Eye care providers prescribe most brand-name medications

The price of prescription medications has skyrocketed over the last few years even for plans considered to have “good” medical coverage. More of the prescription medication burden is being passed on to patients through higher deductible plans with an emphasis on generic substitutions. It has become customary for insurance plans to “prefer” generic medications, whereas branded products are considered “noncovered” with an added out of pocket cost to the subscriber.

Are generics the same as branded? The active ingredient has to be the same between the generic and the branded medication, but that is where the similarity stops. For instance, the pH can make a difference. A higher or lower pH can affect penetration and patient comfort. With an altered pH, the penetration may be adversely impacted, with less than an ideal amount of drug getting across the various layers of the cornea to reach its target tissue. Only 5% of the drug delivered onto the ocular surface is absorbed under ideal circumstances; a slight alteration in absorption can negatively impact drug efficacy. Patient comfort is key for compliance. Stinging and burning with drug instillation due to an altered pH can lead to noncompliance.

A vehicle difference can also have an impact. Product viscosity affects contact time on the ocular surface to enhance drug penetration or negatively impact the corneal epithelial layer leading to surface toxicity issues.

A difference in formula can also affect a drug. Uniformity of drug delivery is a key characteristic with each instilled drop. A suspension has to be shaken to mobilize the active ingredient into the vehicle whereas an emulsion does not require aggressive shaking and hence delivers a measured quantity of drug with every drop.

Lack of clinical trials is the key difference between generics and branded medications. Pharmaceutical companies spend millions of dollars in research and development through FDA-regulated clinical trials to ensure drug safety and efficacy. Generic formulations are not held to the same standard.

It is not all too surprising to see that eye care specialists are the largest group of providers that prescribe the most branded drugs. I can think of a few reasons for this, including dynamic pricing of generic alternatives, lack of same-class substitutions, concerns of efficacy and the greater adverse reaction profile of generic medications. It is well known that there is a rising cost to generic medications across all sectors of medicine, and our subspecialty is not immune to this. Particularly true for patients with commercial insurance plans, manufacturer coupons can often make the out-of-pocket costs aligned closely enough (and sometimes less expensive) than similar generic alternatives. Most importantly, not all formulations are created equally. Anecdotally, certain branded medications outperform their generic substitutes (ie, Pred Forte). As only the active ingredient is equivalent in generic medications, specific adverse reactions such as preservative hypersensitivity reactions to the cornea and conjunctiva can occur more frequently with generic medications. This is particularly common with glaucoma and steroid medications, in which more ocular surface-friendly preservatives and preservative-free options continue to be unique to certain brand medications. A greater instillation frequency is commonly seen with generic medication options, which raises patient compliance concerns, and the lower dosing schedule of newer-generation branded ophthalmic medications is a significant perceived benefit. Lastly, there exists a lack of same-class substitutions in certain areas, notably with anti-inflammatories to treat dry eye disease.

Much anecdotal evidence and now a growing number of clinical studies have shown that generic topical medications do not always deliver the same results as branded products. Our own recent study (pending peer-reviewed publication) of nearly 200 patients, randomized to branded vs. generic nonsteroidals following cataract surgery, showed significant differences in compliance, toxicity and patient comfort, with branded drugs performing better consistently. Ophthalmologists understand these differences intuitively, and our prescribing patterns follow our desire for patient safety. This study nicely defines the economic cost of choosing branded drugs but does not measure the cost of complications that generic drugs are more likely to induce than their brand name counterparts. To be forthright, health economics must be measured not just in dollars, but in patient well-being. This study nicely tells just part of the story.