One of my patients with rheumatoid arthritis had been doing quite well on methotrexate 15 mg/week.
About a year ago he told me that his pharmacy had switched him from the Barr generic methotrexate (MTX) to Roxane generic MTX. About 2 months later, he started having increased pain in his hands, wrists, and shoulders. By the time he came back to see me a few months later, he was quite unhappy with his pharmacy, and he was also convinced that his new generic was not the therapeutic equivalent of his previous generic.
I sympathized with him and shared my conventional wisdom regarding the mixed blessings of generic medications: "You save money," I reminded him, "but once the doctor signs on the ‘may substitute’ side of the prescription, the doctor and patient lose control over which generic the pharmacy chooses to fill the prescription." Usually the pharmacy chooses the least expensive generic. I gave him some lame advice to speak with the pharmacist about getting back on the original generic, or perhaps changing to a different pharmacy to get a different generic.
He came back about 6 months later feeling better. He had changed pharmacies and was now using Mylan generic MTX. I didn’t have objective physical exam or lab findings to confirm that his arthritis had truly flared up during the time he was on Roxane generic MTX, but he was certainly convinced that the pharmacy had given him a dud. The perception is the reality in situations like this – that is, he certainly felt worse – and I didn’t have objective evidence to refute his opinion, or any strong interest in arguing.
I think this is an intriguing anecdote, as the vast majority of patients on MTX are using generics. I’m sure the number of patients in my practice taking brand-name MTX can be counted on one hand. In fact, most of my patients prefer generic medications – many ask if the medication I am prescribing is "genetic" – because it’s much cheaper for them. In a better world, we should be able to prescribe generic medications but also retain some control over which generic is dispensed. Is that too much to ask?
Dr. Greenbaum is a rheumatologist who practices in Greenwood, Ind. You may reach him at rhnews@elsevier.com.