The Cold-Medicine Racket | Hacker News Reader

The Cold-Medicine Racket

theatlantic.com

103 pointsThevet114 comments

This is such a great example to highlight how information asymmetry and choice overload act to undermine markets.

> The difference in price between brand names and generics accounts for tens of billions of dollars "wasted" every year by Americans in pharmacies, according to the economics researchers.

> Consumer confusion, or misplaced trust, is compounded by the fact that a drug store is likely to have upwards of 300 cold-and-flu products

> One myth is that "brand-name drugs are made in modern manufacturing facilities, and generics are often made in substandard facilities." But, the FDA counters with the reminder that it "won't permit drugs to be made in substandard facilities."

Imagine how much consumers would overspend on branded medications if they couldn't count on the FDA as a backstop.

EDIT: By "backstop" I mean the FDA's role in ensuring that generics are bioequivalent and meet manufacturing standards. Imagine how much more effective brand advertising would be if some of the choices on the shelf really were manufactured in a dirty factory in Mexico.

The FDA does try, but it's ineffective and totally overwhelmed. Here's a recent story[1]:

   In January, FDA inspectors paid a surprise
   visit to the facility in Toansa, in a rural
   area north of New Delhi, and found broken
   equipment, windows stuck open and flies
   “too numerous to count,”
   ...
   Workers ran quality tests over and over
   until they got the results they wanted

Just google around and you will find many many many stories like this. It's been an ongoing problem with generics (mostly from India) for quite some time.

I don't know if brand-name drugs are any better, probably many of the same ingredients are sourced from the same suppliers. But at least the brand-name drug has a reputation, i.e. a "brand name" to protect.

Edit: Just wanted to add: RTFA I linked to. My one quote doesn't do the situation justice. The culture at some companies is IMO really really bad.

[1] http://www.bloomberg.com/news/2014-03-06/flies-found-by-fda-...

Stores like CVS and Walgreen's do have their store brand to be concerned about. So if brands do provide some guarantee of quality, buying from those stores is likely not worse than the branded products.

Agree with everything about your comment, except I wouldn't characterize the FDA as "overwhelmed". Read the expose 'Dirty Medicine' on Forbes and you might choose a different adjective. :-/

It is indeed an interesting example of information asymmetry. An economic historian at LSE who I know actually traces the origins of modern advertising to the rise of "brand-name" medicines. Back in the late 17th century, early newspapers started running early ads for proprietary drug recipes that cured things like plague and gout. These were the earliest products to be sold via mass media and to be "branded" using the name of the preparer. I.e. in a world where a consumer would simply go to "Shoe Street" to buy shoes, these early apothecaries pioneered the idea of using mass media to persuade consumers not to buy a generic gout cure, but instead to go specifically to, say, Mr. Merck's shop to buy "Merck's gout elixir" (I use that example because the Merck corporation actually does trace its origins to a late 17th century apothecary).

While the FDA does a fantastic job of reminding the population of the process it uses to ensure generics deliver the same experience, there is still a ton of waste in the system due to brand-name drugs being chosen over generics. Part of the problem is the massive marketing efforts by pharma trying to convince patients and doctors that their brand-name drug is better. For details see:

http://www.iodine.com/blog/do-people-prefer-under-patent-dru...

Part of the problem is that the name brand drug is sometimes better than the generic, and one generic brand is sometimes better than another. I have experienced this as a patient.

as a study of one, how do you know it isn't the placebo effect?

There have been a few examples where the FDA received complaints, looked at the data and asked the generic manufacturer to rest test/reformulate their drug since it wasn't therapeutically equivalent.

The best example is generic Wellbutrin[1]. Many patients complained of side-effects from generics that they didn't experience with the brand-name drug. The FDA did testing and realized that the generic Wellbutrin extended-release resulted in much high blood concentrations than the branded version. The generics in questions were withdrawn from the market.

The interesting thing is that to get approval for an "AB-rated" (therapeutically equivalent) generic drug, you don't have to be identical. The FDA only requires that the generic drug deliver 80-125% of the drug the branded drug does[2]. Normally that range is fine, but for some drugs (antiepileptics are a good example) the differences can produced a less than equivalent therapeutic outcome.

[1]http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInfo...

[2]http://www.nature.com/clpt/journal/v94/n4/full/clpt2013104a....

Problematic generics seem to come up often about extended release formulations when hanging around ADHD communities. Judging from this latest one I remember, it takes a big push for the FDA to start looking into it and ask questions:

http://www.fda.gov/Drugs/DrugSafety/ucm422568.htm

As consumers, we don't really have much of a way to test for placebo effects or when generics are actually subpar other than complaining until someone listens... so... it's a bit of a chicken/egg problem.

I think that's my question, as an individual, you can't say that one is more effective than the other because, as an individual, you can't account for the placebo effect. Personally, if it works, it works, placebo or otherwise.

If you search online, you can find isolated regulatory incidents, patient anecdotes, and even statements by doctors that they prefer patients not switching brands when something works for them. Beyond that, I'm not sure what is really known, or how you would go about studying this phenomenon in a scientific fashion.

Even if it is a placebo, if two medications that are supposedly the same cause different effects on me, e.g. one has much more manageable side effects than the other, then why shouldn't I take the one that makes my life better?

I'm a strong believer in the placebo. If it works, then stay with it...

> information asymmetry and choice overload

In the industry, we call it "patient education."

Or "common sense". It's pretty easy, I just read the list of ingredients.

The information asymmetry and confusion factor are worst in that all these products have just a few ingredients, in my opinion. While the branded/generic price difference is an important issue, I think a larger one is that the huge volume of products takes attention away from the fact that there are only a few basic components, leading many to buy inappropriate products or products with too many components that can cause side effects that could easily be avoided.

People without some prior knowledge of the basic drugs must have a very difficult time walking into a store and choosing the product with the drugs they need without some of the ones they don't. I imagine many people are totally overwhelmed by the product selection and they just pick something, which they then turn to each time they're feeling sick. It's more difficult than normal to perform an assessment of products at the store when you're sick, and the store presentation only makes things more difficult. Even knowing something about these products and knowing exactly what I want, I sometimes find it time-consuming to locate the single-ingredient products among all the endless combinations, especially when they're out of stock.

Things would be so much simpler if stores posted some type of reference. I'm not an expert in the field, but it's such a pet peeve of mine that I've memorized the basics. Here's a start:

  Fever/pain -> Relieve:
  ibuprofin
  acetaminophen [avoid if you have liver problems]
  naproxen
  aspirin

  Nasal congestion -> Reduce:
  pseudoephedrine [quite effective, but the pharmacy must be open; prepare to provide identification, sign, possibly be questioned / receive a dirty look, and have your purchase be entered into a federal database]
  phenelyphrine [of questionable effectiveness]

  Coughs -> Make more productive at clearing congestion:
  guaifenesin

  Coughs -> Suppress:
  dextromethorphan

  Trouble sleeping / allergic sensitivity -> Relieve:
  doxylamine [slightly better for sleeping than allergies]
  diphenhydramine [slightly better for allergies than sleeping]

The store could have a nice section of the products that contain just one of these drugs, making it easy to mix and match, with reference to the list.

I don't think there's anything inherently wrong with the combination products, but it really seems their general effect confuses rather than clarifies, which seems to me to be part of the reason for the design and proliferation.

The author of this piece seems to have similar feelings:

> ...I can't see myself using it, because I usually keep generic single-drug products around. A family, or a sickness-inclined person living alone, could very reasonably keep the five aforementioned individual generic medications in their medicine cabinet and address the symptoms as they arise. I think that's easier than messing with combination products, and usually cheaper. Especially if you consider that you're not taking medications you don't need.

> I tried to convince Angelotti that's the way to go, but she was adamant that many or even most people really like to take one pill that addresses all of their symptoms. "I don't know if people will be likely to have their own inventory of generic over-the-counter medications in their homes," she said.

I think a simple list like this, preferably easily visible in the store, and some better organization in stores would do people a much greater service than the app the article discusses.

Hey there - I'm that Angelotti :).

My problem with this approach: As I'm quoted as saying in Jim's article, I just think it's a non-starter for most people to do this, ie keep an inventory of sorts in their medicine cabinet and recombine them as needed. Jim is thinking like a doctor, not like your average, non-medically-trained person. There's a reason pharma makes combo products — people do like getting multiple ingredients in one pill. It's convenient! Most people have neither the patience nor the medical education to recombine individual generic ingredients on their own. And trying to do so could actually put them at higher risk for drug interactions or other human error. You have to read and reconcile warnings and directions labels from 3 or 4 different product packages, instead of just one.

>"And trying to do so could actually put them at higher risk for drug interactions or other human error. You have to read and reconcile warnings and directions labels from 3 or 4 different product packages, instead of just one."

I don't see how "combined" pills that are vetted by pharmaceutical companies or the FDA stop unwanted interactions from drugs. People don't read the entire huge and tiny-font booklet that comes with most medicine and cross-reference the ingredients from each with all the other medicine they're taking. Sure, they rely on doctors to help them out (if they know/can anticipate), but that's just as much a disaster waiting to happen as what you're arguing against.

So what ends up happening is that the drug interactions occur anyways even though people took approved combinations of ingredients. I'd rather we not promote this whole approved combinations prevent unwanted interactions as people mix different pills anyways.

Having your SOP for dealing with a cold being "select exactly one box from your medicine cabinet [or pharmacy shelf] and take the recommended dose" is likely to produce fewer unwanted interactions than if your SOP is "select 1 to N boxes from your medicine cabinet and take the recommended dosage of each of those medications", especially when the person selecting is far from their peak mental performance due to the cold symptoms they're experiencing.

Many (likely most males under 60) people take zero pills on a given day when not sick.

Hi, and thanks for your reply!

I certainly agree with you that some people are not going to keep a small inventory of common drugs, others can't be bothered to take more than one pill, and a few cannot successfully manage that sort of combination.

On the other hand, though, I think there are a lot of people who would like to learn more in order to make the best choice about what drugs they take, and the branded combination solutions really end up muddying their conceptions of these medicines. I know a number of people who just buy whatever they've decided is their favorite variety of DayQuil when they're feeling sick during the day (you're quoted relating similar experience in the article), and I know a number more who don't realize there are major differences between traditional Alka Seltzer and the proliferation of their cold products. The brands and the proliferation undermine people's ability to concentrate on the drugs they're taking, and they mentally give up on figuring the situation out and determining the best medical choice (especially if they also consider the cost and branded/generic elements of the equation).

The identification with brands rather than the actual drugs is likely the largest problem, especially now that each long-existing drug manufacturer sells combinations of the various drugs under their own name. I wouldn't mind seeing these companies have to devote the top 1/3 of the front of their boxes to a large, unadorned list of the product's active ingredients.

I think people who would like to be more informed consumers, but who struggle because of the current setup, are underaccounted for. I think there are many people who would love an inexpensive pack of 50 of each of these generic drugs to keep a small inventory at home, and who would be perfectly capable of managing it.

While it may be easy for a doctor who is familiar with these medicines to erroneously assume that they are very familiar to others, I think it is also easy for a doctor to not give patients enough credit in being engaged with their health treatment and being willing to spend a small amount of time and effort becoming familiar with a few extremely common drugs.

How often are people, on average, mildly sick in their adult lives? About once per year? How often do they care for others who are sick? These drugs are incredibly common, they are relatively simple, and people are likely to have a lot of contact with them over a lifetime. I think greater familiarity with them would be very useful in the average life, and I think an education effort would provide a lot of health value, even so little as starting with a simple reference in the store.

I am not a medical doctor or a pharmacist, and my list above is from memory (except for spelling). Perhaps I have engaged in the care of illness slightly more than average, but it didn't take a medical text to learn this stuff. It just took some concern over what I was giving myself/others and whether it was appropriate for me/them, and then a small bit of reading. This is an issue I care about because it seems to me the ill are victims in a corporate marketing game where the outcome is often someone sick ending up with an inappropriate product.

Another part of what bothers me about the combination setup is that many people are getting acetaminophen when they don't need it, or even when it could be bad for them. For instance, when I enter "stuffy nose" and "trouble sleeping" into the site, I get products with diphenhydramine, phenylephrine, and... acetaminophen, even though it's not needed for the symptoms. When it is needed for the symptoms, I bet a lot of people take extra tylenol when they have a headache, anyway. Many would be better off with ibuprofin, but in many combinations it's not an option.

I think your project is a very helpful improvement over the status quo, and I'm glad you made it and that it's available! I'll certainly recommend it to my "DayQuil" friends, and someone looking for relief in the store is much more likely to find it with your site than by a first-time confrontation with the cacophony on the cold shelf. My suggestion would be not to discount that people might like--and be capable of--getting down to the basics of each medicine. It's really not hard, and I hold out hope that, contrary to Internet rumors, some people still have some patience and the ability to remember a few things!

The most pernicious recent development is the widespread use of phenylephrine to replace pseudoephedrine. Neither personal nor clinical evidence support the effectiveness of phenylephrine, but it is very clear that phenylephrine causes a dramatic increase in blood pressure in many people.

There are some pseudoephedrine products on the market which are supposed to be diversion-resistant for methamphetamine production but it seems if you stop people from making meth they will just order up some other sympathicomimetic amine from China.

Just get yourself an ephedra plant and steep your own tea. Pseudoephedrine itself does bad things to some people.

Surely you jest. Let me skip the well regulated, well-tested, reliable, precisely dosed, quality controlled and impurities-removed, time-released (if you so desire), mass-market product in favor of a plant that I have to take care of, and cross my fingers when the time comes that it delivers what I need, without potentially dangerous impurities, in the proper dosage and assume that it will be safer?

It would be like ripping out the perfectly functional seatbelt in my car and replacing it with a home-made duct-tape based mechanism for reduced side effects.

Ephedra is a meager little shrub that doesn't have a lot of needs and has been drank as a tea for thousands of years. Ephedrine is also much safer than pseudoephedrine with fewer side effects.

I grow a lot of medicinal herbs and have never had to worry about dangerous impurities or quality control, except for the occasional spider web. I'm not a homeopathic nut, but certain things (mint, ephedra, thyme, sage, peppers) are easy to grow and provide tangible, scientifically confirmed benefits.

I don't know about the others, but mint being "easy to grow" is an understatement. Left unattended, it can take over a garden like the legions of Rome.

Medicinal plants/herbs !== homeopathy; your statement reads like herbalism is somehow related.

Ephedra tea contains pseudoephedrine and ephedrine in potentially inconsistent amounts. Someone who has an adverse reaction to pseudoephedrine tablets is likely to have an adverse reaction to such a tea as well, and just how adverse is harder to predict.

"The idea is to help everyone find exactly the right cold medication."

http://www.iodine.com/cold-and-flu

I work at Iodine (our Cold and Flu tool is featured in this article) and we're watching this thread. Feel free to ask medication related questions of our clinical team or technical questions of our engineering team.

Please look at your website with iPad for example. And then please get rid if of that share bar that annoyingly covers the content. Thanks.

thanks for the tip! we're on it

There is actually an excellent reason to choose a brand name over a generic. People with gluten intolerance, allergies, or those who suffer from Celiac disease need some guaranty that the medicine they are purchasing does not use filler which may contain gluten. Many of the brand name makers actually do make an effort to test for gluten and indicate its presence, but (in my experience) that is less common among generic offerings. (This is particularly so for prescription generics, where you really don't see or think about the maker of the pill.)

That's a great point. I guess I didn't realize the incredible level of sensitivity to trace amounts gluten that comes with Celiac. Is sounds like it's almost to the level of peanut allergy (although a different kind of reaction).

It's too bad the 'Food Allergen Labeling Consumer Protection Act of 2004' didn't cover medication. Sounds like a worthy congressional lobbying cause. Proper labeling really isn't too much to ask.

Did you consider keying everything off of active ingredients (instead of the famous brands)?

that's actually how we built the tool. the symptoms you select are each tied to active ingredients that they treat, and then we show you products (including generic/store brands) that contain those ingredients in the comparison table below. do you think this isn't coming across as we'd hoped?

If I go to http://www.iodine.com/cold-and-flu and click "Cough", I'm presented with a comparison of Delsym, Mucinex, etc. So the first thing I see is the brands. Then I can look down and see what those brands contain and the generics. But the brand is given prominence.

Putting it another way: I understood that you are indexing off of the active ingredients, I was wondering why you chose to emphasize the brand name products (or how intentional that was...).

fair enough! yeah as we've been playing with the design, the generics have moved around a bit. we're still playing, and we absolutely mean to stress generics. that said, from the user's perspective, the thing that's easiest to find on the store shelf is the brand-name product, and then look next to that on the shelf to find the generic equivalent.

503 Server Error. The service you requested is not available yet.

OK, it's back up. You tell people they can save money by buying generic, but your site is all about the brand names, not the active ingredients. I think you're going about it backwards. Then by adding reviews on top of it all -- it just perpetuates the entire brand-name mythos. What's there to "review" about a bottle of Guaifenesin?! It's Guaifenesin!

What people really need to be educated about is; 1) the only thing that matters is active ingredient, and 2) what active ingredients do I want to take for these symptoms?

To that end, I think you want to explain the difference between Guaifenesin and Dextromethorphan, and why you would take one over the other, or both at once. But on your site, I click 'Cough', and I'm just hit with big shiny brand names, and nothing to explain how to decide. So I'm sorry to say I think you're failing entirely on your stated goal.

Edit: OK, I'm basically echoing @maxerickson 12 hours late.

Heyas! Love the idea behind this, but a question about the product itself -

Is there going to be some way to ask for and filter out information for effectiveness etc. depending on the use that you're trying to address? For example, I just looked up gabapentin, which was basically ineffective for treating my non-shingles/diabetic neuropathic pain.. and I can only break down the info by age and sex. Same story with montelukast, great for my asthma but far from a one-pill wonder for my allergic rhinitis despite being marketed/approved for it. Would love to see data like that without having to dig around in the individual comments or for studies!

Structured data for effectiveness is on our radar! It's a bigger project than you'd think. Thanks for the comment.

How does iodine.com (as a company) handle the problem of FDA regulation? Besides the statement on the web site, I mean:

    Iodine doesn't provide medical advice, diagnosis, treatment, or prescriptions. Read our terms of use for more info.

Really, did you have any concerns or regulatory speed bumps in that way when starting the company? Do you figure it's handled by the qualifications of your medical team, or have you actually interfaced with FDA in some way?

What's the medical consensus on Cold-EEZE?

Hey, I'm an MD at Iodine. Basically, zinc works. A Cochrane meta-analysis from 2013 showed that zinc lozenges reduce the severity and duration of common cold symptoms. It’s the closest thing we have yet to a cure for the common cold. Get the lozenges in particular (other forms don’t seem to work as well), and take ‘em on a full stomach or you can get really nauseated.

http://summaries.cochrane.org/CD001364/ARI_zinc-for-the-comm...

You advice on the lozenges seems really good as there seems to be a problem with Zinc in the nasal passages blunting the ability to smell.

http://www.webmd.com/cold-and-flu/news/20100719/study-links-...

I'm actually curious about this too - I've had pretty great success with zinc lozenges, but was off-put by this. Although the study is for some very specific intranasal products from a specific brand, I think.

edit: Link to original study: http://archotol.jamanetwork.com/article.aspx?articleid=49648...

It talks about "homeopathic zinc gluconate gel" and some patients reported a burning sensation while applying it.

I only have anecdotal data to add, but I've been using zinc lozenges for years for when I start to get sick (or my kids are exhibiting symptoms), and it really does dramatically shorten the cold and reduce the severity of the symptoms.

Are you aware of any information on the mechanism by which zinc works? I'm content knowing that it does, but it would be cool to understand what's going on with it.

Zinc is essential for all sorts of human biological processes, including DNA transcription, DNA repair, and antioxidant defence. [1] Since most immune cells are don't live very long[2] one theory goes optimum zinc intake improves all cell reproduction but especially fast turnover cells.

1. http://www.ncbi.nlm.nih.gov/pubmed/15542347 2. http://en.wikipedia.org/wiki/White_blood_cell#Overview

Interesting. Thank you!

I've been using zinc for about 3 years now when I get a cold. It's the best medication I've found. It has a slightly off-putting taste and mouthfeel, but it's worth it IMO.

Really like the idea; what's your plan with respect to pediatric medicines?

We're still thinking through how to approach this, but it's definitely on our radar. Honestly, in my old role in clinical medicine, I'd counsel parents only to treat symptoms if their child seemed uncomfortable or fussy. If they're playing and eating and acting normally, leave em alone. If they seem uncomfortable, children's motrin or ibuprofen is enough to relieve much of their discomfort.

Of course here's my disclaimer that this is not medical advice, and you should talk to a pediatrician. :)

My problem with buying the store brand generics is I don't know how well they are tested and regulated. If it says it is 200mg, how can I trust it?

The generic manufacturers see the same level of oversight and testing as the name brands. Also, why trust Advil more than CVS?

But branding does have an impact on the effectiveness of some over-the-counter medicines (because of the placebo effect):

>The effect of branding--that is, the labelling and marketing--of a well-known proprietary analgesic used to treat headaches was studied in a sample of women given a branded or unbranded form with either an inert or an active formulation....The findings showed that branded tablets were overall significantly more effective than unbranded tablets in relieving headaches.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1505530/

This reminds of of the time I sat the cold/flu aisle looking at cough medicine for so long... Through the haze of my head-cold I finally figured out that there were three different products by the same company that had the exact same dose method, dose size, and active ingredients. The only difference was the name of the product and the price.

*EDITED:

Front: http://i.imgur.com/ZkcPiEY.jpg

Back: http://i.imgur.com/gOj5uYK.jpg

This is amazing- we hadn't noticed this! It feels like they are A/B testing different boxes. I particularly like the MLB logo in the corner of one of those boxes.

Yeah... That is probably be the case. But as someone who hadn't slept more than a few hours at a time due to my cold I was pretty sure I was losing my mind. If/when I go to the cold aisle this year I'll check and see if the packages are still there.

I wonder how much of that wasted money could be saved by taking an approach with brand-name drugs similar to the one taken with cigarette packages: require them to carry a big-ass label. Something to the effect of "THIS PRODUCT IS MEDICALLY EQUIVALENT TO [ insert name of generic here ]" in great big, bold type.

Of course that would cut into pharma's profits, so it would never in a million years actually happen.

Except generics aren't guaranteed to be equivalent. Indian pharma companies have been incredibly corrupt, outright lying about their products:

http://fortune.com/2013/05/15/dirty-medicine/

I'd be very hesitant about buying medicine from such companies. But I agree that if the regulators could assure quality, then yes, pointing out equivalence would help a lot of people.

Incredible.

Is there a data source for companies & drugs that are known bad?

The FDA does a pretty good job of forcing the offending companies to recall the bad product. They even go as far as banning any imports from said companies until they've proven that they have cleaned up their act.

Well... um. Read the Fortune article, and that pretty much invalidates your statement. This particular company was in the middle of an investigation and was still shipping product. Similar situations have occurred in the past (I can't recall names anymore though).

I would love to pull up an app, tap a few buttons, and ask the pharmacist to change the meds to brand name when they are selling me products produced by $sketchy_fraudulent_company.

I'm not saying the FDA does a good job of catching this activity early. The only way they find out is either through inspections (they are horribly understaffed) or through product complaints.

When do they find out they drop the hammer. Most (all?) Ranbaxy plants are banned from importing product into the US and many products were recalled.

Really? Articles from early 2014 say 4 plants are banned, while Ranbaxy's website boasts 21 manufacturing locations.

Sun Pharma, which is buying (or bought?) Ranbaxy, recently got a plant ban for the same types of issues. (They delete test info if it isn't in their favour, and have terrible hygiene at the labs.) It's obviously endemic. And Sun quickly noted that the ban only affects 1% of their revenue.

It seems unbelievable that this deep level of corruption is exposed, and the FDA does limited bans and recalls. Instead of, say, completely banning the company and high-level individuals involved, until a complete end-to-end audit is completed. It's simply counterfactual to think these limited bans are accomplishing anything, or that a company is going to utterly and completely change the way they conduct themselves from individual techs all the way up to the board.

The Fortune article says none of the FDA inspectors would ever personally buy drugs from Ranbaxy, ban or not.

Articles from early 2014 say 4 plants are banned, while Ranbaxy's website boasts 21 manufacturing locations.

Interesting, I looked it up and yes, the FDA is banning each plant separately. One could argue that the FDA can only ban the plants they find problems at, however, I would agree with you that Ranbaxy's behavior is bad enough to stop all shipments into the US. Not sure why the FDA decided to be more lenient. Maybe the law governing the FDA limits how far it can go? I don't know.

No, according to that article, the FDA can only (or only does) ban specific manufacturing facilities. So in Ranbuxy's case, even though it's clear the entire company is totally and utterly corrupt, with contempt for users and disregard for any semblance of proper engineering, they only got a few of their facilities closed. The fact that they were bought by Sun Pharma discredits that entire set of companies.

It's simply not possible to see how such a company can be redeemed; it's rotten to the core.

Are they any less guaranteed than the name brands?

The Indian companies had s very hard time getting their EU and American employees to go along with this kind of stuff. From my personal experience in Central America and what I've heard from first person accounts of India and other places in the world, outright corruption and total disregard for safety or QA seems less likely to affect North/Western countries.

I'm trying to phrase that politely, but yes, there seems to be much reason to trust the main name brands over those generic companies.

Are the name brands never manufactured in India and similar places?

It seems like they use less Indian plants, and more EU plants, based on some quick searches. But I didn't find a comprehensive list.

But additionally, it's part of corporate culture. In fact, the article I linked to says that Ranbuxy had a manufacturing plant in the US, and that plant ended up making pills containing glass fragments. So it seems more of who is "in charge". That said, I'd trust stuff manufactured by a EU company in a EU location more than manufactured in a less controlled location.

I have noticed that local companies of a global corp will misbehave in incredible ways. And some US companies might not realise just how bad it can get on-site, in country. They are big on deferring things to their local subsidiaries, figuring they know best. For instance, MS has had huge problems with local companies in Latin America. From misrepresenting the success and adoption, to pure outright theft. It's unlikely you'd see the same thing happening on the same scale at MS's North Carolina or Toronto office, for instance -- just because there's a higher chance of someone speaking up.

I'm not saying the US or EU are infallible or better, just that people might not be acutely aware of how "flexible" other countries can be at breaking laws. (And not that I blame "the locals" entirely, the risk/reward is so excellent, in addition to a generally poor background situation, that I'm not sure I'd necessarily do better put in the same position. (Same for crime: If I could pull a gun on someone with low risk of being caught, and make off with several months' salary, it'd be a large temptation if I didn't have steady housing/food/etc.))

Of course, this might be selection bias plus some personal biases I have just poking through.

Of course that would cut into pharma's profits, so it would never in a million years actually happen.

That's a cynically opinion.

When it comes to prescription drugs, most states have generic substitution requirements. That is, if your doctor writes a script for Lipitor, the pharmacist is required to fill it with the generic unless the doctor writes (DAW = dispense as written).

When it comes to OTC drugs, I think it's up to the consumer to educate themselves.

Here's another racket: "decongestants" containing phenylephrine as the active ingredient (most U.S. over the counter decongestant products).

"Phenylephrine was not significantly different from placebo in the primary end point, mean change in nasal congestion score at more than 6 hours (P = .56), whereas pseudoephedrine was significantly more effective than both placebo (P < .01) and phenylephrine (P = .01)"

http://www.ncbi.nlm.nih.gov/pubmed/19230461

yup, that data was very obviously suppressed to keep the DEA happy and prevent meth labs from easily obtaining large amounts of pseudo-ephedrine.

Ask any seasonal allergy sufferer, we all look to find out where the 24 hour pharmacies are so we can get access to the "good stuff" when sinus trouble inexplicably hits and you need the behind the counter pseudo-ephedrine to get through it.

If I actually trusted the FDA to do their job properly maybe I could spend less time staring at brand names in the cold aisle.

If we all trusted the FDA implicitly, then the next logical step could be to actually ban the entire concept of applying brand names to off-patent pharmaceuticals and rework the entire cold aisle into a patient-education + active ingredient grab bag. In such a world, phenylephrine is phenylephrine, guaifenesin is guaifenesin, and all shoppers would care about is the form factor and dosages.

I've read on HN about exactly how many fucks the FDA gives these days when billion dollar pharma is forging test results while they knowingly pump crap generic meds with zero quality control out of their dirty factories. See, for example, https://news.ycombinator.com/item?id=8468099. So that leaves us with the flimsy fallback of hoping brands like Mucinex believe good QC is absolutely essential to maintaining their market position.

TFA claims American consumers waste "tens of billions" on brand name pills. I'm sure this stat isn't just cold/flu meds, but probably including blockbusters like Lipitor vs generic as well. That's like a $10 billion tax because we can't fully trusted the quality and bio-equivalence reviews the FDA is tasked to enforce?! By comparison, the total FDA budget is $4.5 billion.

To give a specific example of where this works in practice, take buying a good piece of steak. While some chains try to brand their beef one way or another, all you really want to look for is "USDA Prime". The USDA... they really, really know how to grade a cut of beef. I trust them implicitly, when I see "USDA Prime" I know exactly what I'm going to get.

Now imagine having that same level of trust in the FDA. "Guaifenesin 1200mg 24 Hour - FDA Prime" would be all I need to see, and I'm grabbing that bottle. Spend a cool $5 billion setting up that program for the Top 100 generics, and you save Americans, what, maybe about a trillion dollars over the next 30 years?

Just like with beef, this isn't about controlling production, or subsidizing the factory, but simply establishing public trust in an inspection process.

An interesting analogy of the situation which didn't make the article is a good analogy of the cold medicine racket would be, imagine if liquor stores were not able to legally sell components of mixed drinks. So a liquor store could only sell tens of thousands of different ready to drink products such as screwdrivers, old fashioneds, rum and cokes, mint juleps, but it was practically impossible if not illegal to buy plain old vodka in a bottle.

And for marketing and trademark reasons you had to study the fine print to figure out what is in each bottle. So you can't buy a bottle of ready to drink screwdriver, you have to look in the fine print for "Slammer Canadian Lite Extra Dry Extreme" to figure out its a bottle of screwdriver.

I'm not suggesting I want bulk generic powder guafenisien but life would be a lot simpler if it was more like the produce aisle, OK I got runny nose and cough so take one of pseudoephedrine and one of dextromethorphan and call it good, instead of the "confuseopoly" system we currently have, which I'm sure reduces everyone's quality of life while increasing profits.

One of the points made in the article is that you can buy single drug generics and combine them as needed.

So for your analogy, the liquor store would have to have a small shelf of mixers and giant coolers full of premixed stuff. But flavor is easier to deal with than medicine, so people won't put up with it, so liquor stores mostly sell ingredients.

This reads like a big ad for Iodine.com

I thought the author actually had a pretty skeptical take on things. The ending quote is pretty hilarious:

"It's a press release, Mary. The iodine algorithm saved your husband from the brink of ruin. His newfound sense of consumer empowerment was so invigorating to his spirit that he no longer needed any Mucinex at all."

Well, we are trying to counter all the pharma ads!

But really, we hear from users all the time that they get confused in the cold and flu section of the pharmacy. We hope to help address this problem.

I've been waiting for awhile to catch a cold so I can try a neti pot. My usual goto is zinc lozenges as soon as the cold hits/gargling with hot salt water/staying well hydrated/and resting.

Try to do it first thing in the morning before you blow your nose. I have found that blowing my nose drives the mucus two directions... out my nose and up into my ears.... this prevents the neti pot from being able to properly clear out your nose, since it can't reach the mucus that has been driven up into your nose.

remember not to use water fresh out the tap.

I think the real racket is that people are taking medications to suppress cold symptoms in the first place. A healthy adult should be out no more than a week from a strong cold/flu. That wouldn't be a big deal except people get so little time off from work they don't want to waste it on a cold.

Wether they spend $10 on symptom suppressors or $50 is besides the point. Taking medications for what your body should be capable of handling with proper nutrition and rest cannot be healthy.

I'm an MD, and I used to avoid treating cold symptoms for these exact reasons, until I came down with a nasty sinus infection that was a complication of my cold virus. Basically, because I left my sinuses all stuffed up, I created a nidus for infection -- ie the perfect environment for bacteria to breed -- so I had a cold for a week, and then I had a bacterial sinusitis for another 2 weeks and finally broke down to take antibiotics. I could have avoided the sinus infection (and the antibiotics to tamp it down) if I'd just taken a decongestant when I had the cold. And the side benefit is my cold would have felt less miserable, too. And it wasn't about not taking time off from work because a lot of this was during a vacation anyway.

Point is, treating cold symptoms can actually prevent complications, so it's not all bad.

Actually, the FDA recommends against using any cold treatments in kids, as they cause more harm than good:

http://globalnews.ca/news/1723414/are-your-young-kids-fighti...

In general all these cold and flu medications do is suppress your immune response, which is obviously not the smartest thing to do. You might get rid of some symptoms, but you're also hindering your body from actually getting rid of the infection.

The article above does say that in adults decongestants might be helpful. I think you need to know when it's a good idea to "help" your body treat the infection, and when you're just treating the symptoms and just hindering it. Most people just want rid of the symptoms.

In general all these cold and flu medications do is suppress your immune response

That's not true at all. Over the counter cold formulations contain one of four products: decongestant, cough suppressant, pain reliever and antihistamine.

None of those suppress your immune system.

EDIT: I think know what you meant now. You mean your immune system reacts to a cold by making you cough and the drugs suppress your cough (thus your immune response)? In that case, I see your point.

Aren't histamines part of your immune response, thus making antihistamines immunosuppressors?

Yes, they are. Also, I believe most pain medications (apart from opioids) work by knocking out some part of the immune response.

Now, even assuming that the medication doesn't actually interfere with your immune system and just gets rid of the symptoms and makes you feel great, you should be aware that your immune system deliberately makes you feel crappy ("sickness behaviour") so that you'll rest and give your immune system a chance to kill the infection. This is more an issue with the flu rather than the cold.

I think what threw me off is the use of the word "immune suppression". That word has a specific meaning when referring to drugs and tends to refer to drugs that to interrupt immune response far upstream. These drugs have severe side effects as your body can't fight invading viruses and bacteria.

I think the difference with cold remedies is that they tend to interfere with immune responses that are far downstream that tend to be more symptomatic, rather than major mechanisms by which the body's immune system works.

I'm just one data point, but my children usually suffer pretty badly when they have colds. I teach them that you can't fight the cold, but you can make it more comfortable to sleep (which goes a long way towards fighting the cold).

I give Acetaminophen/Paracetamol/Tylenol for pain, and a mucogenic (Guifanesin or the much better Mucosolvan/Ambroxol if I can get it from Europe) to thin out the mucus secretions.

It goes against instinct but making more mucus keeps it from building up and turning into that gunk that starts sinus/ear infections and never gets out of your lungs once the cold has passed.

I really wish Ambroxol would be approved in the USA, but apparently it's too old of a molecule to successfully recoup the FDA approval expenses.

Yes and certain foods can also be used to reduce symptoms, but of course they're not as powerful. Did that option fail for you?

The case I see more often is people get obvious cold symptoms and are back at work the next day. Thanks to symptom reducers they don't have to rest or eat properly for the condition, so their light symptoms persist for weeks. That also leads to complications.

Also I should have mentioned that most adults are not healthy and don't eat healthy to begin with, which creates a ripe market for band aid medications.

So, you've backed off your original point of not doing anything to reduce symptoms at all?

My original point was taking medications to suppress symptoms. For example they'll open your sinuses in 5 minutes and keep them open for hours.

Typically food will reduce symptoms by stimulating the immune system to work faster. Attempts at immediate relief will be short lived. That's how people traditionally treated disease. It's still a valid approach for light ailments where modern medicine can be a harmful crutch.

>>Taking medications for what your body should be capable of handling with proper nutrition and rest cannot be healthy.

Could you explain a bit more as I can think of a case where this seems to be false: While my child's body can eventually handle colds and flus, if his temperature goes above a certain level there's a significant chance for brain-damage, so I counteract the bodies natural fever with medication.

It should be noted that a low fever appears to be helpful for the immune response. http://www.nbcnews.com/health/health-news/sick-feverish-suff...

If you're running a 101 degree fever, it may be more effective not to suppress it.

yeah i wrote a pretty comprehensive blog post about this - ie when it's better NOT to treat a fever http://www.iodine.com/blog/should-you-treat-a-fever/

I'm no medical professional so take my statements with healthy skepticism, do your own research, etc, but as a father myself I share the concern and my understanding was that common viral infections like the flu, common colds, ear/throat/sinus infections, whatever, do not cause dangerous fevers (>105ºF). Your temperature regulation usually has to be impaired in some other way like being in hot conditions, overexertion, or a combination of them. Obviously in infants the story is different due to physiological immaturity but the fever response to infection is a positive indicator of the body's thermal regulation working correctly and treating a fever is simply for symptom relief and possibly even detrimental to treating the illness.

I did say healthy adults. Not that most adults are healthy.

"what your body should be capable of handling with proper ... rest"

Which sets up a glorious chicken and egg where due to the peculiar anatomy of my sinuses or whatever, I find it nearly impossible to rest without some form of cold medicine. By the end of a simple cold, I'm really looking forward to finally getting a decent nights sleep and not feeling miserable when I'm sitting around.

It would be interesting to know about eating and lifestyle habits in such situations.

I don't exactly enjoy the state of being sick.

Me neither.

Got a cold-like thing that turned into bronchitis a few weeks before my wedding. Still had it during my honeymoon a couple weeks later and lingering symptoms for a couple more months afterwards. With the veritable arsenal of meds I had, I barely scraped by and with no ER visits even after waking up most nights of the week for a couple weeks with asthma attacks at its worst. Wooo. Not something I'd wish on my worst enemy. I'm amazed I did what I did given how tired and shitty I felt despite everything. Feeling sick really sucks.

Ate well, exercised regularly, actually just straight up stopped working for other reasons so I had plenty of time to rest. < for parent commenter who seems to care about such things.

Cold symptoms are mostly an immune overreaction. The way the body responds is very much suboptimal. Just because we (usually) recover on our own doesn't mean medicine is bad.

Do you have a reference for that? The FDA says not to use cold medications in children as they cause more harm than good (see my other comment).

What, you think I actually know something about medicine just because I act like I do?

Ahem. Anyway, here's what Wikipedia has to say:

"The symptoms of the common cold are believed to be primarily related to the immune response to the virus. The mechanism of this immune response is virus specific. For example, the rhinovirus is typically acquired by direct contact; it binds to human ICAM-1 receptors through unknown mechanisms to trigger the release of inflammatory mediators. These inflammatory mediators then produce the symptoms."

Wikipedia may not be any more reliable than me, but at least it's something. Unfortunately it looks like the cited paper is behind a paywall.

Yes, the symptoms are primarily the immune response. Hence my point that it's probably not smart to interfere with the immune response just because you don't like the symptoms. The immune response is the only thing that will actually get rid of the virus. That sentence from wikipedia doesn't mention anything about an "overreaction".

Well excuse me for not reading your mind as to what you meant by "that." :P

I'm not aware of anything that shows that people who take medications to alleviate symptoms take longer to recover than those who don't, while they're often more comfortable in the meantime. That seems sufficient to establish "overreaction."

Wow, would you really not spend $50 to avoid a week's worth of cold symptoms? Sounds like a bargain to me, even just for the improved enjoyment of the after-working-hours time.

I use a netipot with lukewarm water and a pinch of salt to flush my sinus if I have any cold symptoms. I never had any real cold since 2007. Never took any cold medication.

I would love to see this represented in an infographic or some sort of visual aid. The biggest racket in my opinion is the whole Tylenol / generic or ibuprofen / generic the prices can be ridiculously different. One thing about the pain relievers is the quality of the shell or coating you are getting. Some of the generics come broken up into tiny pieces while you won't see that with brand name meds.

I learned all about this stuff from some pill popping raver kids. 300 brands and about 6 different ingredients. One of the ingredients only purpose is to make you vomit.

Agree in general but remember the case of Ranbaxy? FDA oversight is not uniform and becomes weak outside the US

Good: Brand

Better: Generic

Best: Nothing

"If takes about 1 week to get over a cold if you don't take medicine, but only 7 days to get over a cold if you take medicine."

The medicine isn't supposed to improve your recovery time, it's supposed to lessen the ill effects of having the cold. Your comment doesn't make sense in that context at all.

"It takes about 1 week to get over a cold if you don't take medicine. It still takes 1 week to get over a cold with medicine, but you'll feel much less hindered by the effects of the cold itself."

Reply on news.ycombinator.com