A colleague of mine, Dr. Alberto, was telling me about his patient and asking some advice on how to manage her. Mary was a seventy year old smoker with a history of sarcoidosis. She had been on numerous medications for her medical condition, but wasn’t feeling any better with regards to her breathing. When I asked if she was still a smoker, Dr. Alberto said yes. “I’ve tried to get her to quit, but you know how it is.” Mary was then referred to the pulmonologist for another opinion. Mary had been on steroids in the past, and while they helped her symptoms, she heard that taking them too often can be bad and so she didn’t want to get back on them. She was wanting a different, better medical option to treat her symptoms. So what does the pulmonologist do? He puts her on a unique hormone medication to try to help with the sarcoidosis. She had been on the medication now for almost a year and really hadn’t noticed any improvement. The medication is currently costing Mary’s insurance close to $100,000 per month. Over the course of the past year, the bill has tallied over one million dollars, just for one medication that didn’t seem to improve the patient’s quality of life. More expensive does not necessarily mean better.
This reminds me of a story from when I was in high school. When I was a kid, I remember wanting sneakers that were branded by Michael Jordan. They were black with red trim, a little uncomfortable, and if I were being completely honest, kind of ugly. They were also extremely expensive, running at least $150 a pair. I wanted them nonetheless, so when I started nagging my parents for them, they gave me a nasty look and would ask how I can justify spending so much money on a pair of sneakers. I had some crazy notion that if I were to wear these ugly, uncomfortable sneakers that I would somehow become an amazing basketball player, somehow channeling my inner Michael Jordan. Like the old Gatorade commercials, I wanted to “be like Mike.” Obviously, there was no way a 5’8” skinny Filipino kid was going to play like a 6’6” black basketball god just by wearing a pair of sneakers, but I somehow convinced myself that I might. In truth, I was just as bad at basketball playing in my Jordans as I was playing in my Reeboks. Generally speaking, the same can be said about brand versus generic drugs.
Typically, the treatment for sarcoidosis will include steroids, which is a cheap, generic drug. In some cases, drugs that are used to affect the immune system are also used to alleviate the symptoms. In some cases, they are effective. In some cases, they aren’t. In the case of steroids, they are effective, but with long term use, it can lead to other problems, like immunosuppression, adrenal insufficiency, and diabetes. At $20 a prescription, you might expect some side effects or problems with the medication, but at $100,000 a month? With a medication that cost $100,000 a month, you would think you had the cure for the disease. At minimum, you would think that they would have those side effects and problems with the medication figured out, but they actually don’t.
And that’s the main difference between generic and brand name drugs: cost. Drug companies justify charging a premium for a brand name drug because of the production cost. The production cost includes research and development of the drug as well as the numerous drug trials, marketing campaigns, and manufacturing that all medications have to go through. This can be in the cost of billions of dollars. After a seven year period the medication’s patent expires and it becomes generic. There are some exceptions, like insulin, as some drug companies use legal loopholes to try to extend their patent, but in most cases, there is usually a generic equivalent to the most commonly used drugs.
There are other smaller differences. The FDA requires that generic drugs have the exact same active components in their brand name counterpart, but the inactive components can be different. So when a medication like Glucophage goes generic and becomes Metformin, people find themselves having a difficult time tolerating the medication. My theory is that the inactive components to these medications are possibly making certain drugs more palatable in their brand name versions. This does not make their generics any less effective than their brands in terms of managing a certain disease condition. Metformin is still a first line drug for diabetes and it will likely continue to be because it is effective.
There are only a few scenarios where a brand name drug makes sense to take over a generic. One of those instances is when a brand name drug has a clear, superior advantage over its generic. As an example, blood thinners like Warfarin, have an extremely small therapeutic window and thus, has to be consistently monitored with routine blood tests. Now, there are a plethora of other blood thinners out there that don’t need to be regularly monitored, and so when the inconvenience of taking a generic drug becomes too much of a burden, a switch is typically recommended. Another example would be in the case where a generic medication is ineffective and the only alternative is a brand, as is the case with certain antibiotics, where a serious infection will not respond to a generic medication, but will only respond to stronger antibiotic, say like Zyvox.
Outside of these examples, however, generics are equal in most other ways. The only other benefit of taking a brand name is perhaps a placebo effect, where patients believe that the cost of the brand infers a better product, and so they may feel better on it, like my belief that I could actually “be like Mike.”
Truth be told, the cost of brand name drugs is one of the reasons for the climbing costs of healthcare and when patients refuse to take a generic drug that they can tolerate, the problem only gets worse. I told Dr. Alberto that Mary needed to get some more perspective on her medications. Dr. Alberto agreed and so now, Mary is getting a second opinion with another pulmonologist on how to better manage her sarcoidosis without breaking the bank.