title: Intracerebral hemorrhage associated with use of an imported medication.
abstract: BACKGROUND
  The importation of medications is strongly discouraged in the United States. However, with the cost of prescription medications on the rise, an increasing number of patients are seeking alternative ways of obtaining drugs. Although medication errors involving imported drugs have been described in the literature, there is little available information on the prevalence of such problems.
  
  
  METHODS
  A 74-year-old woman who had been taking warfarin therapy for >2 years presented to the emergency department with new-onset headache. She was found to have a small subdural hematoma on computed tomography and a prothrombin time >120 seconds. Warfarin was stopped and anticoagulation was corrected with fresh frozen plasma. At follow-up testing, the international normalized ratio (INR) continued to be >2 despite vitamin K therapy and the patient's insistence that she had discontinued warfarin. Further evaluation by a hematologist detected warfarin in the blood. Subsequent inspection of her medications revealed unmarked white tablets labeled "phenytoin" that had been dispensed by a pharmacy in another country. The INR normalized after these tablets were discarded and a new prescription for phenytoin was started.
  
  
  CONCLUSIONS
  Application of the Naranjo scale to this case suggested a high likelihood of an adverse drug reaction (ADR). Potential causes of the ADR included the placement of warfarin in a bottle mislabeled "phenytoin" and contamination of phenytoin with warfarin.
  
  
  CONCLUSIONS
  Obtaining medications from pharmacies in or by mail order from other countries means that patients miss the opportunity to ask questions and receive counseling from a pharmacist. Physicians and pharmacists should inspect patients' medications to ensure product legitimacy and confirm that the indications, dispensing, and labeling are accurate.
authors.affiliation: Mayo Clinic College of Medicine, Rochester, Minnesota 55905, USA. haidar.wael@mayo.edu
authors.forename: Wael N
authors.initials: WN
authors.lastname: Haidar
authors.forename: Robert W
authors.initials: RW
authors.lastname: Hoel
authors.forename: Paul Y
authors.initials: PY
authors.lastname: Takahashi
mesh_terms: D000368:Aged; D000925:Anticoagulants / Q000009:adverse effects* / Q000627:therapeutic use; D000927:Anticonvulsants / Q000627:therapeutic use*; D002543:Cerebral Hemorrhage / Q000139:chemically induced*; D004340:Drug Contamination; D004348:Drug Labeling; D005260:Female; D006801:Humans; D019934:International Normalized Ratio; D008508:Medication Errors; D010672:Phenytoin / Q000627:therapeutic use*; D013607:Tablets; D014859:Warfarin / Q000009:adverse effects* / Q000627:therapeutic use
chemical_list: D000925:Anticoagulants; D000927:Anticonvulsants; D013607:Tablets; D014859:Warfarin; D010672:Phenytoin