Unpronounceable drug names

Welcome to the Australian Prescriber Podcast. Australian Prescriber, independent, peer-reviewed and free.

I’m Dr David Liew, your host for this episode. Today I’ll be speaking to Craig Patterson, the editor of the Australian Medicines Handbook, and we’ll be discussing the editorial he’s written on unpronounceable drug names. Craig welcome to the program.

Thanks for inviting me David.

So, let’s ask the key question here – why does how we pronounce a name really make a difference? Especially if we work largely in a world of written medicines and electronic medical records and written prescriptions? Why does it make a difference how we say the name?

Well David I think perhaps we should start with a disclaimer that however drug names are pronounced in the podcast that they’re the pronunciation stylings of the author and they don’t represent Australian Prescriber or anyone else who might believe they’re pronounced differently. And that sort of gets to the nub of the problem which we’ll get to later. For me why I think it’s important is it’s as simple as being the commonality of language. It’s how we’re understood, it’s how we connect, it’s how we avoid misunderstanding and I don’t think it necessarily always has to be complicated, like you know hard-to-pronounce drug name, sometimes a misunderstanding can be quite simple. An example that springs to mind is in Australia we would say oral for taking something by mouth and aural for putting something in your ear but when I worked in the UK I noticed that they pronounced oral as aural. So from my perspective I heard people being told to put their tablets in their ear three times a day which was clearly not the intention.

Well we definitely don’t recommend that and neither does Australia Prescriber. I can see how those kinds of things can make a difference but what about subtle changes in the drug name?

So, when I was doing the background research for the article there was nothing really published much in the medical literature that was investigating errors that might occur through differences in pronunciation. So, we're working in the dark a little here. I guess for me the stand out examples are scenarios where verbal instructions about prescribing are being given and also technologies like voice recognition software and text-to-speech systems where things are being interpreted. So, if we talk about verbal instructions that might happen at clinical handover or during a ward round and you know instructions to chart a drug might come from the consultant or the registrar and it's falling to the intern with the least experience in the team. So, medicines always had its jargon, its vernacular, but these new drug names really have the feel of learning a foreign language. You're confronted by strings of letters that are not natively present in English and so you don't have any reference points really to draw upon, and I think the risk then becomes that kind of unfamiliarity means that people will try to backfill that knowledge gap and guess and so that could lead to confusion and the wrong drug being prescribed.

Absolutely. Most rational people looking at a drug name can think of more than one way to say it so how do we decide how to pronounce a drug name in our Australian context?

Yeah, I think you're absolutely right that we can arrive at different places. In the article I used the klo-pidd-oh-grell [clopidogrel] example and at the time when I heard the variant which was cloppy-dog-rel, clopidogrell had been around for quite a long time. I never heard it pronounced any differently, so it wasn't like a an early adopter situation where this was a variation of pronunciation. That's why it took me aback as much as it did because it had been around for years and this was the first time I'd ever heard somebody have a counteroffer of how to say it. But to be honest I think really, I think we're left to our own devices and end up using our own intuition and experience with these things. So, it ends up being about where people put the emphasis and where they put the breaks in syllables and that's where the variation begins.

There's a systematic way of naming a number of drugs, isn't there, but that's not necessarily something that flows across classes.

Yeah, so we start in this area, I think, by recognising that the WHO as the International Non-proprietary Naming System so you often hear people talk about INNS and in fact the TGA has changed the names of a number of drugs in Australia in the last couple of years in order to try and harmonise the Australian drug names with the INN system and so that system establishes what the rules are for how you name drugs and establishes the stems that will standardise drug names within a class that have similar pharmacological actions. So listeners will be familiar with things like -olol for beta blockers and -statin for statins or -sarten for angiotensin II receptor antagonists and so on, and so it's a system that's designed to give us as users an insight into what's in a name so that when I see a new drug and the new drug might be pitavastatin I can make assumptions of what that drug might be without actually really knowing anything about it. So that's those older drugs. I think the long unpronounceable drug names are potentially a cynicism that they're intentionally hard to pronounce so that the brand name is preferenced and I'm sure that's at play as well, but it might be surprising for people to know that there is a system around naming biological drugs and particularly with monoclonal antibodies. So, things that end in -mab, MAB’s an abbreviation for monoclonal antibodies. We can pull that system apart which might make things a little bit easier. So, if we use say something like trastuzumab, if we start at the end of the word and go backwards. As I mentioned earlier the MAB part of it indicates that it's a monoclonal antibody but then the next syllable to the left relates to the source of the drug or how it's made and so in this case it's a ZU, and that indicates it's humanised and then the one next to that to the left again relates to the target system which the drug is directed towards. So cardiovascular system, the immune system, it might be a virus, interleukins, so in this case with trastuzumab the TU indicates that the target is a tumour and then you get to the front of the word so the prefix in the word is the only free form part of the word where people are free to invent a way. The other endings, listeners will see with biologicals is they are often -nibs or -mibs or -gibs. The -ib suffix indicates that they're inhibitors. It might be an inhibitor of an enzyme or a protein.

Well that's really interesting because clearly when those, say for example with the monoclonal antibodies, those drug names are created, there’s a clear intention where the syllables should be given those meanings of syllables. So, that's one point in which we know what to pronounce across the intended syllables. There are some clues in the origin of names to the way we pronounce drugs, aren't they?

Yes but see I think that that's where the knowledge part of it comes in and you know once you understand the rules then yes you can see where the syllables fall and it makes it pronounceable but when you're just confronted with a 15-letter word and some of the strings of letters in there aren't part of English and so you don't know where to parse it with the syllables then that's I think where the variation in pronunciation occurs. And the other variation of course with any of this, it's about what we say in Australia versus what we get as pronunciations elsewhere. So that's particularly a case if we're listening to presentations on YouTube or something like that. We might end up with a pronunciation that doesn't ring true in Australia so when we were doing, in NPS, we were doing the RADAR program, initially we thought it would be very easy to give pronunciations to drugs, that we would be able to source that pronunciation for the drug somewhere, and we thought it was important because of what I said right at the beginning. It's that common currency of how people are going to talk to each other. It ended up being almost unattainable and even when we did find things and often we went to American websites in particular the American branches. So, if the WHO has all of the INN names there's a separate organisation that does that in the United States called the United States Adopted Name. They produce phonetic pronunciations of drugs, but you could tell that for some of them it wasn't the way we would say it and I only encountered this a couple of days ago when I was watching something and it was from the US and they mentioned kwy-nine [quinine] instead of kwin-ine. So those differences in the vowels mean that we really need something local I guess to be instructive of how we might say the words.

So how do we tackle that?

If you think of writing any sort of health literacy and they talk about making it like eighth grade, then doing something similar with the phonetic speech and just breaking the rules I guess and just writing it down how you want it to be said is a perfectly reasonable thing to do.

Is there anything else?

I think what I would like to see so to me, though whether we like it or not, pharmaceutical companies are the predominant people who bring drugs to market now and so they've got hold of the drug when it just has a string of letters and numbers as a name in clinical trials and giving it a name and submitting that name to the WHO. So, I feel like they are the custodians of bringing drugs to the market and that they could be instructive in establishing what the pronunciation might be and then the local company taking ownership of if it's going to be said somehow differently in Australia because it would make more sense. So, once they decide on how a drug might be referred to in this country, it would be really good if product information and CMIs started to include a phonetic pronunciation and when I say that I don't just mean the brand name, I mean the generic drug name too because they're a widely distributed reference and so it would give users a starting point about how to pronounce the drugs in Australia. And then the final thing which I think this is almost the most important thing in terms of mass distribution, is that maybe we could have audio files available. So right now, if you go to the TGA website you can go the Australian Register of Therapeutic Goods. You can access the PIs and CMIs. So, it would be good if we could have an audio file there as well that was suggesting this is how we say this drug name in Australia and that definitely be a real human voice not a text-to-speech sort of voice.

Well I'd employ you Craig to do the pronunciation, someone's got to do it, and I nominate you.

I think maybe it's somebody who's got a nice voice that does talking books like Stephen Fry or something like that.

An Australian Stephen Fry because we need it to be Australian.

Yes, an Australian Stephen Fry.

Craig that's all we've got time for today. It's been a pleasure speaking to you. Thanks very much for joining us on the podcast.

Thanks for the opportunity David.

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The views of the guests and the host of this podcast are their own and may not represent Australian Prescriber or NPS MedicineWise. I’m Dr David Liew and thank you very much once again for joining us on the Australian Prescriber Podcast.