It is a fact that in today’s 1 hour cash advance lenders Pharmaceutical World there are so many manufacturers that when a doctor prescribes by the generic name, it will be the Pharmacist (qualified or unqualified) who will decide what the patient will actually get. Even if the doctor prescribes amoxicillin SPC, Pharmacist may give what they have stocked and what gives them the highest commission. It has been observed that some cheaper amoxicillin brands do not produce the characteristic smell of ampicillin in the urine even after 3 days. This smell is usually observed when 5 doses of amoxicillin with good bio-availability is prescribed. Furthermore there was the instance when SPC did their own brand with paracetamol (pettha pottha controversy) and that would be contrary to Prof Bibile doctrine. Furthermore, one cannot expect generic producers to be more altruistic than brand producers and their intention would also be profitability. So they could adopt ruses that give them greater profit. This would be obviated if a Government begins to manufacture drugs with strict quality control procedures. SPMC is a step in the right direction. The dire need is proper quality control checking for generics or brands that would be approved. As I said at the beginning, when a doctor now prescribes generic what the patient gets is an unknown brand.
Danger of Changing Brands
There are also drugs like phenytoin used for epilepsy with historic examples where changing the manufacturer (brand) has resulted in severe adverse effects or return of seizures depending on the additives in the new brand which could increase the available phenytoin strength causing toxicity or reduce available phenytoin resulting in seizures. One would ask an epilepsy patient to always stick to one brand for the above reasons. This problem arises with drugs that operate in a narrow therapeutic window where slight increase of drug level causes toxicity and slight drop causes loss of therapeutic effect. With such drugs any sane practitioner would prescribe a trusted brand.
Ethical Issues of Brand Prescribing
Yet there are problems in brand prescribing that only doctors can rectify. It is not only a doctor’s political hue or NGO employment that raises issue with certain brand prescription patterns.
While I was in my previous academic post, I observed that a brand of piroxicam was aggressively pushed and was freely prescribed. Piroxicam is an aspirin like drug with far more adverse effects than aspirin. I have produced material and published in the Ceylon Medical Journal and Kandy Medical Journal to prove that, with the exception of ibuprofen in doses less than 20mg per kg body weight per day, aspirin remains the safest and most effective non steroidal anti inflammatory drug (NSAID) for joint disorders. This was demonstrated by a well designed trial conducted by UK Committee for Safe Medicine in 1985. Yet far more expensive drugs (NSAIDS) 10 minute cash loans are prescribed which are less effective and more toxic. Even with ibuprofen the effective antirheumatic dose is often more than the safe dose. Bayer has recognized the safety of aspirin and recently produced a cherry flavoured expensive brand of aspirin.
Co-amoxyclav (Augmentin) is another over-prescribed drug when amoxicillin alone is sufficient. Cost difference is huge and the former has more side effects. It would be unethical to prescribe co-amoxyclav when amoxycillin is sufficient for most upper respiratory bacterial infections.. Brand prescribing of ibuprofen syrup for fever is another undesirable practice considering the many side effects of the drug. There is evidence that anti-inflammatory drugs prolong the viraemia in simple fever. There are scientific reasons to give only paracetamol for viral fever even in adults. Similarly pushing Panadol syrup for fever is another unacceptable brand pressure practice which may end up with a child getting more than six hourly doses which would be toxic. Vitamins in expensive brand prescription – especially the dubious benefits of vitamin E (except the proven benefit to reduce incidence of breast cancer in combination with Primrose oil), impoverish the already poor.
Internationally too, there were instances where brand pushing made room for fraud. A well known recent instance is when the results of a drug trial (Rofecoxib) was published only for the first six months because serious adverse effects appeared in the next six months. Results were suppressed and the drug appeared on the market being prescribed as an antirheumatic drug with minimal gastric problems. Patients got heart attacks and the drug was withdrawn. A journalist of New York Times exposed the fraud. Details can be found on www.WorstPills.org
It is also true that in pushing brand drugs many glossy promotional materials quote statistical data without statistical significance to “prove” the superiority of a drug.
Generic or Brand
There is no simple solution to the issue.
- Reliable generics must be available; quality control is must. In the present scenario even the most socially conscious doctors may be reluctant to prescribe generics because of unreliability.
- With manufacturers producing generics under some name, the difference between generic and brand that Prof Bibile identified is at present artificial. The solution is for government sponsored quality drug manufacture. Like the transport system and water supply, drug supply cannot be left in the hands of the Private sector alone.
- An essential drugs list even today will prevent poor people having to buy unnecessary drugs
- When prescribing Drugs with narrow therapeutic window, it is inevitable that doctors will prescribe a trusted brand
- Expensive drugs get prescribed when cheaper more appropriate drugs are available.
- Expensive drugs get prescribed when there is no medical indication E.g. antibiotics within first 24 hours of viral fever.
- Unscientific poly-pharmacy for reasons other than medical.