Medical Matters: Take care, generic drugs could be a prescription for confusion and misuse

Drug costs are a significant part of our public health budget. Community drugs schemes cost the taxpayer €1.7 billion in 2012. Innovation and more comprehensive prescribing means the cost of prescribed medications follows a rising curve.

Historically, the Republic has been out of step with its European neighbours when it comes to using less-expensive versions of a particular drug. For example, the use of generic medicines in the UK is four times that of Ireland. And one-third of medical card holders here are not using generic drugs.

To his credit, former Minister for Health James Reilly was responsible for the introduction of legislation in an attempt to flatten this inexorable rise in spending.

The Health (Pricing and Supply of Medical Goods) Act 2013 was enacted last summer. Generic substitution, under this legislation, encourages pharmacists to substitute a brand medicine with a generic version which has been designated as interchangeable by the Health Products Regulatory Authority, formerly the Irish Medicines Board.

So far, the list of interchangeable medicines includes cholesterol- lowering drugs, blood pressure medication and commonly prescribed acid-suppressant drugs.

Substantial savings

Savings on one class of drugs alone can be substantial. The Health Service Executive’s medicine management programme reckons it could save the taxpayer some €4 million annually by changing to the generic version of just two types of commonly prescribed blood pressure drugs.

However, generic prescribing is not without its downside, as I discovered recently.

Relatives of a 90-year-old patient were concerned when their mother became increasingly confused over a couple of days. Housebound due to mobility problems, this nonagenarian is nonetheless usually quite sharp. So this was a definite turn for the worse.

One of the commonest causes for an acute confusional state in older people is infection, but there was no sign of sepsis in this woman. Nor was there any obvious metabolic cause for her symptoms.

However, when I asked to see her medications, a quick perusal of her tablet-dispenser box offered a clue.

Several different generic types of the ACE inhibitor ramipril (a blood pressure medication) were scattered randomly throughout the daily time slots. And there were two versions of omeprazole, a drug used to control stomach acid.

When I checked the plastic bag full of the original medicine packets, it quickly became apparent that the woman had been changed from a branded version of the drugs some months previously and was now being dispensed generic substitutes.

Lost track

However, the original generics had themselves been “substituted”, meaning the patient had experienced multiple changes in tablet shape and size. Not surprisingly, she had lost track of the particular dose and timing of each. As well as being cost-effective, drug prescribing and dispensing must be safe.

Alerted by this episode, I have since uncovered more instances of patient uncertainty about generics, thankfully before any harm was done. But it is a salutary reminder that for patients on long-term medication, even a slight alteration in the appearance of a medication they have become familiar with over many years, can raise doubts in their minds – doubts which may progress to poor compliance and outright misuse of the drug.

Research suggests the shape and colour differences between branded and generic drugs could be contributing to non-adherence. Last year in a survey on Patient Non-Adherence in Ireland, respondents rated talking regularly to a doctor as the most important factor in ensuring people took their tablets regularly.

About four in 10 rated having a good understanding of the illness and having good knowledge of how their medication works as important factors.

Asking the pharmacist to prepare an older person’s medication in calendar packs, so that the person themselves no longer have to take medicines from packs and place them in tablet boxes is an option. It certainly has helped my confused nonagenarian to regain her mental sharpness.

See hse.ie/generics mhouston@irishtimes.com muirishouston.com