Last week I had a patient sheepishly ask me if I could change any of her medications to generic. It seems she was paying a small fortune for her medications and wanted to use her precious social security dollars for something that better improves her quality of life, like, say, food. It was heartbreaking for me to see the way she approached asking me—seemed sort of like Oliver Twist asking for more gruel—and I tried to reassure her that she shouldn’t be embarrassed about asking to explore a less expensive treatment option.
Her case brings up a subject I’d like to discuss. We are very fortunate in the cardiology world today to have numerous effective and inexpensive generic options to treat our most common problems.
Let’s take an example. Our first patient—we’ll call him Warren B.—is a self-made man, a generous philanthropist who has enjoyed success in the business world and therefore can afford insurance that offers him access to premium medications. For those drugs not well covered by his plan Warren can afford to pay the steep out-of-pocket costs. He has coronary disease, mild heart failure, and high blood pressure. Here’s his current list of drugs:
Aspirin, Cozaar, Coreg CR, Crestor, Plavix
Patient number 2 is an elderly lady of modest means—we’ll name her M. Theresa—who has devoted her life to administering to poor residents of third-world countries. She has the same medical problems as Mr. B, but has only bare-bones medical coverage and no meaningful income. Here’s her list:
Aspirin, Lisinopril, Carvedilol, Simvastatin, Plavix
If each patient were to purchase a month’s worth of medication out of pocket here’s what the price tag would be:
Warren B.: $479.58
M. Theresa: $162.81
Quite a difference. The interesting thing about these patients is that they are both receiving the same basic therapy for the same problems, but at vastly different costs. Let’s look at the breakdown. Aspirin and Plavix are the same for both, with the former (aspirin) being available over the counter for a nominal fee and the latter (Plavix, $150.35) being an expensive trade drug for which no generic is available. Both medications are prescribed to block platelet-based clots from forming in the arteries of the heart and brain.
Cozaar ($92.62) is a member of the vast ARB (angiotensin receptor blockade) class that includes numerous other medications but for which there is yet no generic. This blood pressure medication is often used in the treatment of congestive heart failure. Fortunately, a similar class of drugs—the ACE-inhibitors, in this case lisinopril ($3.33)—is widely available in generic, is similar to the ARBs in effectiveness, and has been extensively studied with great success in patients with heart failure. In general, the generic ACE-inhibitors are a good substitute for the more expensive ARBs.
Coreg CR ($121.10) is the extended-release formulation of carvedilol ($3.33) and is reported to have fewer side effects than the generic but is considerably more expensive.
Simvastatin ($5.90) is a relatively inexpensive generic “statin” cholesterol-lowering medication that has been thoroughly tested through the years and has been found to significantly cut the risk of heart attack and stroke. Crestor ($115.51) is more potent at lowering cholesterol levels but has not been the subject of as many research trials. For moderate levels of cholesterol elevation either drug would be adequate.
In the end, I would maintain that inexpensive generics are adequate for the uncomplicated patient with typical heart problems of high blood pressure, high cholesterol, coronary disease, and congestive heart failure. In this case, Warren B. is getting no benefit beyond what M. Theresa gets despite the extra outlay in cash.
To be fair (before some of you heat up your keyboards with critical comments) there are many situations where the brand-named drug will provide some benefit that the generic is lacking. The medical complexities of individual patients are often far more nuanced than my simplified example would suggest. Nevertheless, with few exceptions, we in the cardiology corner of the medical world can handle the majority of our business with tier 1 medications.
So don’t be afraid to ask your doctor to take a second look at your list to see if any of your trade drugs can be switched to generics. He or she won’t mind and will give you an honest answer if switching to generic is not a good idea. It will also give you another opportunity to discuss your drug list and why you are on each medication.