The Importance of Being Generic: Avoiding Brand Names for Safety and Clarity

The number and complexity of drugs is ever-increasing. There are over 20,000 prescription drugs available on the market in the United States¹ and over 40 new drugs have been approved in each year from 2017–2021,². In this context it is unsurprising that drug errors abound³: as the number of drugs and prevalence of polypharmacy increase, the potential for prescribing errors and unrecognized drug-drug interactions also increase. The existence of multiple names for a single drug – at minimum generic and brand names – increases the cognitive load surrounding each drug and may predispose to these errors. Combination drugs are of particular concern: patients and healthcare workers alike may forget or not even know, for example, that “Percocet” contains both acetaminophen and oxycodone, which may lead to an unintentional but potentially fatal acetaminophen overdose. In addition, use of brand names may inadvertently imply allegiance to a particular pharmaceutical company. Consistent use of generic names may help learners and patients alike recognize medications in the same class with common mechanisms of action (e.g., -cillin for penicilllins, -mab for monoclonal antibodies, -prazole for proton pump inhibitors). Indeed, an emphasis on generic names would help eliminate ambiguity, promote a perception among the public that doctors are focused on active drug ingredients rather than drug companies, and decrease cognitive load.

We thus find the study by Steinkamp et al.⁴ published in this issue of the Journal of Hospital Medicine to be timely and relevant. This serial cross-sectional study examined the frequency of use of generic and brand names for 518 medications in all notes in all clinical contexts written by all author types within a large academic healthcare system over a 6-year period (2015–2020). Of the >162,000,000 medication mentions, 64% of mentions were generic names, and frequency of brand name usage decreased during the 6-year period. Among the 100 most frequently mentioned medications, some were nearly exclusively mentioned using generic names (e.g., heparin) while others were primarily mentioned using brand names (e.g., levetiracetam/”Keppra”). Using a multivariable logistic regression model, the authors identified characteristics associated with brand name usage: brand names were used more commonly in Obstetrics/Gynecology notes and, in order of decreasing frequency of use, notes from registered nurses, physician assistants, nurse practitioners, and physicians, providing potential targeted opportunities for education. Conversely, inpatient notes (as compared with notes from the emergency setting) and notes from pharmacists were associated with decreased brand name usage.

As noted by the authors, this study has multiple limitations, including the omission of medication abbreviations and typographical errors, and the exclusion of combination drugs. Omitting abbreviations and typographical errors likely led to underestimation of generic name usage. The authors found that generic names usually have more syllables and characters and are thus likely more subject to abbreviation use. Therefore, it is plausible that generic names may be used more frequently than reported by their exclusion of abbreviations. However, excluding combination drugs may have underestimated brand name usage given the complexity of generic names of combination drugs. Characterizing the frequency of combination drug brand name usage would have been prescient, as combination drugs carry an increased risk of adverse drug events, such as unintentional overdoses or drug-drug interactions. While the FDA has tried to decrease the potential for toxicity from acetaminophen in combination drugs through the withdrawal of all prescription combination drugs with more than 325 mg acetaminophen in the early 2010’s, consumers may still use acetaminophen concurrently with combination drugs that include acetaminophen when brand names are used and they are not educated on the components.⁵ In addition, without naming the components of combination drugs, it may be easier to miss potential drug-drug interactions between one component of a combination drug and another medication. The recent approval and use of the combination drug, nirmatrelvir/ritonavir (“Paxlovid”), highlights the potential for unrecognized drug-drug interactions. Ritonavir is a strong inhibitor of CYP3A4/5, which metabolizes numerous drugs, and is thus a perpetrator of several drug-drug interactions. Concomitant use of ritonavir with immunosuppressants like tacrolimus can lead to increased tacrolimus concentrations and toxicity. Meanwhile, ritonavir inhibits formation of the active metabolite of clopidogrel, decreasing its anti-platelet effect. If both prescribers and patients are not mindful of the presence of ritonavir in “Paxlovid” when reviewing medication lists for potential drug-drug interactions, its prescription could lead to harmful consequences.

The 21^st Century Cares Act appropriately enshrined transparency of clinical notes to promote patients’ accessibility to their own protected healthcare information. Therefore, our clinical documentation must be clear and unambiguous not only to fellow healthcare workers but also to patients and families who will be reading our notes. This shift will require a multi-pronged educational and quality improvement effort centered on both provider and patient education as to the importance of generic name usage. While these efforts will not be trivial, commitment to documenting generic names whenever possible is feasible and will help both decrease ambiguity in clinical notes and demonstrate our commitment to patient safety.