Do Not Let “Depo-” Medications Be a Depot for Mistakes

Several longstanding medications are available on the market with names that begin with the prefix “Depo-,” meaning they are administered via a depot injection that deposits the drug into localized tissue from which it is gradually absorbed by surrounding tissue. These injections, typically subcutaneous, intramuscular, or intra-articular, allow the active compound to be released consistently over a longer period of time.

Many of these medications with the prefix “Depo-” have been on the market for 30 to 50 years, some even longer. Misadministration of these medications by the intravenous (IV) route has been consistently reported throughout the years, as has confusing one “Depo-” medication with another. More recently, mix-ups between different strengths and volumes of containers of a “Depo-” drug have occurred. The “Depo-” medications most often involved in these wrong route, wrong drug, or wrong strength/volume errors include: 

• DEPO-PROVERA, DEPO-PROVERA Contraceptive Injection, and DEPO-SUBQ PROVERA 104 (medroxyPROGESTERone acetate): an intramuscular or subcutaneous progestin used as a contraceptive, or to treat endometriosis or endometrial carcinoma.
• DEPO-MEDROL (methylPREDNISolone acetate): an anti-inflammatory or immunosuppressive corticosteroid given via intramuscular or intra-articular injection.
• DEPO-TESTOSTERONE (testosterone cypionate): an intramuscular androgen used to treat male hypogonadism.

Today, the “Depo-” naming convention would be a concern for FDA based on its proprietary name review criteria. However, when these drugs were first approved, the risk associated with this prefix was not considered. It would be very difficult to change the names of these products today—it may even make the risk of errors greater since these drug names are widely recognized.

What strategies does your organization have in place to prevent mix-ups between these “Depo” products?

Matthew Grissinger, RPh, FISMP, FASCP, is the Director of Error Reporting Programs at the Institute for Safe Medication Practices.