Phive is NOT Phour!

Early one script-filled afternoon doing a locum shift in a busy suburban pharmacy, a pharmacy assistant received a prescription from a dark African man with a deeply toned accent. He requested she first ask one of the pharmacists how much the brand name item would cost him as well as the price of the generic alternative. I responded to this request, discovering the original item to be Coversyl 5mg.

My research concluded that this particular supermarket pharmacy sold the Coversyl 5mg brand, at the time, for approximately $23 and the generic for around $16. I relayed this information to the assistant who explained to the African patient. He eagerly decided to take the cheaper option, saving money from the last time he purchased at another pharmacy.

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Now, before I continue the story further, there's something I must explain to you about Coversyl 5mg and the generic versions. The active ingredient in Coversyl 5mg is perindopril attached to the molecule arginine as a salt. Before Coversyl came off patent in Australia (the patent expired sometime early 2007, from memory), the makers & sponsors of Coversyl in Australia, Servier, changed the salt from perindopril erbumine to its current from of perindopril arginine in August 2006. As I have already mentioned, Coversyl 5mg is perindopril arginine 5mg, but the old perindopril erbumine salt was 4mg!

At the time of the change, Servier explained that the strengths were bioequivalent. See this NPS article for proof: Click this boring article.

The purpose of this change, while generic companies were in the middle of creating their own generic perindopril erbumine, was to prevent those same generic companies from coming onto the market and also prevent patients from switching to cheaper alternatives. Therefore, Servier would see less of their profits go to generic companies. Patients would now see them as different strengths, and initially, this system worked. This process is called ever-greening and is just another common form of corporate greed in the pharmaceutical industry.

The main reason this sneaky change worked was because it took nearly 6 months for Australian authorities to officially list the generic perindopril erbumine 4mg as an equivalent product to the Coveryl, perindopril arginine 5mg. This was so stupid and I will explain using the following formula:

Servier told us: perindopril erbumine 4mg = perindopril arginine 5mg

Which is: Coversyl 4mg = Coversyl 5mg

Generic companies produced their products to be exactly equivalent to Coversyl's perindopril 4mg.

Therefore: Coversyl 4mg = Generic 4mg

Finally, this should mean: Generic 4mg = Coversyl 5mg

Not hard maths, is it?

This was possibly one of the most boring explanations I ever wrote... Let's continue.
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Now, after I dispensed the prescription, the assistant took the medication to the patient. Immediately, he questioned why it was now 4mg instead of 5mg and asked to speak to me. I stepped down from the dispensary and began my above (boring) explanation. As I barely finished my first sentence, he looked at me with anger in his eyes and said, "I've done chemisty, and I know that 5mg is not 4mg!"

"I know," empathising with him, "but please let me explain."

"No!" He replied, boiling. "5mg is not 4mg! I know chemistry!"

"OKAY, OKAY," I responded with calm. "I'll change it to the 5mg version." I adjusted the prescription back to the $23 Coversyl 5mg brand and handed it to the assistant to put through the payment at the till.

I continued with other prescriptions when suddenly, the same assistant was standing next to me and said, "The African gentleman changed his mind and wants the $16 version."

"OKAY..." I uttered with slight frustration, and changed the prescription back to the 4mg Generic worth $16.

About 20 seconds later, I clearly heard the yelling coming from the counter area, "5MG IS NOT 4MG!!!"

I went down to the cash register, armed with a stapler, where the African gentleman was standing. I calmly took back the medication, removed the dispensing stickers from the prescription, stapled it back the way it was before he entered the pharmacy, and as I handed the prescription back to him, said, "I'm sorry, we can't help you." I then turned around and headed back to the dispensary.