Tuesday, 19 June 2018

Does the Medication Brand Really Matter? When practicing as a Pharmacist in the USA, I would tell you that most of the time the manufacturer doesn’t matter. There are some drugs are called “narrow therapeutic drugs” which means just a slight difference in the amount of drug in a given product could change the way it works in the human body and for these drugs, we usually recommend that a patient always gets the same brand. For example, levothyroxine is synthetic thyroid hormone that patients have to take if their thyroid doesn’t work or was surgically removed. Synthroid and Levoxyl are examples of two products that both contain levothyroxine. Both are equally good, but if you start with one brand, it is generally recommended you stay with that specific brand.

When a drug first comes to market, it was developed and made by one manufacturer. This unique product is usually pretty expensive when it is first available. After 17 years, though, the patent expires and other manufacturers can apply for the right to create a generic version and market it, at least this is the process in the USA. This product is almost exactly the same and it costs way less. The USA Food and Drug Administration (FDA) tests it and if it meets pre-specified criteria, they give it an AB rating which means a Pharmacist can dispense the generic version, even if the prescriber wrote a brand name product on the prescription. The only exception is if the prescriber specified “brand necessary” but this rarely happens. Health insurance helps the majority of Americans pay for their medications and they usually won’t pay for a brand name product if an AB generic is a available and so the patients usually ask for generic drugs to keep the costs low.

The opposite occurs in Uganda, and likely in other developing countries. Contrary to what you’d think, patients who have little money are willing to pay more for drugs that are produced in countries with a reputable pharmaceutical industry such as anywhere in Europe, Canada, or the USA because brands from certain countries are thought to be of poor quality. For example, unless a patient is very poor, he or she will not purchase drugs made in India. The story on the street is that drugs from India just don’t work. I was told about this problem way back when I first started coming to Uganda. The issue is so prevalent it comes up over and over. The other day, I had a very interesting conversation with Noah and Derrick, the Ugandan Pharmacy Interns. Derrick was telling me how he is having problems with many of his patients coming to the pharmacy asking for a specific country brand of a drug that doesn’t exist. For example, he said someone was asking for the UK brand of Clexane. The actual drug in Clexane is Enoxaparin and it is made in France. There is no such thing as Enoxaparin made by a UK manufacturer. He tries to explain but patients are just adamant about purchasing the UK brand because of the UK’s good reputation. They don’t quite get the concept that not all drugs are made by every manufacturer. I believe this was the patient who actually left his pharmacy to go find another pharmacy that could sell him the UK brand of Clexane. He said that sometimes patients will refuse to purchase a lower cost drug product because of the poor brand and instead will spend more money on an expensive brand from Europe but will not be able to afford the whole amount so they only buy a few tablets. But, “an expensive drug you can’t afford is useless” Derrick profoundly stated. Instead of taking the whole course of an antibiotic, they prefer to take a partial course of an expensive drug. This practice can worsen the antibiotic resistance problem that Uganda has. And a person may only take a medication for high blood pressure for part of the month because they don’t want to purchase the full supply of drug from India. This will not prevent the complications of high blood pressure like stroke and cardiovascular disease.

Derrick and Noah were suggesting that a marketing campaign to the public to explain and dispel the myths of certain drug product brands may be necessary. “So, you think the products from India are OK. I mean you would purchase them for yourself and your mother?” I asked them. Well, that brought on giggles. No, they both admitted they wouldn’t purchase them. Obviously there is either truth to the fact that the Indian drugs (just using India as my example because that is what I’ve been told) OR even the health care professionals are prone to peer pressure and “the word on the street”. If you asked 100 USA Pharmacists if they use generic drugs for themselves and their family, you would probably get almost 100% of them to say “yes!”, at least most of the time. (Exception is those narrow therapeutic index drugs.) I can use this to support my recommendation to patients to spend less money on drugs by buying the generics. But, here in Uganda, if the healthcare professionals won’t use those drugs themselves, how can we possibly convince our patients it is right to do so. This is truly a dilemma because Derrick is right—taking only part of a prescribed drug regimen could do more harm than good.

The only thing I can think of is for the National Drug Authority (NDA), equivalent to the FDA, to engage in more drug testing and to make these results available to at least healthcare professionals, if not the public to dispel the “talk on the street”. Noah is currently finishing up his NDA rotation as an Intern and he explained to me that when a drug manufacturer first applies to have their drug product registered in Uganda, they need to provide documentation of all of the quality testing and the NDA conducts its own tests of the actual tablets and then compares the results. If they match, the product is approved. For every subsequent order than comes into Uganda, the documentation is reviewed and compared. It is let into the Uganda drug supply if the documents are fine. There is no further NDA testing unless physicians petition the NDA in instances of major concerns about a drug product and from my conversations, this happens rarely. Until something is done, this problem won’t be solved. This is just one more challenge to overcome to improve the health of Ugandans.

I didn’t take any photos today but let me leave you with one of the snack I had last week. This shows two of my favorite Ugandan foods: samosas and g-nuts. G-nuts are “ground nuts” which are roasted like peanuts but much better. They pack a nice crunch. Samosas are meat or veggies in a pastry. I’ve had them in the States but these are better- crispier.