The Price and Quality of Methylphenidate Products

OBJECTIVE

For many products, generic markets are very mature, with aggressive competition driving down the price of products for manufacturers. Under these conditions, manufacturers may not have an ability to invest in high-quality manufacturing processes.

METHOD

We acquired samples of all available methylphenidate products in immediate release tablet (IR), extended-release tablet (ERT), and extended-release capsule (ERC) formulations in all available doses from all available labelers listed at one major wholesaler in February 2023. Products were analyzed for variations in dissolution parameters and for the presence of the N-nitroso-methylphenidate. Finally, we examined the cost and quality of tested products.

RESULTS

All immediate-release methylphenidate products had similar dissolution profiles. For extended-release products, the confidence intervals of the difference factors for 12 of the 24 generic extended-release tablets sampled did not contain the null value, indicating a statistically significant difference in dissolution from the branded product. N-nitroso-methylphenidate, a probable human carcinogen, was detected above regulatory thresholds in generic immediate-release products for 7 of the 15 unique products sampled. N-nitroso-methlyphenidate was detected below regulatory thresholds in extended-release tablets and was not detected above the limit of quantification in extended-release capsules. The average price for products with and without elevated N-nitroso-methlyphenidate was not significantly different.

CONCLUSION

Independent laboratory testing of generic methylphenidate products found significant product quality concerns. Making product quality transparent could offer the potential to dramatically improve the quality of generic drugs at no additional cost.

Intended and Unintended Impacts of '4+7' Volume-Based Drug Procurement on the Use of Drugs in China: A Natural Experimental Study

Background: Volume-based drug procurement is regarded as a pharmaceutical cost-containment measure in healthcare provision globally. The Centralized Volume-Based Drug Procurement (CVBDP) launched in March 2019 in China, also known as the '4+7' policy. 11 cities, including Xi'an city in Shaanxi Province, were set up as pilots. This study aims to examine the intended and unintended impacts of the '4+7' policy on the use of original and generic drugs in city-level and county-level hospitals in Shaanxi, China. Methods: The data used in this study came from the Shaanxi Drug and Apparatus Centralized Procurement Platform (SDACPP). In total, 111,999 drug procurement order records of 118 policy-related drugs (including 25 '4+7' policy-list drugs and 93 alternative drugs by generic name) from April 2017 to November 2019 were included in analyses. Policy-list drugs were divided into bid-winning and non-winning drug products. The volume and the expenditure of the drugs served as the outcome variables, measured by Defined Daily Doses (DDDs) and Chinese yuan (CNY), respectively. A difference-in-differences (DID) approach was used to estimate the policy's net effect. Results: After the '4+7' policy, the volume of bid-winning, policy-list, and policy-related drugs increased. An unexpected increase in volume was observed among alternative drugs, especially original drugs in city-level hospitals. The expenditure of policy-list and non-winning drugs declined, whereas that of alternative drugs unanticipatedly increased. Changes in volume and expenditure were both greater in generic drugs and in city-level hospitals, compared to their original and county-level hospital counterparts. Conclusions: Our findings highlight the positive effects of the '4+7' policy on generic drug substitution and pharmaceutical expenditure containment, which are greater in city-level hospitals. The unanticipatedly incremental volume of original drugs in city-level hospitals suggests the potential risk of the poor quality of bid-winning drugs, lower compliance with bid-winning drugs among patients, or physicians' profit-seeking behaviors in urban areas. More regulations and supervisions for the prescription and financial incentives of physicians are needed to address these concerns.

Uncovering patients' preferences for brand among essential classes of coronary heart disease medications using a discrete choice experiment

Patient preferences for medications strongly correlate with adherence; one area of interest is the choice between branded and generic drugs. Despite extensive research about brand-versus-generic drug preferences, few studies have explored severe-illness patients like those with coronary heart disease (CHD). We could not locate studies measuring preference weights of branded drugs in different classes within guideline-recommended regimens using discrete choice experiments (DCE). We aimed to explore the preference for branded medications used for secondary prevention of CHD events among patients receiving treatment at one of the largest Egyptian health insurance clinics. Patients with CHD were interviewed to choose between various therapy regimens containing brand-name and generic versions of aspirin, beta-blockers, statins, and renin-angiotensin-aldosterone system blockers (RAAS blockers). The study employed a DCE technique and followed the recommendations of the International Society of Pharmacoeconomics and Outcomes Research (ISPOR). Seventy-two percent (149) of the 208 patients questioned were dissatisfied with at least one of their generic medications. The majority of unsatisfied patients displayed brand preferences across the four medicine classes, primarily due to the notion that generics may be less effective. Patients preferred the RAAS blocker brand the most (adjusted odds ratio [AOR]: 3.14; 95% confidence interval [CI] 2.83 to 3.48), followed by beta-blockers (AOR: 2.06; 95% CI 1.88 to 2.27) and statins (AOR: 1.5; 95% CI 1.50 to 1.61). The relative importance of each class from the patient's perspective showed the highest importance with RAAS blockers (22.2%) and beta-blockers (14.1%), while statins and aspirin had minor importance (7.8% and 6.6%, respectively). In the present study, branded drugs for secondary CHD prevention were preferred over generic alternatives. This finding has two implications for clinical practice. Firstly, physicians and pharmacists need to assure patients about the quality of generics to insure patient satisfaction and adherence to medication. Secondly, health insurance providers need to confirm the effectiveness of generics through observational studies. Despite the well-proven protective effects of aspirin and statins, they had minor importance from the patient's perspective, highlighting the need to enhance patient knowledge. DCE was demonstrated to be a useful tool for eliciting the genuine preferences of patients treated within the setting of health insurance.

Assessing the longevity of attribute framing in attenuating the nocebo effect to brand and generic medication

The perception of taking a generic, relative to brand, medication has been demonstrated to exacerbate the nocebo effect. Conversely, positive attribute framing has been shown to attenuate the nocebo effect. However, little is known about the longevity of positive attribute framing nor how it interacts with generic versus brand treatment cues. Healthy participants (N = 205) were randomised to receive either sham-modafinil capsules with a brand or generic appearance, in conjunction with standard negative side effect framing (brand-negative: N = 42; generic-negative: N = 41) or positive side effect framing (brand-positive: N = 40; generic-positive: N = 40). The remainder were randomised to a no-treatment control (N = 42). Participants were informed that modafinil could enhance alertness and cognitive performance and reduce fatigue. Critically, modafinil was described as having several potential side effects. Treatment-related side effects, alertness, fatigue and cognitive performance were measured at baseline, 30-min post-treatment and 24 h later. Nocebo and placebo effects were observed across modafinil-treated participants relative to control. Positive framing significantly reduced warned side effects for 24 h. Perceived side effect likelihood, severity, and worry mediated the nocebo, but not framing, effect. Results have important implications for the presentation of side effect information, providing a potential route to reduce unwanted negative effects of generic medication.

Perceptions of generic medicines and medication adherence after percutaneous coronary intervention: a prospective multicentre cohort study

OBJECTIVE

To determine patient perceptions of generic medicines 2 and 6 months after percutaneous coronary intervention (PCI), and to determine whether these perceptions moderate medication adherence.

DESIGN

Prospective multicentre cohort study with repeated measures of perceptions of generic medicines and medication adherence.

SETTING

The CONCARDPCI study conducted at seven large referral PCI centres in Norway and Denmark between June 2017 and May 2020.

PARTICIPANTS

A total of 3417 adults (78% men), using both generic and brand name medicines, with a mean age of 66 years (SD 11) who underwent PCI were followed up 2 and 6 months after discharge from hospital.

MAIN OUTCOME MEASURES

Perceptions of generic medicines were the main outcome. The secondary outcome was medication adherence.

RESULTS

Perceptions of generic medicines were significantly more negative at 2 than at 6 months (1.10, 95% CI 0.41 to 1.79, p=0.002). Female sex (-4.21, 95% CI -6.75 to -1.71, p=0.001), older age (-0.12, 95% CI -0.23 to -0.02, p=0.020), lower education level (overall p<0.001), ethnicity (overall p=0.002), Norwegian nationality (10.27, 95% CI 8.19 to 12.40, p<0.001) and reduced self-reported health status (0.19, 95% CI 0.09 to 0.41, p=0.003) were significantly associated with negative perceptions of generic medicines. There was no evidence to suggest that perceptions of generic medicines moderate the association between sociodemographic and clinical variables and medication adherence (p≥0.077 for all covariates). Moreover, self-reported medication adherence was high, with 99% scoring at or above the Medication Adherence Report Scale midpoint at both time points. There were no substantial correlations between negative perceptions of generic medicines and medication non-adherence at 2 months (r=0.041, 95% CI 0.002 to 0.081, p=0.037) or 6 months (r=0.038, 95% CI -0.005 to 0.081, p=0.057).

CONCLUSIONS

Mistrust and uncertainty about the safety and efficacy of generic medicines remains in a sizeable proportion of patients after PCI. This applies especially to those of lower socioeconomic status, older age, female sex, immigrants and those with poorer mental health. However, this study demonstrated a shift towards more positive perceptions of generic medicines in the longer term.

The problem of choice: original drug or generic? Emphasis on rosuvastatin

An increase in the life expectancy of the population and the number of polymorbid patients with a combination of two or more diseases in different age categories, including among young people, has led to a significant increase in the cost of medical care in the field of public health. The transition from original drugs to generic ones has become a common measure to contain these costs. While this is an important goal for healthcare systems around the world, the impact of this practice on patient outcomes needs to be carefully considered. In some cases, generics may represent a suitable alternative to branded products, but this is not always the case. In particular, studies have shown that changing the drug can negatively affect not only patients' adherence to treatment, but also clinical outcomes, and a subsequent increase in the total cost of treatment, therefore, the use of generics in clinical practice still causes caution and concerns on the part of both the doctor and the patient. Due to the high prevalence of dyslipidemia and hypercholesterolemia both worldwide and in Russia, in this review the problem of choosing an original drug or generic is described by the example of such a hypolipidemic agent as rosuvastatin. According to numerous studies, rosuvastatin is one of the most potent and widely prescribed statins. Considering that most of the clinically significant effects of this drug are demonstrated in relation to its original form, the review emphasizes the importance of prescribing the original drug rosuvastatin in routine clinical practice.

[Treatment persistence with brand-name vs. generic metformin in monotherapy for type 2 diabetes: real-life retrospective study using the propensity matching score]

OBJECTIVE

To evaluate treatment persistence in patients with polymedicated type 2 diabetes (DM2) receiving new treatment with brand-name vs. generic metformin 850mg in usual clinical practice.

PATIENTS AND METHODS

Observational, retrospective study based on the medical records of patients aged ≥50 years who initiated metformin treatment (brand-name vs. generic) between 01/01/2016 and 31/12/2017. The follow up was two years.

MAIN MEASURES

treatment persistence and clinical consequences (metabolic control [HbA1c] and hospital admissions). Each patient in the brand-name group (reference) was paired with a patient from the generic group using propensity score matching. A Cox proportional risk model was constructed (p<0.05).

RESULTS

863 patients receiving brand-name metformin were matched (ratio 1:1) with patients receiving generic metformin. The median age was 60.8 years (SD: 8.8) years and 52.6% were female. Persistence at 24 months was 8.6% higher for brand-name vs. generic metformin (63.2% vs. 58.2%; p=0.034). The hazard ratio for brand-name metformin was 0.83 (95% CI: 0.71-0.96, p=0.013). During the follow-up there was a greater percentage reduction of HbA1c in the brand-name vs. generic group (-6.8% vs. -4.1%; p=0.013). There was a non-significant 19.1% reduction in hospital admissions in the brand-name vs. generic group (8.9% vs. 11.0%; p=0.148).

CONCLUSIONS

Polymedicated patients who initiated new brand-name metformin treatment for DM2 had greater treatment persistence than those who initiated it with generic metformin and had better metabolic control (percentage reduction in HbA1c).