Beware of confusion between the medication Lytos (sodium clodronate tetrahydrate) and the food supplement Lithos (potassium and magnesium citrate)

A risk of confusion between the medication Lytos and the food supplement Lithos has been reported when dispensing these products in pharmacies.

The French National Agency for Medicines and Health Products Safety (ANSM) and the French Agency for Food, Environmental and Occupational Health & Safety (ANSES) would like to inform healthcare professionals and patients about this risk of error.

The medication Lytos by the Riemser Pharma GmbH laboratory is a biphosphonate indicated for certain severe cases of hypercalcaemia (high level of calcium in the blood) as follow-up to the form for injection, and for certain bone tissue disorders with or without hypercalcaemia.

The food supplement Lithos marketed by Biohealth Italia is used in the event of significant loss of fluid related to excessive perspiration, substantial diuresis, or diarrhoea.

Since these two products are pronounced the same in French and have similar spellings, confusion and medication errors can easily occur.

In order to limit this risk, the agencies recommend:

For prescribers: 

  • systematically prescribing the medication Lytos by its international nonproprietary name (INN) in additional to its trade name;
  • for the food supplement Lithos and in general for all food supplements: adding the product's status (food supplement), separating them from medications, and including the word "recommendation" on prescriptions if possible.

For pharmacists:

  • if a prescription is hard to read or if you have doubts about what is written, contacting the prescriber to verify the prescribed product, clarifying its status and the active substance and the indication if appropriate;
  • making sure you have the intended product, when ordering it orally or electronically from the wholesaler-distributor, when receiving an order, and when dispensing the product to patients, in particular by verifying the active substance of the prescribed product.

For wholesalers-distributors:

  • verifying, when orders are placed orally or in writing by pharmacies, if they are for medications or food supplements, especially by confirming the active substance or verifying the product's spelling;
  • making sure you have the right product when preparing an order.

For patients:

  • asking your pharmacist or doctor questions if in doubt.