Generic vs Branded Medications

We get a few emails asking if they can have brand of X or is brand Y better than brand Z. Usually people mean this in terms of manufacturer e.g. Accord brand of dutasteride, or Roma brand of minoxidil, that is mainly what this article will target. We will also quickly look at when brands do matter and branded generics.

If you're taking a prescription or OTC medicine you've likely received a different manufacturer/brand on multiple occasions and thought to yourself, is one better than the other. The answer you're looking for is mostly no, apart from in very specific circumstances the brand makes 0 difference whatsoever.

The two most common reasons for people asking this question are usually coming from different places.

"Do you have the Accord brand? The others give me side effects."

For a tablet or a capsule, the manufacturer is very unlikely to be what's causing it. Manufacturers often change when we order from a wholesaler as we order by medicine e.g. Dutasteride not Accord, TEVA etc. So a bad month gets pinned on whichever box of medication that was taken. After that it holds, because you notice that company's name every time it arrives and you don't notice the months it doesn't.

"I've only ever had Roma and I don't want to risk changing."

This one isn't really about the medicine, it's about not wanting to disturb something that's working. Worth asking yourself, though: you got Roma because that's what was on our shelf the week you started. If it had been Milpharm that week, Milpharm is what you'd be asking us for now, and you'd never have known Roma existed.

Almost every prescription in the UK is written generically. It gives the drug, the strength and the form, and we supply a licensed product that matches. It doesn't name a company.

Which company that turns out to be depends on what our wholesalers had in stock when we last ordered. That moves around with price, availability and shortages, so the manufacturer we send this month may not be the one we send next month. That's why we can't tell you in advance which one you'll get. 

It works the other way round if a prescription names a brand. Then we have to supply that brand, and we can't swap it for anything else without going back to the prescriber first. So being kept on one specific product is possible, it just has to start with the prescriber deciding there's a reason for it.

That's also why branded generics exist. Zapain is co-codamol 30/500 and Emozul is esomeprazole, and both are the same medicines you can get without a trade name on the front. These are usually chosen as Zapain might be cheaper than prescribing generic co-codamol (thanks to weirdness with the drug tariff) but the science remains the same, branded generics are the same as unbranded generics.

Before a generic goes on sale in the UK it has to be tested head to head against the original in volunteers. People take one product, then the other, with blood samples taken across the day. Two numbers come out of it: how much of the drug got into the bloodstream in total, and the highest level it reached.

You might see it on various forums that the generic is allowed to land anywhere between 80% and 125% of the original. That isn't what the rule says, and the difference is worth understanding because the real version is much stricter.

A study of this kind gives you two things. The first is the best estimate of how the two products compare. The second is a range showing how certain the study is about that estimate, which is wide if the study was small or messy and narrow if it was large and well run. The 80% to 125% requirement applies to that second thing. The entire range has to sit inside the window, not just the estimate.

Once you follow that through, it stops being a wide margin. If a generic really did come out 15% below the original, the uncertainty around that figure would drag part of the range below 80% and the product would fail. To get the whole range inside the window, the estimate has to sit close to the middle. Products that pass are typically within a few percent of the original, not near the edges. And a lazy study doesn't help you, because a smaller study produces a wider range and makes failing more likely, not less.

The window isn't there because generics are allowed to be "sloppy" and just because they're cheaper not work as well. It's there because people's bodies aren't consistent. The same tablet taken by the same person on two different days gives different blood levels depending on food, timing and everything else going on, and two batches of the original brand vary against each other for the same reason. Any test comparing two products has to allow room for that or nothing would ever pass, including the brand against itself. ^[1][2]

For a small group of medicines where minor changes in blood level genuinely matter, the window is tightened further, to roughly 90% to 111%.

Excipients are the ingredients that hold a tablet together and give it its coating and colour, and manufacturers don't have to use the same ones. For nearly everyone this makes no difference at all. If you have a specific sensitivity, e.g. lactose intolerance a change of manufacturer might genuinely give you a problem. 

The size, shape and coating of a tablet/capsule can vary too. Some brands do have large "horse sized" tablets compared to others for some reason, and trying to swallow something noticeably bigger than what you had before can put you off taking them.

Taste and smell can change as well. It only really matters for anything dispersible or liquid, and for anything you're giving a child, but it's a common reason we see in the pharmacy for antibiotics "do you have the banana flavour" for example. We usually advise to put it in yoghurt (ask before you do this to make sure it can be taken with food) or a syringe rather than a syringe if we don't have a specific flavour in stock.

Topicals are the exception to most of this. Two solutions contain the same amount of the same drug, but they aren't made to the same formula, and for example they may contain propylene glycol in different amounts. This can cause an itchy or flaky scalp on one and not another. If that's happened to you, the manufacturer probably was the problem or even the form, and it's worth telling us which one suited you.

Everything written abour before is about ordinary tablets and capsules, which is 99% of what we dispense. There is a short list where it's different, and it splits into two kinds.

Where a regulator has said to stay put

Epilepsy medicines. The MHRA sorts these into three groups depending on how much difference a change of manufacturer could make.^[3][5]

1. Category 1: carbamazepine, phenobarbital, phenytoin and primidone. Stay on one manufacturer's product.
2. Category 2: lamotrigine, valproate, topiramate, clobazam, clonazepam, oxcarbazepine, perampanel, rufinamide and zonisamide. A judgement call, based on how often you have seizures and what your treatment history looks like.
3. Category 3: levetiracetam, gabapentin, pregabalin, lacosamide, brivaracetam, ethosuximide, tiagabine and vigabatrin. Switching is normally fine, though the MHRA still asks prescribers to think about whether an unfamiliar tablet would unsettle someone enough to affect how reliably they take it.

Worth being clear on what category 1 means, because it gets misreported. It means the same manufacturer's product, not a brand. If Teva is what you've always had, Teva is what you should keep getting.

Lithium. Different lithium preparations don't release the same way, so it's prescribed by brand rather than generically and shouldn't be swapped.

Modified-release preparations. The mechanism controlling how fast the drug is released belongs to the product rather than to the drug, so two versions can behave quite differently. This covers modified-release diltiazem, nifedipine, mesalazine and methylphenidate, and all tacrolimus.

Levothyroxine, but only in one situation. Generic prescribing is still right for most people taking it. If you get persistent symptoms after your product changes, MHRA advice is that your thyroid function gets retested, and if symptoms continue after that, you can be kept on one product that suits you.^[4]

Where it's the delivery rather than the drug

Inhalers and injector devices. This isn't really a generic question. The medicine inside can be identical while the device works differently, and with an inhaler your technique is what decides how much of the dose reaches your lungs. Being handed a device you haven't used before without anyone showing you how is the actual risk.

Biosimilars. Worth knowing because the words get mixed up. Biological medicines are made in living cells and are too complex to copy exactly, so what comes after the original isn't a generic and isn't treated like one.

If you're not sure whether this applies to you, it probably doesn't. Everything on this list is either prescribed by brand already or is something your prescriber will have raised with you. If you're on an ordinary tablet or capsule and nobody has ever told you to stay on one product, you aren't on it.

The basic version is straight forward branded paracetamol and branded ibuprofen contain the same drug at the same strength as the plain boxes, and cost several times as much. The active ingredient and the strength are on the front of every box, so as long as these match what you want, buy the cheaper one.

Targeted boxes. These are quite sneaky, they can market themselves as period pain, migraine, tension headache, joint pain, back pain and then inside them will just be ibuprofen 200mg/iburpofen 400mg.

Combinations. One tablet with two drugs in it costs considerably more than taking two cheap tablets. You're paying for swallowing one thing instead of two, which can be worth it to you, as long as you know you're paying for conviencne.

Pharmacy-only doesn't mean stronger. Some products sit behind the counter for licensing reasons rather than because they're a different strength, and the shelf version can be the same drug at the same dose for less.

Every medicine licensed in the UK has a Product Licence (PL) number printed on the carton, it's the licence the product is sold under.

Sometimes the branded box and the cheap box carry the same PL number. If they are the exact same then they aren't similar products, they're literally the same product, made in the same place under the same licence, with a different name then printed on the front. Then are definitely paying for the fancy packaging and marketing.

Just because the two differ doesn't mean one is better than the other or they are completely different from each other, you are just looking at two separate licences. Both have been assessed and both were approved, and it doesn't tell you one is better than the other.

For example if you're looking at Accord dutasteride's and Milpharm's dutasteride it is likely the PL numbers will be different, because they're different companies. The drug name and the strength on the box on this occasion are the same and that tells you what is in the box.