Phosphonorm® is used to treat hyperphosphataemia in advanced kidney disease and secondary hyperparathyroidism. In the intestine Phosphonorm binds the phosphate ingested with food and reduces its absorption. By contrast, Phoscap capsules contain phosphate and are used to treat hypophosphataemia. Cases of hypophosphataemia occur for example in connection with alcohol use disorders, burns, hunger or the use of diuretics.
Phosphonorm® administered instead of Phoscap capsules
Incident data |
Description |
|---|---|
Age: adult Sex: female Medicinal products: Phosphonorm® Active substance(s): aluminium chloride hydroxide complex Indication/ADR: Wrong product administered in hypophosphataemia, product name confusion Outcome: recovered |
A female patient in intensive care should have received phosphate replacement with Phoscap to treat hypophosphataemia. However, she was mistakenly given Phosphonorm®. After two doses, the administration of Phosphonorm® was stopped and the treatment with Phoscap was started. No adverse drug reactions associated with the incorrect medication were reported. The similarly sounding product name was stated as the cause of the medication error. |
Summary and recommendation
Phoscap and Phosphonorm® are used for opposite indications. Mistakenly treating a hypophosphataemia with Phosphonorm® can exacerbate the patient's condition. Healthcare professionals in Switzerland should be particularly aware of the correct indication of Phosphonorm®, i.e. the treatment of hyperphosphataemia.
Statutory duty of healthcare professionals to report adverse drug reactions (ADRs)
In Switzerland, healthcare professionals who are authorised to dispense or administer medicinal products are obligated to report severe and/or previously unknown side effects. Reports to Swissmedic can be entered and sent in the Electronic Vigilance Reporting Portal “ElViS” (ElViS login).
Reporting adverse drug reactions
Electronic reports via the ElVis portal
Note for marketing authorisation holders
If articles in this section refer to individual cases, these cases are already recorded in the Swiss spontaneous reporting system and have been transmitted to all responsible institutions. We ask affected marketing authorisation holders not to report these cases again (“back report”) to Swissmedic.