Generic Drugs: Frugal Pharmaceuticals or Penny-Pinching Problems?

Illustration by Mark H. Adams

Given the high cost of medications, especially if you’re taking lots of pills and trying to live on SSDI, many people look to save money by switching from brand-name drugs to cheaper generic meds. Often, there’s no problem in being frugal and taking a generic drug. However, pinching pennies can cause problems if you’re not aware of the sometimes significant differences that allow generics to be cheaper than brand-name drugs and the interactions between the drugs you’re taking and with the foods you eat.

It Ain’t Necessarily So 
“Generic products will perform the same as their respective brand-name” drugs, says The Food and Drug Administration Office of Generic Drugs, “with respect to identity, strength, quality, purity and potency.” But federal law says generic drugs do not have to “perform the same” as brand-name drugs with respect to strength and potency. By law a generic can put between 20 percent less to 25 percent more drug in your blood than the brand-name drug. Say you take a 500 mg capsule of Tylenol. You then decide to buy the much cheaper generic acetaminophen and take 500 mg. The generic may be giving you 400 mg or as much as 625 mg of acetaminophen. That 225 mg range may be insignificant when taking one acetaminophen. But, if you’re on a medication where the dose is critical, like drugs for irregular heart rhythms, blood pressure or epilepsy, a small increase of the drug in your blood could make you toxic, while a small decrease could render the drug ineffective.

If a generic drug must be chemically identical to the brand-name drug, why can there be such a wide difference in the amount of the generic in your blood? In order to manufacture a solid pill, the “active” medication is combined with inactive ingredients called “excipients” — flavors, fillers, binders and dyes — that can differ widely in generics from those in brand-name pills. Some excipients, like lactose or gluten, can themselves cause adverse reactions. Others are very important in timed-release medications because they determine where the chemical is released — in your stomach or intestines — and how quickly it is absorbed into your blood. Increased drug release is the problem one polio survivor had on her generic roller-coaster ride.

No Stomach for Generics
“I choked last night!” That’s how Patty, a 60-something polio survivor, introduced her problem. I asked what she was eating (rice), if she’d had swallowing trouble before (no), and if anything new was going on in her body and life (no and no). She said that she’d choked because she “didn’t have enough saliva to get the food down.”

Dry mouth, one of the most common side effects of all medications, is even more common in polio survivors whose vagus nerve is damaged by the poliovirus – the vagus nerve turns on the salivary glands, swallowing muscles, stomach and intestines. I asked if she’d changed any meds. Patty said “no” and then looked at her pill bottles. “I have the right number of bottles but there’s no Ditropan XL.” Patty had been using Ditropan XL to control a leaky bladder for years without problems.

“Does one bottle say ‘oxybutynin,'” I asked?

“Yes! How did you know?”

Patty had gotten caught in the generic bait and switch. Without telling her, Patty’s mail-order drug company had switched her from brand-name Ditropan XL to a cheaper generic “extended release” oxybutynin, the active ingredient in Ditropan XL. You may be shocked to learn that nine states allow substitution of generics for brand-name drugs without your consent or knowledge.

The problem with Patty’s generic wasn’t the oxybutynin, it was the excipients that provided the “extended release.” The Ditropan XL pill is an ingenious device. A precision-laser drills an opening in each tablet. When the pill enters the intestine, water flows through the opening and causes an inner layer of excipients to expand and push the oxybutynin out of the pill at a controlled rate. The pill containing generic oxybutynin that Patty was now taking was not so precise. Its oxybutynin was dissolved in a gel that “eroded” to release the drug. In Patty’s case, the gel apparently released too much drug, causing severe dry mouth and making her choke.

Patty called the mail-order drug company and was told that they wouldn’t give her Ditropan XL, but that they would send her a different generic oxybutynin. Two days after Patty started the new generic, her mouth was no longer dry, but she became severely constipated as the drug slowed down her intestines. Adding embarrassment to injury, the new generic oxybutynin did not control Patty’s bladder.

Patty saw her doctor, who gave her a prescription for Ditropan XL on which he wrote, “Brand name medically necessary, do not substitute.” Patty was also given medication to stimulate her intestines and had X-rays to make sure her gut hadn’t stopped working. Any savings gained by giving Patty generic oxybutynin were lost many times over in emotional stress, physical pain and the cost of doctor visits and tests.

Penny Wise and Paxil Foolish
Mike, a 50-something wheelchair user with multiple sclerosis, takes baclofen for spasticity, Nexium for acid reflux and Paxil for a past depression. When he got an e-mail from his mail-order pharmacy telling him that it was time to renew his prescriptions, it included a message he’d never before seen: “Start saving on prescription costs with generic drugs. Choose lower-cost alternatives you want your doctor to consider.” Nexium was listed with a yearly co-pay of $300. Two “alternatives” were also listed: omeprazole ($68 per year) and cimetidine ($8 per year.)

“I saw $8 per year, called my doctor and asked for a cimetidine prescription,” says Mike. He sent the prescription to his mail-order pharmacy and started cimetidine. Unlike Nexium, which he took in the morning, cimetidine had to be taken in the morning and evening, when Mike also took Paxil. Several days after beginning cimetidine, Mike’s problems started.

“I felt very dizzy, nauseous and had trouble with my memory. I’d go from one room to another and forget why I’d made the trip.”

Afraid he was having an MS flare-up, Mike went to his neurologist, who agreed and prescribed an oral steroid without asking what drugs Mike was taking or if any of them had changed. When he felt no better a week later, Mike thought back and dated his symptoms from the day he started cimetidine. Mike went online and found a drug interaction website, entered “cimetidine and Paxil” and saw this warning:

Cimetidine can increase the amount of Paxil in your blood. Contact your doctor if you experience dizziness, nausea or confusion while taking cimetidine and Paxil together.

“I wasn’t having a flare-up!” Mike said. “I was overdosing on Paxil by taking cimetidine.”

Mike went back on Nexium and his symptoms disappeared. “I spent weeks feeling rotten and paid more on the doctor and steroids than I would have saved taking cimetidine,” says Mike. “Some ‘lower-cost alternative.'”

What Then Must You Do?
Mike’s family doc should have known about the interaction with Paxil before giving him a prescription for cimetidine. But gone are the days when doctors take the time to know the drugs you’re taking. Also becoming a thing of the past is the corner pharmacy, where the pharmacist knows you and your meds. Today, you need to be your own pharmacist.

First, make a list of the drugs you’re taking, the dose, the time of day you take each pill, size, shape, color and markings on the pill, and its manufacturer. Your mail-order drug company may change generic drug makers from refill to refill if they can get the drug more cheaply. So, keep the current pill containers and make sure the manufacturer is the same with each refill. Call your doctor if the pharmacy pulls the generic bait and switch and you have new symptoms or the drug no longer works for you. And, remind your doctors to write “do not substitute, brand name medically necessary” on the prescription if you want the brand-name drug. You can appeal to the mail-order pharmacy to charge you the same for the brand-name drug as the generic if your doctor says it’s medically necessary.

Second, list the supplements you’re taking (vitamins and herbs) and all over-the-counter meds (antihistamines and pain meds) and discuss their potential interactions with your doctor and pharmacist.

Finally, you may be surprised that food can affect drug release. Increasing the acidity of your stomach by eating grapefruit, or decreasing acidity by taking an antacid, can prevent a drug from being released or cause the amount in your blood to be increased.

Generic drugs can be a lifesaver, literally, if you can’t afford brand-name meds and the Medicare “doughnut hole” is actually a trap door to bankruptcy. But, we need to take responsibility for what goes into our bodies, be it a prescribed medication, an over-the-counter drug or our morning grapefruit.

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