Generic Concerta Not Working Like the Brand Used To?

Note: there is an update of this post here. It is much easier to follow, since the original post has so many updates.

I used to be a huge fan of generics. They save money, right? They are equivalent to the brand name, right?

That's what I've always been taught and what I teach taught.

I've been jaded by many problems and now disagree with the above.

Generics aren't always cheaper than the brand name.

Some generics are not equivalent to the name brand.

A recent discussion on a psychology/pharmaceutical listserv I follow brought up the issue of generic Methylphenidate HCl not working as well as the brand name Concerta. Several members had some great insight into why this is. The discussion peaked my interest in the issue and I started looking online for information earlier this week.

Ironically today I went to pick up a family member's medicine. We have filled at the same pharmacy previously for generic "Concerta" and have always gotten the equivalent generic. When I looked at the pills in the bottle today, I told the pharmacy tech they weren't OROS (see below). She looked confused. She had no clue what I was talking about.  (Lesson to all: if you have any questions, ask to talk to the pharmacist. Hopefully they will understand the pharmacology better than the tech.)

Generics for Concerta (Methlyphenidate HCl) might have the same active ingredient, but have a completely different time release system, resulting in varying drug peaks in the bloodstream. The original generic for Concerta (from Watson pharmaceuticals) uses a special technology to time-release the active drug. This time release technology is called OROS (osmotic controlled release oral delivery system). There are several other time release methods. The active ingredient may be imbedded in various substances from which the medicine must exit slowly or a gel cap is filled with beads that dissolve at different rates. With the technology used by Concerta, the capsule IS the time release. It doesn't dissolve. The medicine is slowly released through a small hole in one end of the capsule. The pill works like a pump, pulling in water from the intestines, pushing the medicine out of the tube slowly throughout the day. See this photo from Medscape.

from http://www.medscape.org/viewarticle/547415_10

I have recently learned that not all generic formulations of Methylphenidate HCl are using this technology. This alters the time-release nature of the active medicine.  For some people this substitute might be just fine, or even preferable. But if it seems like your medicine isn't lasting long enough, has times that it works well followed by times it doesn't until the next peak, or any other problems -- check your pills!

You can tell the difference by closely looking at the capsules. The OROS capsules are a unique shape, a little more blunted than a standard capsule. If you look really closely at the ends, you will find that one has a "dimple" where there is a small hole covered by a thin layer matching the rest of the capsule. I just happen to have at least one of three dosages:

Photos of the Mallinckrodt brand are now listed under "Updates."

So if any medicine doesn't work like it used to, look closely at the pill itself to see if it is the same as previously. If you don't have any left, ask the pharmacy for the company / maker of the medicines you've filled over the past several months. Let your doctor know if you can't use a substitution so they can specify "Watson brand only."  If the new "brand" works better, be sure to ask for that manufacturer.

Better yet, call ahead and see who the manufacturer is of the generic for Concerta sold at your pharmacy. Watson Pharmaceuticals is the one that makes the OROS system. If they don't use that generic and you plan to shop elsewhere, be sure to let them know why!

Let me know your experiences with generics... See the Updates below if you want to report your experience to the FDA.

Update 4/29/13:

Reporting Adverse Events: A pharmacologist from the listserv I mentioned above suggests that if you have an issue with the duration of action of a different brand of Methylphenidate HCl you should report it to the FDA. This will allow them to review cases and possibly stop the substitution of these non-equivocal products. Click on this link for the MedWatch Report. Thank you SS!

Manufacturer Clarification: Watson Pharmaceuticals is authorized to market Concerta in the US for Ortho McNeill Janssen Pharmaceuticals, the original manufacturer.

Teva markets another type (not OROS) in Canada and Mallinckrodt markets another type (not OROS) in the US.

Update 5/27/13:

Photos of the Mallinckrodt pills (from www.mallinckrodt.com):

As a comparison, the pill shape of the OROS pills (Janssen Pharmaceuticals, McNeil, and Watson all look identical -- from www.goodrx.com):

Update 10/5/13:

I just learned another company is making a generic for Concerta. A patient suddenly found the medicine to be not effective. It looked entirely different, so suspected it was the wrong medication. The pharmacist confirmed that it is another generic for Methylphenidate HCl ER from Kremers Urban Pharmaceuticals. The parent sent me this picture of the 18mg pill and I found the 27mg on the Kremers website:

From http://www.kremersurban.com/products/Product_Details.aspx?ProdName=MetaT&ProdID=62175-311-37

If your pharmacist says he can't order a drug because of a shortage, you can check to see predictions of how long the shortage will last at ASHP.org. Be sure to look closely for the generic name and if it is an extended or immediate release form because it can be confusing.

Update 12/12/13:

Watson Pharmaceuticals will now be called Actavis, so ask for the OROS pill instead of a brand. I think I will do a whole new blog on this topic since there are so many updates since April. Watch for it!

This is a great resource on the difference in authorized vs true generics: An Update on Generic Concerta.

Update 5/1/14:

I'm excited to hear that the FDA has this issue on their watch list. Please read Gina Pera's We Did It! Concerta Generics on FDA Watch List.

Update 11/16/14:

Generics that are non-OROS will no longer be automatically substituted. They will still be available. See ADHD Roller Coaster's blog on the topic for details.

Resources:

The Pre-MMA 180-Day Exclusivity Punt? What Gives? A legal blog explaining how medicines lose their exclusivity and can become generically available, specifically the Concerta dispute.

How To Tell The Difference Between Concerta and Generic Concerta A Canadian ADHD blog provided the picture of how to recognize the difference. Generic formulations have been available in Canada years prior to in the US.

Special thanks to the members of the Child-Pharm listserv!

How to get kids to take medicine

A recent facebook post discussed how to give medicine to children, but left out how to give liquid medicine. A reader asked for advice, and I wanted to expand my original answer.

The article:   Medical Mom: A spoon full of sugar helps the medicine go down

The facebook question:   She gives great advice on pills, but what about liquid medications that kids just WON'T swallow? I've tried putting it in his cheeks, but the flavor they mixed it with he hates :(

Of course, there is so much to giving medicine to kids.  They already feel sick for most of the medicines we give, and anything is distasteful when you feel sick, regardless of the flavor the pharmacist adds.  Some medicines have a horrible aftertaste that is difficult to mask.  Some upset the stomach.

If medicine is vomited within 30 minutes, it generally can be given again. If your child vomits more than 30 minutes after the medicine is swallowed, do not offer it again.

I don't miss the days of liquid medicines! My son (who suffered from many ear infections) spit out most medicine (and often vomited what he swallowed).  My daughter didn't need as many medicines as him, but as the expert vomiter (she would vomit whenever she didn't get her way as an infant) and expert manipulator, she had unique issues to get the medicine down.


Needless to say, I learned a lot of tricks trying to get them to keep medicines down.


Most liquids taste better cold, so check with your pharmacist if the medicine can (or should) be refrigerated.  Also ask if it can be mixed with juice or foods.  Some should be given on an empty stomach without food and only sips of water. 


Be sure you have a properly sized medicine syringe or medicine cup for all liquid medicines.  Shake the bottle well before dispensing.


If it can be mixed into juice, jelly, or yogurt, be sure to mix in a small enough volume that you can ensure your child will take the entire amount.  You can measure the amount of medicine in a syringe, then fill the remainder of the syringe with drinkable yogurt, juice, or whatever liquid is okay to mix with the medicine.  (Always ask your pharmacist first!) 

Sometimes using a medicine that comes in a capsule that can be sprinkled onto a spoon of yogurt, jelly, or applesauce works well.   Yogurt tubes are especially great for this if your child eats these. Put the contents from the capsule on the top of the open tube, and they suck it down as they enjoy the yogurt.  Ask your pharmacist if you can mix the medicine with foods first!  

For infants: Try squirting it in the inner cheek and blowing on the face. I don't know why, but it seems to make infants swallow.  You can also put it in a nipple and allow them to drink from the nipple, which bypasses most of the taste buds on the tongue! After the medicine is swallowed, use the nipple for water or formula/milk to rinse all the medicine down as long as it does not need to be given on an empty stomach. 


Preschoolers: This age might feel "big" if allowed to hold the medicine cup themselves.  Supervise closely so they don't spill it.  Praise when they did it!


Preschool and up: Offer a chocolate syrup chaser. Syrup is thick and masks a lot!  Another trick is to offer a popsicle (or ice) first.  This numbs the taste buds, making the medicine taste less noticeable.


Holding the child's cheeks to make them pucker their lips until swallowed sometimes works (though I found kids can still spit it out that way!) 


You can also have the pharmacist flavor most medicines, and if you pick the right flavor, it can help. Ask for suggestions, since the flavor added might not be the best for the particular medicine. 


Bribery works with preschoolers and up. (A thing I promised myself I would NEVER do... but once I had kids and realized bribery works, I reserve it for the really important things.)


As for most of my behavioral advice: praise a job well done! If they took the medicine, tell them you are happy they did.


When you think your child is able to swallow pills without choking, teach with small candies, such as Tic Tacs or mini M&Ms.  I always suggest using a cup with a straw, since when you drink out of a cup you tilt your head back, narrowing the throat.  A straw allows you to keep your neck neutral. Once swallowing a small candy is mastered, you can use real medicine capsules or tablets, as long as the dose is correct for the child's weight.


Sometimes making a game of it works. My husband came up with this trick for our daughter when she was 5-6 years old.  Remember she was the expert manipulator.  She threw a fit about taking a medicine and made getting out of the house for school on time difficult a couple of days. He suggested that if she was ready for school by 7:15, she could throw a fit for 10 minutes. If she wasn't ready until after 7:20, she could only throw a fit for 30 seconds.  Either way we would set the timer for her fit, then she would take the medicine.  Of course we knew she'd never be ready early (and she really couldn't tell time well in kindergarten) so when it was time for medicine, we set the timer for 30 seconds and told her to throw a good fit.  She threw a great fit, then took the medicine without a problem. It was as if owning it worked for her, and she then took the medicine each day for the rest of the week after setting the timer for a fit.  By the end of the week she could hardly throw a fit she was giggling so much!


The most important thing is to remember why you are giving the medicine.  If it is an antibiotic or other medicine that is important to completely take, then it is more important than if you are simply trying to give a fever reducer.  A fever reducer might make your child feel better, but it really isn't required.  If it is required, then you need to play hard ball and do whatever it takes to get the medicine down.  


What has worked for your kids to take medicine?  Please share your tips!