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Wrong medication dispensed!!!!! Wrong medication dispensed!!!!!

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Unread 02-20-2003, 07:54 PM
Wrong medication dispensed!!!!!


I just found out that my old pharmacy dispensed the wrong medication to me for my bladder!!!! I just changed to a closer pharmacy and had a refill of Elmiron for my Interstitial Cystitis filled. The capsules were white. The former pharmacy dispensed a little pinkish ball. When I got home last night, I noticed the new ones were different looking so I called the pharmacy this morning. They looked it up in the book and Elmiron ONLY comes in the white capsules!!!!!!!!!

This morning, after I called the new pharmacy, I peeled part of the label off and saw underneath it says "Prometrium" - the pharmacy assistant from the new place just called as they've been researching this and KNEW before I even told them what the little round pink ones were!!!!


As many of you know, I've been having severe lower pelvic pain for past couple of months which has been much worse for the past month....I started taking the wrong med on Jan. 13, the day I was diagnosed with IC.

So, now....I've been taking 3 of these little pink balls for the past month, every day. I'm scheduled for a lap on 3/13 and now I wonder what is really in there??????

Does anyone know what could happen if you take Progesterone with no uterus, etc. I take Menest also.....

How will I sleep tonight??????

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Unread 02-20-2003, 09:19 PM
Wrong medication dispensed!!!!!

(((Lori)))) I'm soooo sorry you're dealing with yet another issues It's little surprise that you were not improving!!!!

Since I have my ovaries and they are, kind of, working, I haven't really explored the HRT issues. However, I do know that some women who have had total hysterectomies and BSO's have had some success with Progesterone, so it may not be as bad as you fear. A good place to ask this question would be in The Hormone Jungle message board, where you'll find the answers regarding surgical menopause and HRT.

I would also contact your doctor and inform him/her of what's happenned, since this may have an impact on the course of treatment chosen for you.

Sending lots of ing s your way. Please keep us posted.
Unread 02-20-2003, 09:20 PM
Uh, Oh....

Sounds like you were on a hormone therapy without knowing it (Yikes!). SO sorry to hear this....

I'm not sure that any damage was done; bloodwork will probably be needed to check P4 (Progest.) levels.

The b/w and Lap will give more conclusive evidence; try not to panic and just see how things go 1 step at a time. It's easy for me to say, I realize, but you getting aggrevated is only going to make the IC worse with pain from the stress. I feel so bad for you with this situation.

Let's hear how you're doing.....
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Unread 02-20-2003, 09:57 PM
Wrong medication dispensed!!!!!

Hi Lori~I saw your post and thought that you may like to know that Prometrium is often prescribed now for people who had endometriosis; even though their uterus was removed. It works by inhibiting estrogen and preventing further growth of endometrial lesions or implants. It's totally bio-identical. I take 200mg or 2 pink pills every night in addition to estrogen and testosterone. It probably didn't hurt anything but you should definately discuss this situation with your prescribing doctor. The mislabeling is not good in any case. Some find that with endo, they are unable to tolerate very much estrogen as it causes the endometriosis to grow.
Unread 02-20-2003, 10:24 PM
Wrong medication dispensed!!!!!

Hi (((Lori))) how awful that this happened to you! I would not be nearly so concerned about the fact that you've taken a month of progesterone when you didn't need it.... while it might have caused some drowsiness or aching, it may have had no effect at all... but I'd be more concerned about your having missed that whole month's worth of Elmiron that you were supposed to be taking.

I would definitely give your DR a call in the morning and make sure he/she understands what happened, and that you've been taking the wrong medication for the past month. He/she may want to check your hormone levels or do a few more tests or give you more time on the (real) Elmiron before doing your lap.

Try not to worry too much, try to focus on the fact that you've now got the right medication and hopefully it will start to help you feel better.
Unread 02-20-2003, 10:34 PM
Thank you Sisters...

Thank you for your quick responses to my post tonight.....it's a bit unnerving and actually very scary that something like this could happen.

I do feel some relief knowing now why I was feeling worse and not better.

I will call my GYN and Uro first thing in the morning...promise to keep you updated.

No wonder it felt like my ovaries were growing back and I had PMS!!!

Good Night all,
Unread 02-21-2003, 12:10 AM
Wrong medication dispensed!!!!!


The good news is that your PMS should disappear relatively soon.

However, you need to contact the manager of your old pharmacy -- that ongoing medication error should be investigated as it could have had dangerous implications...among other potential problems, Prometrium is in a peanut oil base -- had that been dispensed to someone with a peanut allergy (or who lived with a family member who was allergic) it could have been a fatal mistake. That's a major error on the part of the dispensing pharmacist!!

Hang on to your bottle with its label. The initials of whoever filled it will be on there, and the manager of the pharmacy (not just the shift manager, but should be the managing pharmacist) will want that information.

Many of us do take Prometrium -- mostly it would have interfered with the estrogen's effects in the Menest you are taking.

But please, please, make sure this is followed up...a dangerous mistake like this must be disciplined and protocols put in place so it doesn't happen again...

Unread 02-21-2003, 02:50 AM
Can't sleep tonight - pain

Thanks Audrey for your post and info.

I'm having a tough time sleeping tonight due to pelvic/bladder pain. I came down to get an ice pack to sleep with...my DH thinks I'm crazy, but it really helps.

I will definetly be following up on this. The owner of the pharmacy is one of the pharmacists there, I've never cared much for him. The other 2 pharmacists are super guys. I really don't remember who actually "handed me" the new med, but I definetly remember no one asked me about peanut allergy! I read up on the Prometrium and saw the allergy info....FORTUNATELY for me (and them) I don't have one, but that would have been a disaster if I had.

Still, as one sister said, I have not been taking the meds for the bladder I thought I was, and in fact have been taking something I don't need.

Back to bed now with my frozen friend.

Unread 02-21-2003, 06:58 AM
Wrong medication dispensed!!!!!

How maddening and frightening. I've noticed that lately, when I pick up my meds, the pharmacist opens the bottle, tells me the name of the drug and what the pill should look like, and shows it to me. My pharmacist is a grouchy little so-and-so, but I love him. He fusses at the doctors when they don't write the dosage exactly correctly, and just generally wants things to be absolutely correct at all times.

I hope that you start getting some real relief now that you have the right meds.
Unread 02-21-2003, 10:56 AM
Wrong medication dispensed!!!!!

What a scary mistake! I have always been nervous about this happening to me. I keep a pill book handy and check the pic against what I'm given. Of course, if it's generic then there is a difference. I agree with everything that Audrey said. Good luck and keep us posted.

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