This column was prepared by the Institute for Safe Medication Practices (ISMP), an ECRI affiliate. 

A doctor told a woman with a vaginal infection to use boric acid suppositories to help relieve symptoms that often accompany vaginitis, such as a bad odor. Boric acid (a pesticide that is harmful when taken orally) suppositories are sold over-the-counter and do not require a prescription. What is confusing is that boric acid suppositories come as a powder inside a gelatin capsule that looks similar to oral capsules. Also, they are often packaged in plastic bottles as loose capsules that resemble oral medications or dietary supplement products. In fact, people who have had an infection in the past may have been prescribed medication in a capsule, such as an oral antibiotic, to treat the infection. Patients may not be familiar with capsules used as suppositories.  

In the report the Institute for Safe Medication Practices (ISMP) received, the patient swallowed one of the suppositories. Later, when she read the container label more carefully, she realized the capsules were suppositories meant for vaginal insertion. There was also a warning on the container that said, “For vaginal use only, not for oral consumption. If swallowed, get medical help and call poison control right away.” The woman decided to go to an emergency room. According to poison control, the small amount of boric acid in a single capsule would not be expected to cause harm. However, ingesting large amounts of boric acid may result in gastrointestinal distress, kidney problems, or death. Fortunately, the patient did not suffer any serious problems. A search of the internet revealed numerous other cases of women swallowing boric acid suppositories unintentionally.  

Given that the basic problem is patients confusing boric acid suppositories for oral capsules, ISMP is asking Food and Drug Administration and product manufacturers to investigate ways this common error can be prevented. For example, consider reformulating products so they are shaped as suppositories. Most suppositories are waxy and small, with a round or cone shape; vaginal suppositories are usually oval and are not gelatin capsules filled with powder. These products should also be sold in unit-of-use blister packs, with the carton holding enough for use over a typical course of treatment, which is seven to 14 days. Vaginal products should also include an applicator with instructions and a link to a professional video that explains what a vaginal suppository is and how to properly use them. Additionally, the cartons and individual blisters need to call out the name of the product (boric acid) and a more conspicuous warning, such as “For vaginal insertion only.” Community pharmacies may consider moving these products closer to the pharmacy counter to better enable pharmacists to support and educate patients on the safe use of these products.