Generic Drugs

An article published online on May 9, 2016 in JAMA Internal Medicine (ME Johansen and C Richardson. Estimation of potential savings through therapeutic substitution.) presented estimates of “excess expenditure due to branded drug overuse when a lower-cost generic in the same class with the same indication was available” between 2010 and 2012. The “excess expenditure” in the US was $10.9 billion for statins, $6.12 billion for proton pump inhibitors, and $5.53 billion for angiotensin receptor blockers. None of the drugs in any of those drug classes has a narrow therapeutic window. Well-documented therapeutic inequivalence between brand-name and FDA-approved generic products has not been reported for any of them.

Many publications write about drug prices. The Medical Letter is one of the few that tells its readers what those prices actually are. Looking back at our most recent article on Drugs for Lipids, published in 2014 (an update is in preparation), we see that the wholesale acquisition cost for a 30-day supply of generic atorvastatin at the lowest recommended dose was $10.50, compared to $147 for the same amount of Lipitor. Generic simvastatin cost $4.20, compared to $186.60 for Zocor. In our article on Which PPI? published about a year ago, the cost for a month’s supply was $16.30 for generic omeprazole, $218.70 for Prilosec, and (bizarrely) $16.80 for Prilosec OTC.  In the 2014 article on Drugs for Hypertension, our table showed that the wholesale cost for 30 days of generic enalapril was $3.00, compared to $135.50 for Vasotec.

Clearly, many clinicians feel more comfortable prescribing brand-name drugs. And for many of us, that is still our prerogative. But maintaining awareness of the existence of generic equivalents and the huge disparities in cost between some of them and their brand-name counterparts seems like a good idea. And one way to do that would be for you and your institution to subscribe to The Medical Letter. You could save billions.

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  1. Gordon Yanchyshyn says:

    Your stance on generic drugs disappoints me greatly.. First you point out that, for statins, PPI’s and angiotensin receptor blockers, “well-documented therapeutic inequivalence between brand-name and FDA-approved generic products has not been reported…”. But then in the final paragraph you meekly say that “for many of us, that (ie, prescribing brand-name drugs) is our prerogative”. For a publication that prides itself on unbiased reporting, that’s an irresponsible cop-out.

  2. Ken Grauer, MD says:

    I have to say that Gordon Yanchyshyn makes a very valid point! I understand that More@MedLetter probably wants to be diplomatic and allow clinicians the option of prescribing whatever medication they feel most comfortable with. That said, given the multi-billion dollar yearly extra expense of brand-name products (and the more than 10-fold increased price tag for these drugs compared to at-the-least fairly comparable generic products) — it would seem that the most conscientious/justifiable way for clinicians who feel a need to “exercise their prerogative” — would be to provide their patients with the relevant information and enlist patient preference into decision-making. I suspect far fewer patients would opt for the dramatically more expensive brand name products if they were aware of the actual price tag AND the lack of evidence showing clinical superiority … Isn’t this called “Choosing Wisely?”.

  3. Clifford Dacso, MD says:

    The Medical Letter has been a rock of sanity for at least the 41 years during which I have subscribed. We desperately need the editor to advocate strongly and unequivocally for sanity in therapeutic decision making. Physician and patient autonomy is rapidly waning in an era of “pre-certification [read: denial] of tests and drugs. But generic equivalence is well established and is a locus where patients, payers, and physicians can make common cause. I support both Grauer and Yanchsyn above.

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