The adverse effects of brand-name drug prescribing ================================================== * Ken Flegel Prescribing drugs by their brand name appears to be more prevalent than ever.1 Is this good practice? In particular, is it good for the prescribing physician? The answer to both questions has to be a resounding no. It is bad practice and it is bad for the physician’s mind and soul. It is bad practice because it is expensive, accounting for half of all prescriptions and 80% of the billions of dollars spent on them.1 Also using brand names can be dangerous. Drugs with similar names, such as Losec and Lasix, Pradax and Plavix or Lamictal and Lamisil, have been cross-prescribed. Here the hapless patient assumes only risk (sometimes life-threatening) and expense for no potential benefit.2 But allow me to focus on the prescribing physician. Let’s concede the point up front that a short and clever brand name is easy to remember and quick to write. Typically, that’s where any intellectual benefit of the name ends; it offers no other useful information. It is purely designed to allure, to promote and to sell. But for the prescribing physician, brand names present other difficulties. Brand-name drugs often vary among countries, which means that foreign drugs may have the same brand name as a domestic one but contain different ingredients. Worse, within a country the same drug can be marketed under more than one brand name, which means physicians may not be aware of what the patient is taking. A generic drug name, on the other hand, ones like ABCDstatin or LMNOpril or WXYZolol serve to remind the doctor that the first will change enzyme action in the liver to lower LDL (low-density-lipoprotein) cholesterol, the second, to block angiotension conversion to lower high blood pressure, and the last, to block β receptors to keep the heart calm. Let us now take a brief look into threats to the good doctor’s soul. A potential ethical conflict arises when the doctor is the one actually selling the drug to the patient as still happens in some remote areas and in some cancer chemotherapy settings. Here, choosing the brand-name drug can increase the cost and the doctor’s profit margin by a double-digit multiple.3 In addition, some drugs are marketed as generic, but actually they are branded by the name of the generic manufacturer and have a hefty price minimum — occasionally even a price subsidized by a provincial or state government.4 The drug companies frequently claim that the brand-name drug is safer or has more predictable action than the generic.5 The burden of proof is on the company making such a claim. The ethical conflicts should always be resolved in favour of the patient: if safety and efficacy have not been shown to be different, the least expensive option should be selected. ![Figure1](http://www.cmaj.ca/https://www.cmaj.ca/content/cmaj/184/5/616/F1.medium.gif) [Figure1](http://www.cmaj.ca/content/184/5/616/F1) Image courtesy of © 2012 Thinkstock It is heartening that our medical students typically still arrive on the wards innocent of drug brands. And the behaviour of the profession indicates it is not unaware of this principle of best practice in drug prescribing. But the drug companies’ practices are difficult to ignore. Perhaps one of the most corrosive aspects is the branding of new drug combinations. This makes the brand easy to remember, but not the constituent generic drugs. How quickly can you name the constituent drugs in Advair or Symbicort, Atripla or Trizivir, or Hyzaar and Tenoretic? This is big business. Why even the US Food and Drug Administration has indicated to the drug companies that they can make a profit by rebranding into drug combinations.6 The problem is that these combinations contain some powerful drugs capable of immense good or immense harm. Our patients rightfully assume that we always know which chemical we are asking them to put into their bodies. Finally, some names are created to be reassuring or promising — so-called “benefit-led” names such as Paxil, Celebrex and Gluconorm — when they actually need to be prescribed with great care and consideration of the drug’s potential effects on the individual patient. At a minimum, physicians ought to pressure the drug companies to invent generic names that are as easy to remember as the brand. In the meantime, because we prescribing physicians are free to arrive at our own view on the matter, one can go no further than merely to exhort one and all to return to generic drug prescribing as a routine. We are free, that is, unless one’s mind or soul is being slowly purchased by a pharmaceutical company culture that needs you to help it sell drugs. ## References 1. Connell J. Anti-Counterfeiting Trade Agreement (ACTA). Ottawa (ON): Canadian Generic Pharmaceutical Association; 2012. Available: [www.canadiangenerics.ca/en/news/anti_counterfeiting.asp](http://www.canadiangenerics.ca/en/news/anti_counterfeiting.asp) (accessed 2011 Nov. 24). 2. Pradax (dabigatran etexilate) and Plavix (clopido-grel bisulfate) — risk of potential patient harm associated with brand name confusion — for the public. Ottawa (ON): Health Canada; 2011. Available: [www.hc-sc.gc.ca/dhp-mps/medeff/advisories-avis/public/\_2011/plavix\_2\_pc-cp-eng.php](http://www.hc-sc.gc.ca/dhp-mps/medeff/advisories-avis/public/_2011/plavix_2_pc-cp-eng.php) (accessed 2011 Nov. 28). 3. Gatesman ML, Smith TJ. The shortage of essential chemotherapy drugs in the United States. N Engl J Med 2011;18:1653–5. 4. ‘Professional allowances’ and the price of generic drugs. Toronto (ON): CBC News; 2010. Available: [www.cbc.ca/news/health/story/2010/04/09/f-generic-drugs-professional-allowances-implications.html](http://www.cbc.ca/news/health/story/2010/04/09/f-generic-drugs-professional-allowances-implications.html) (accessed 2011 Nov. 25). 5. US Food and Drug Administration. Facts and myths about generic drugs. Silver Spring (MD): The Administration; 2009. Available: [www.fda.gov/Drugs/ResourcesForYou/Consumers/BuyingUsingMedicineSafely/UnderstandingGenericDrugs/ucm167991.htm](http://www.fda.gov/Drugs/ResourcesForYou/Consumers/BuyingUsingMedicineSafely/UnderstandingGenericDrugs/ucm167991.htm) (accessed 2011 Nov. 25). 6. US Food and Drug Administration. Fixed-combination drugs. New business models drive profits, patent protection. Silver Spring (MD): The Administration; 2009. Available: [www.fdanews.com/conference/detail?eventId=2867](http://www.fdanews.com/conference/detail?eventId=2867) (accessed 2011 Nov. 25).