GP dilemma: Should I prescribe generic or branded drugs?

I think I should prescribe the generic brand of a drug, even though my patient is requesting the branded version. What are my professional obligations?

Kirsa Morganti, medicolegal adviser at Medical Protection, writes:
As generic drug formulations are usually cheaper than branded products, it is common for local prescribing advisers to advise the use of generics for all patients. Indeed, it is also common for GP practices to be financially incentivised for such prescribing.

While it is acceptable for most patients to receive their prescription as the generic drug product, the medication that is dispensed can on occasion be a branded product. This can lead to difficulties when the patient requests future prescriptions to be in this brand as it 'worked better' or had 'fewer side effects'.

In generic drugs, the active ingredient will always be the same as the branded version. However, the other excipients may differ, which can in some cases result in a patient experiencing side effects. In addition, there can be a degree of individual variation in the drug’s efficacy resulting from the differing excipients impacting on the bioavailability of the active ingredient.

Discuss matter openly

According to the GMC's guidance on consent, the doctor-patient relationship should be based on openness, trust and good communication. This means that when a patient requests a branded prescription drug due to issues with the generic equivalent, it is necessary to discuss the matter openly with the patient.

This would involve carefully eliciting the reasons behind the request for the branded product. It is not uncommon for patients to attribute symptoms to a change in medication, however, they may in fact be due to other causes, so a detailed history may enable the doctor to clarify the patient’s concerns and reassure them of the appropriateness of their generic prescription.

Should the history confirm a plausible difficulty with the generic product, the doctor may consider prescribing the requested branded product or perhaps consider changing the prescribed medication to an alternative suitable product which could be given generically. The doctor’s rationale should then be carefully documented in the patient’s records.

It is important to remember that the issue of cost is a reasonable factor to take into consideration when prescribing, but does not override the requirement to provide a treatment of overall benefit to the patient. A GP should not provide treatment to a patient that they consider to not be of benefit.

There will be a small minority of patients who genuinely seem unable to tolerate a generic product, with no other generic alternative providing the same level of efficacy as the brand they are requesting. In such patients, it is appropriate to prescribe the brand requested in order to provide effective treatments based on the best available evidence. The impact that this will have on prescribing targets is of secondary importance to the doctor’s obligation to their patient.

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