RECENTLY, managed-care insurance companies have been increasing their pressure on me and other doctors to change patients over to generic alternatives to some of our most popular drugs. On the surface, this would appear to be a good idea, one that saves money and thus should be a primary consideration when prescribing drugs.
Sometimes it is -- but not always.
It had taken me several years to convince Roger to take Lipitor (atorvastatin), a cholesterol-lowering medication. Although he didn't have known heart disease, his family history (his father had died of it at 55) and high cholesterol made it seem likely to me that his coronary arteries were already clogging up with plaque. He had begun to exercise two to three times a week, and he insisted he was improving his diet, eating less meat and dairy, and more vegetables, fish and fruit.
Nevertheless, his cholesterol numbers continued to climb. When his bad cholesterol (LDL) reached 155, he finally agreed to take a medicine to lower it. Studies had shown Lipitor's effectiveness at stabilizing coronary plaque and reducing heart attacks and strokes in patients with heart disease, so I started him on that.
In the past, Roger had tended to be intolerant of medications. He had occasional bouts of bronchitis and sinusitis, for which I would prescribe antibiotics. But because he often developed diarrhea and fatigue, he would sometimes stop them before the course was completed. He also suffered from gastric reflux disease, but reported that stomach medicines made him nauseated. I held my breath when he started Lipitor, but to my amazement, the days went by and he didn't call to complain.
Any muscle aches? I asked him when he returned to my office for blood tests. No, he said. In fact Roger had no complaints at all, and his blood tests showed normal muscle and liver enzymes, not to mention a dramatic lowering of his cholesterol.
We were both quite happy until the day a year ago that his insurance company decided it would no longer cover Lipitor. It suggested simvastatin instead, a new generic version of the cholesterol drug Zocor, another popular statin. Simvastatin hadn't fared quite as dramatically as Lipitor in studies, but it was a reasonable alternative and was generally well tolerated.
Still, it made no sense to me to change from a drug that was likely more effective and was being tolerated to one that was unknown. I intended to call the insurance company to protest, but in the meantime, Roger agreed to try simvastatin.
A week later he was back. Cramping muscle pain in his legs and arms had caused him to stop the drug. I found that the muscle enzyme CPK was elevated and told Roger that I was going to change him back to Lipitor. By that point, however, he was afraid to take any cholesterol drug, and it took me several weeks to convince him to give it another try.
In the meantime, my sample closet was filling up with Lipitor, probably because of the new threat that the generic simvastatin posed to the blockbuster drug's share of the market. (Drug samples arrive more frequently when a drug company fears new competition.) I set aside a three-month's supply for Roger, and when he next came to see me, I handed him the drug in a small plastic bag.
Everyone likes a freebie, and it was this gesture that convinced Roger to start taking the drug again. Again he tolerated it well, and I used the time I had bought him before the samples ran out to convince the insurance company to cover it. Roger was a self-employed carpenter, and he could never have afforded to pay for the drug himself.
The story had a happy ending, but I couldn't help but wonder if Roger's case represented cost-effective medical care. Should we push generic drugs all the time, even when the drug being replaced is working and is well tolerated?
For me, a practicing internist who believes that medicine is sometimes an art, not an equation, the answer to the question is clearly no.
Dr. Marc Siegel is an internist and an associate professor of medicine at New York University School of Medicine.