Leave Well Enough Alone

I read with interest the article “Pharmaceutical Giants Embroiled in Generic-Drug Controversy” in the December 15, 2000, issue.

I am affiliated with an outpatient clinic that treats a group of 60 to 70 of the most treatment-resistant and chronically ill patients in the community. Funding is entirely through a contract with the county mental health administration. About a dozen of these patients are on clozapine.

About a year and a half ago, we tried to switch our patients from the brand name Clozaril to one of the generic brands of clozapine. Switches were made to the same dosage of the generic drug, with no titration period. Within two weeks, all of the patients seemed to be doing worse, with an increase of psychotic symptomatology. We immediately switched them back to brand-name Clozaril, and they all restabilized, fortunately without any hospitalizations. Since that time, we have left well enough alone and have not tried to switch to a generic again.

While placebo effect or random fluctuations of illness might account for some cases of decompensation, it seemed to me unlikely that all of these patients were promptly worsening on that basis. I suspect there is a problem with differing bioavailability, or at least there was at the time.

I agree that starting a patient on a generic brand is less likely to pose a problem. I would agree with those who have expressed caution regarding switching well-stabilized patients from the brand-name to a generic version of clozapine.