It Takes A College Diploma To Convince People Not To Waste Money On Name-Brand Meds

[FarCenter]

Even doctors know it's pointless to spend money on name-brand medications.

A new study from the University of Chicago business school finds that pharmacists are much more likely to buy generic over-the-counter pain relievers than spend more money on name brands.

Store brand, generic OTC pain relievers almost always have the exact same dosages and active ingredients of their name-brand counterparts (the FDA makes sure of that). Even so, consumers have proven they still have a hard time passing up recognizable brands like Tylenol and Advil in favor of cheaper generics.

The study finds:

In a case study of headache remedies, we find that college education, working in a healthcare occupation, and other proxies for product knowledge predict more purchases of private labels relative to brands. Pharmacists devote almost 90% of headache remedy purchases to private labels, against 71% for the average consumer. ... We conclude that a significant share of the willingness to pay for brands in these categories would disappear in a world where consumers were fully informed.

Read more: http://www.businessinsider.com/dont-waste-money-on-name-brand-medications-2013-6

[StrayKat]

1. It depends.

Some generics really are equivalent, but others aren't.

I remember my own grandmother used to take a name brand (Coumadin) until 'equivalents' were FDA approved at which point her HMO would only cover the cost of the generic. She switched to the generic, which only cost 40% of the name brand, but had to take 3 times the dose (verified by blood tests). It was not efficient or cost effective to use the generic in this case.

[cyberswede]

2. But this excerpt is talking about OTC meds, not prescription meds.

[StrayKat]

3. True.

I just disagree with the article's assertion that the differences don't apply to OTC meds. I've noted differences between name brand and generic OTC meds. But, the diff is more subjective.

[Ms. Toad]

5. Coumadin is one of the few where there is medical recommendation against switching

It isn't that the generic doesn't do the same thing, but that it is such a hard drug to get just the right amount so even the permitted manufacturing variation in dosage makes switching dangerous.

If one starts on Coumadin, one should generally continue on it. If one starts with a generic version of warfarin, one should generally stay on the same generic brand.

“Taken together, these results suggest that generic warfarin products meeting FDA standards for bio-equivalence are probably as safe and effective as brand name products. We conclude, therefore, that patients may be safely treated with generic warfarin. However, closer monitoring may be reasonable when switching brands, as variations in individual INR response may be seen. Furthermore, we recommend that individual patients infrequently change warfarin manufacturers, allowing the development of a stable warfarin dosage" ( Francesco Dentali, M.D.; Marco P. Donadini, M.D.; Nathan Clark, Pharm.D.; Mark A. Crowther, M.D.; David Garcia, M.D.; Elaine Hylek, M.D.; Dan M. Witt, Pharm.D.; Walter Ageno, M.D. Brand Name versus Generic Warfarin: A Systematic Review of the Literature. Pharmacotherapy. 2011;31(4):386-393.)

Not that I've ever looked into this specific issue with this specific drug...I can't even get stabilized without a brand switch and with rigorous tracking of Vitamin K intake.

[StrayKat]

6. Is it that rare?

The article in the OP links to another that discusses the FDA changing its decision on generic Wellbutrin and indicates that the differences in prescription meds might not be that rare.

Consumers are told that generics are just like their name-brand counterparts. More medical professionals are starting to say that's not the case. - CNNMoney

It also points to the loose definition of biological equivalent:

The FDA's rules effectively acknowledge that. The agency's definition of bioequivalence is surprisingly broad: A generic's maximum concentration of active ingredient in the blood must not fall more than 20% below or 25% above that of the brand name. This means a potential range of 45%, by that measure, among generics labeled as being the same.

Combined with the differences that can exist in non-active ingredients, buffers, individual biology of consumers, etc. I think there is much room for even meds declared bioequivalent to behave quite differently in the body. And, I think these differences extend to OTC meds, not just prescriptions.

I also think that perceived differences like not relieving a headache as effectively are more likely to be dismissed by healthcare professionals and researchers than measurable ones like blood cell counts. That's one of the reasons I mentioned the less subjective observation of the effect of generic vs brand name Coumadin in my grandmother's case. She also suffered more subjective side effects like tiredness and body aches from being on the Warfarin, which would be expected of anyone required to take a triple dose of any medication.

[Ms. Toad]

7. Wellbutrin & coumadin

both fall into this category:

The committee voted to support the tightening of bioequivalence standards for narrow therapeutic index drugs. The FDA's Davit says the agency is working on a proposal to "narrow the acceptance criteria."

Essentially - it means that if dosage REALLY matters for treatment, then the bioequivalence window they allow for generics needs to be tightened. AND (I don't know if the article says it or not) one should not switch brands during therapy, because even a narrowed window may mean a huge difference.

For most drugs, the dosage window really isn't that narrow. If you think about how many drugs are prescribed, the same dosage is used by someone 100 lbs v. someone 300 lbs. There's statistically significantly more blood circulating in the latter than the former - so if dosage precision mattered the dosage should be different.

What the drug is packaged with (the non-active ingredients - other than ones added to alter the bioequivalence) doesn't make the drug behave differently, but it may give you side effects.

For example - my daughter takes mesalamine. There are numerous delivery vehicles for mesalamine. She takes Pentasa - which delivers it essentially by capsules containing the equivalent of hundreds of teeny tiny balls full of the chemical. At a certain Ph in the gut the balls develop teeny tiny holes and spew their contents through the gut - as if they were "whiffle" balls filled with powder. Asacol contains exactly the same active ingredient - but is packaged differently. It is a capsule which releases its mesalamine through some other means which I don't actually know - other than it is a chemical based reaction rather than an Ph based container deterioration. Lots of people experience overwhelming fatigue from Asacol because of the mechanism which makes it bio-available. And it is sometimes hard to convince doctors that is what is going on.

Those release mechanism responses are in addition to things like inert ingredients to which some people are sensitive.

In your grandmother's case, all she was doing was just taking enough extra pills to get the same dosage she was receiving using the brand name, so I would suspect there was something else going on for your grandmother.

[StrayKat]

8. I don't think we're disagreeing too much on the facts, just the interpretation of them.

What I'm really arguing is that there may be more reasons than susceptibility to marketing that influence people's decisions to use name brand products over generic.

The reason for choosing a name brand may be because, as you point out, sometimes it's not advised to make the switch to the generic as with Coumadin or Wellbutrin or Synthyroid or some epilepsy drugs etc. Or, people may find generics inferior due to common or uncommon allergy or sensitivity to inactive ingredients. Or the generic 'equivalent' may interact with other medications in a way that the name brand didn't. Or the active ingredient of the generic equivalent may not provide the same therapeutic effect for an individual. Or generic drug manufacturers may feel the pressure to take cost cutting measures to the point they are intentionally creating a subpar product (as with Ranbaxy).

These reasons, whatever they may be, still mean the generic isn't always equivalent to the name brand. I only very briefly skimmed the original study, but I didn't see alternative reasons accounted for by the study.

[Ms. Toad]

9. I still suspect most of the motivation to insist on the name brand

is marketing (both to doctors and patients) and lack of education.

There are valid reasons to stick with the name brand (or, at a minimum the brand you started with) - but the demand for name brand is far more than the fewer instances in which it really makes a difference.

There are a few drugs which are off patent with the generic manufacturers going through the process to establish equivalent bioavailability which I've been watching. It really is a strict process - and vigorously fought by the patent owner who is about to face competition and has motivation to prove the soon-to-be-competitor does not create the same bioavailbility.

Our difference isn't in substance - it is in how frequently it makes a medical difference (either effectiveness of the drug, or different adverse side effects). I believe it is a relatively rare occurrence - it seems to me you believe it is much more common.

[RobinA]

10. My Morivation

For insisting on brand drugs was learning the definition of "bio equivalent." Also, most doctors I have talked to prefer brands. Guess they weren't part of this study.

[Ms. Toad]

12. Actually -

I don't have a single doctor who prefers brands, and we are extremely heavy users of the medical system. We currently have 15 I can think of, off the top of my head and consume$60,000 - $110,000 of medical care a year.

For all but a very few drugs, the bio-equivalence requirements are sufficient to establish that there is no medically significant difference. There are a few drugs which are extremely dose sensitive - then it does matter that you stay with the same manufacturer (or be extremely careful in transitioning from one to the other). But even for those few drugs, the brand itself is not critical. What is critical is not switching midstream. Aside from that, the only medically valid concern is how the medication is packaged (inert ingredients to which one might be sensitive, or release mechanisms which can create their own side effects).

And, even more than doctors, pharmacists whose job it is to work with medications - specifically working with multiple brands of the same drug - buy generics at a rate of 90%. Unlike doctors (see below), pharmacists are not subjected to intense brand marketing and are basing their evaluation far more on (1) training on pharmaceuticals, testing, bioequvalence, etc. and (2) reports they receive from patients using a variety of brands of the same pharmaceutical (because there are fewer pharmacies than there are doctors, they see far more patients taking a variety of brands of the same drug than doctors do).

It really is a waste of money, for most products, to buy a name. You should invest some time in understanding the testing process AND for any particular drug how closely the dose needs to be tailored to weight (or gut length, or dermal coverage - or whatever the treatment target is).

As far as doctors - generally - you are aware that doctors are visited on a weekly basis by pharmaceutical reps bearing gifts (both samples and lunch for the office) specifically with the goal of building brand name loyalty, right? (And it is only weekly because most offices I am familiar with limit visits to one day a week.)

[blue neen]

13. Pharmaceutical reps also visit some pharmacies.

Conversely, many doctors have banned the reps from their offices.

Just an FYI: You mention upthread that you're having a hard time getting warfarin levels regulated. There is a genetic condition called VKORC1 (Coumadin Resistance). It's something the medical community is just now becoming familiar with. It's also more common than previously thought.

Good luck.

[Ms. Toad]

14. I'm not currently taking it -

Last edited Sun Jun 30, 2013, 02:19 AM - Edit history (1)

but I'll keep it in mind, since I still have the structural cause intact for half of a bilateral problem. I expect that is not an issue, though, since I have had two complete work-ups for thrombosis and my issue seems to be purely structural (VTOS). I've had a rib removed on one side - the other rib is still there, but I have collateral circulation around what was (at one time) a complete blockage. If it ever clots significantly again, that rib will go as well - so it would be a very short term treatment and likely limited to enoxaparin sodium to make sure I am not at risk for PE while waiting for surgery to be scheduled.

But back to reps visits - as a general rule, though, pharmacists are much less likely to have the rep in the office every week. Since pharmacists can't prescribe drugs directly - or give out samples - the return on the visit-investment is much lower. Unfortunately, the doctor out of our collection of doctors who is most likely to be influenced by reps has not yet chosen to ban them. He does tend to talk, and prescribe, brand name (e.g. I say warfarin sodium, he responds coumadin; I say azithromycin, he says Z-pak) - but he also admits, if I ask him, that in the vast majority of cases there is no difference in effectiveness between brand names and generic. And, when there is a difference sticking with the same brand (not necessarily the non-generic one) is what is important.

[xmas74]

17. When I passed meds in a state hospital

they never, ever switched patients from Coumadin to warfarin. Coumadin was possibly the only name brand script that had a generic on the market but was still filled in its name brand form by our on campus pharmacy.

Coumadin is just too tricky to switch. Our doctors refused to prescribe the generic, saying that they didn't want anything that could go wrong to be their responsibility.

[Ms. Toad]

18. Coumadin actually is warfarin sodium-

It is just the version of warfarin sodium which is produced by Bristol Meyers Squibb.

And it is switching which is the issue (the doctors in that hospital were right to be very cautious about that). But using (and staying on) a generic brand, rather than Coumadin, is just as safe. Each manufacturer has a particular process which creates reliable and consistent quantities within its own product (although even within a manufacturer there can occasionally be issues if you have to split pills). The big problem is Coumadin brand sodium warfarin isn't necessarily consistent with the brand produced by Barr Laboratories. I've used both - and although the dosage was slightly different there wasn't any substantial difference between my stability on one v. the other (which is to say it was lousy on both).

I've been on warfarin sodium under the care of at least 4 doctors - the last one was extremely freaked out by the process. I had to find a lab that could get results back the same day, because he would not adjust medication first thing Tuesday morning based on bloodwork drawn Monday night. Since I was with Kaiser in Ohio, that was an issue - even their stat bloodwork had to be transported by car from one city to the next, specially marked, preferably with a phone call as well. The first time I had a PT/INR drawn I had to have three draws because the first wasn't marked stat. The second was, but after about a dozen phone calls they couldn't confirm that the blood had arrived - or that they would get results by 5 PM when the doctor's office closed, so I ended up going to an independent lab (before they took all those off the Kaiser plan) where they processed the blood in house. (I figure the doc must have had a patient with some major incident because he is usually extremely laid back). But - even with all that drama - he wasn't a bit concerned about using a generic - as long as I didn't switch from one brand to another.

[Mariana]

11. My Mom is allergic to one of the inactive ingredients

in the generic version of a medicine she takes (sorry, don't know which one it is). The assholes at the insurance company won't pay for the name brand unless the doctor's office calls them to explain why she must have it. Fair enough. But they have to make the same call EVERY FUCKING MONTH, every single time she gets a refill they have to go through the same PITA procedure to get authorization so they'll pay for the name brand. She's been taking this drug particular drug for decades and she will until she dies. I can't get over the stupidity.

[nadinbrzezinski]

4. I just need to be careful with what starches are ussed

corn starch, or potato starch are fine. If the ingredients say starch, I assume wheat. So if the OTC (target one is a good one) says Corn Starch, I get that. If not, not all formulations of brand tylenol are safe either.

Gluten allergies, it sucks

[Nevernose]

15. I read somewhere that 80% of generics

I read somewhere that 80% of generics, in some categories, are made in the exact same factories as the name brands. Sometimes the name brands are just subcontracting out the production, and sometimes they control the generic company as well.

[csziggy]

16. One problem I see with using generic prescription drugs is the variation

Between different manufacturers. While in many, if not most, cases that may not be a problem, with some of the drugs it can make a huge difference.

I take one generic medication that every time recently it is refilled, the pills are completely different - little blue lozenges, white lozenges, white round pills, green round pills. Its the only generic I have ever had that changed frequently. It's beginning to concern me and I think I will discuss my concerns with the pharmacist.

For some of the medications that have a narrow range of tolerance, as discussed in other messages here, changing the manufacturer could change the needed dose and cause some serious problems!

[burrowowl]

19. K&R

[ecstatic]

20. For some things, generics don't work as well (acid reflux)

The cheapest reflux med I can take is Prilosec, and that's not as effective as Nexium (slightly different ingredients). Generics work well enough when it comes to pain medication.