Monday, August 13, 2007

I thought I could teach her something...

Today, a woman came to the pharmacy and picked up her prescription for Toprol XL 50mg. Recently, Toprol XL went generic, so in the name of saving our customers money, we've been dispensing said generic.

No more than 20 seconds after walking away from the counter, the woman came right back. "I usually get Toprol XL. What is this Metoprolol XL?"

Me: "Toprol XL just went generic within the past week or so. Metoprolol XL is the generic for Toprol XL."

Lady: "Who authorized switching to the generic?"

Me: "Generally, once a generic becomes available, we automatically substitute unless the doctor or patient requests otherwise. Generics are exactly the same as the brand medication. The only difference is that they're less expensive."

Lady: "Well, my doctor wrote the prescription for Toprol XL, and he said that even if the medication is the same, generics can have different fillers. I've always gotten the brand, and I want to stick with it."

Me: "Before you make that decision, let me show you something."

This is where I thought I was going to completely blow her mind. I ran back to the shelves, picked out a bottle of Toprol XL 50mg and a bottle of Metoprolol XL 50mg, and ran right back to the counter.

Me: "Here's a bottle of Toprol XL. You can see that it is made by AstraZeneca. Now, here's a bottle of Metoprolol XL. Look, it's also made by AstraZeneca. The company that makes Toprol XL is the one making the generic for it. This isn't almost exactly the same medication. It is the EXACT SAME medication. They just took their Toprol XL and threw a different label on the bottle."

Lady: "I've always gotten Toprol though, and that's what I want."

I was just completely shocked. I didn't even know what else to say to her, so I just took back the bottle and gave her the brand name, which amazingly only cost her $9.20 more, which is still ridiculous considering it's EXACTLY THE SAME.

I'm still utterly confused by it all. Why on earth would someone pay more money for exactly the same thing. The only difference is the freaking label on the bottle (and the tablet looks slightly different because it's not scored). What did this woman think, that AstraZeneca would waste time and money coming up with a different formula to make a generic version of their own drug???

Now, I know that I just wrote an entry about how customers cannot be expected to know very much about medications, and they can't be expected to understand that generics work just as well as brand drugs. However, when I show someone that their "new generic" is made by the same company that makes their trusted brand, and she still doesn't believe they work the same, I have to chalk that up to personal stupidity on her part. What else can it be? It's completely asinine.


amanda.pepperpourri said...

Just one question: are all generics as good as their original brands? A friend once told me that generic Cetrizine didn't work as well as Zyrtec for her. I don't have any personal experience on that though.

I suppose the excipients have something to do with it? (since the excipients are different, the drug solubility profile will be affected somewhat?)

Pharmacy Mike said...

Unless you know something I don't about drugs marketed in other countries, the patent on Zyrtec has no expired, so there aren't any generic companies make Cetirizine.

There are only a few drugs that you would hesitate switching between brand and generic. The most noteable are Synthroid (or any other form of levothyroxine) and Coumadin. It's not that the generic versions of those work worse than the brand versions. The difference is due the body's sensitivity to slight changes in bioavailability. Dilantin is another drug that can affect people differently than the generic because a slight change in bioavailability can cause a significant change if blood concentration.

You also get a very very very very small percentage of people that can have an allergy or an intolerance to a different filler used in the generic version of drugs. I can't stress enough how exceedingly rare this is.

Eric, AKA The Pragmatic Caregiver said...

Actually, cetirizine is off-patent or teetering on the verge in most markets now, which is why UCB has so much enthusiasm for their fabulous new single-enantiomer agent, levocetirizine.
cou*bs patent dodge*gh

Reactine has been off-patent in Canada for at least six years now.

Levothyroxine is always trotted out as something where the generics aren't equivalent, but back when Knoll was still part of BASF, weren't there a number of internal documents revealed in discovery in a series of lawsuits that found that not only were the generics bioequivalent, but the inter-tablet consistency of the brand Synthroid wasn't any better than the generics....

With warfarin, I've always wondered if the variability is more an issue of normal dietary variation than actual bioequivalency problems.


pepperpourri said...

Generic Cetirizine is available over here. I remember packing the wrong drug the last time I was training at a hospital pharmacy. The prescription said Cetirizine but I took Zyrtec because I didn't know there was a generic, until the pharmacist corrected me.

By the way, thanks a lot for the information :)

Pharmacy Mike said...

Actually, I did hear something about levocetirizine, so the generic for Zyrtec must be coming pretty soon. It's not available here yet though.

About bioequivalency: Unless the drug information sources I read are incorrect (and I'll admit that it is a possibility), the FDA considers a generic bioequivalent to the brand if the bioavailability falls in a range of something like 80%-125% of the brand name product.

Since levothyroxine is dosed in very small increments (it can go up and down a mere 0.025mg), a slight difference in bioavailability between products could cause changes in TSH levels and, more importantly, changes in clinical response. (*note that it COULD, not that it WILL).

I've worked in a Coumadin clinic before, and I've seen patients who's INR has been stable for months all of a sudden fall out of range due to a switch from brand to generic or generic to another generic. When we adjust coumadin doses, we usually go up or down 10% of the total weekly dose. Therefore, if you have a 15% variation in bioavailability (which according to what I've read would still be considered bioequivalent), there could be a fluctation in INR.

greensunflower said...

Being gluten intolerant I do notice that some medications give me issues.

Other than that, which is legitimate... I am convinced that Tri-Nessa doesnt work like ortho tri cyclen. Not that I have ever gotten pregnant on either one. I just "feel" diffrent. Stupid huh? Oh well, the copay difference is $10, so i got the Tri Nessa.

In the PICU we use brand name ativan of all things, and most other things are generic, unless of course pretty new, but mostly generic. Why do we have brand name IV ativan? hmmmmm. anyway babbling now.

Pharmacy Mike said...

As I have very little idea of which generics are available in hospitals, I can only guess that the reason you use brand name Ativan is simply because nobody felt like making a generic version for injection.

I don't know this for certain, so I could be entirely wrong, and if so, I apologize in advance.

Anonymous said...

This blog is pretty i doubt you'll even see this. But, i would just try to see it from her point of view a little harder. This lady probably knows almost nothing about biology and so she has to rely on the opinion of professionals on what to do. She's probably more likely to follow her doctors advice who she has a better connection with than a pharmasist who is seen as less knowledgeable, according to common stereotypes.