non-proprietary name).

* The proprietary (brand or trade) name--which is the name given by a pharmaceutical manufacturer. For example, adrenaline is marketed in Britain as Epipen for intramuscular injection and as Eppy or Simplene eyedrops.

The chemical name is an unambiguous description of a drug's structure, but it is cumbersome and irrelevant to practical prescribing. As for brand names, pharmaceutical manufacturers make their own choices, although to avoid confusion between similar names of different drugs or formulations, these are subject to some restrictions.[2] But the existence of different approved names in different countries is unnecessary and potentially confusing. The European Community therefore issued a directive in 1992, decreeing that in member countries the recommended international non-proprietary name should be used exclusively.[3]

The practicalities

Three cases arise in following this directive.

* In most cases, the British approved name and other national names are the same as the recommended non-proprietary names, and no changes are required.

* In many other cases, the British approved names and recommended international non-proprietary name are similar, and the changes are trivial (for example, we shall prescribe amoxicillin, not amoxycillin). A list of these names is given as "List 2" in the British National Formulary.[4]

* In a few cases (although a much longer list has been proposed[5]), the Medicines Control Agency considers that the change of name constitutes a high public health risk.[6] In the United Kingdom these names will change over at least five years, and there will be dual labelling of medicines during that time. For instance, frusemide will eventually be called furosemide, bendrofluazide will become bendroflumethiazide, and lignocaine will become lidocaine--but during the transition period both names will be printed on labels and in information leaflets for patients. A list of these drugs ("List 1") is given in the British National Formulary) Other versions of this list[7 8] do not tally exactly with that in the British National Formulary, but the drugs number roughly two dozen.

In 1995 the Medicines Control Agency announced its intention to implement the changes required by the 1992 directive.[9 10] Full implementation was planned for 1998, but it was subsequently estimated that the necessary statutory instrument would not be published before the middle of 1999 at the earliest.[11] At the time of writing (July 1999) it was not in force.

Opposition

Some people in the United Kingdom will deplore these changes,[12] partly because they will regard them as a wholesale abandonment of British approved names in favour of American ones. But they will be wrong. Although some of the recommended international non-proprietary names that replace current British approved names also happen to be United States adopted names, there are many opposite cases (table 1).

Table 1 Some recommended international non-proprietary names that are British approved names, not United States adopted names

British approved name (and recommended           United States
international non-proprietary name)              adopted name

Glibenclamide                                    Glyburide
Isoprenaline                                     Isoproterenol
Moracizine                                       Moricizine
Orciprenaline                                    Metaproterenol
Paracetamol                                      Acetaminophen
Pethidine                                        Meperidine
Rifampicin                                       Rifampin
Salbutamol                                       Albuterol
Torasemide                                       Torsemide