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Comment by mikeyouse | Hacker News Reader

The active ingredient is the same - the binders and fillers and capsule materials are mostly inert. This isn't true for all drugs - for the blood thinner Coumadin, you're meant to stick to generic or brand name and not switch between the two since there are known differences in efficacy.

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I do not think the results for Coumadin/Warfarin are at all clear: https://www.ncbi.nlm.nih.gov/pubmed/21449627

Thanks for the update - interesting study.

I understand that. OP said:

> There is no sensible reason to pay a premium for brand name if the generic is chemically equivalent.

If they're not chemically equivalent and have different medicinal effects as a result, then it's much easier to justify a price difference. I understand chemistry is more than just a list of ingredients. It's how those ingredients are combined that gives them their unique interactions.

For sake of the discussion here, bio-equivalence is the more helpful way for meaningfully comparing generic to brand names. The filler might be different, but if the biological effect is identical at half the cost, one would be prudent to chose the generic option.

Yet we see drugs that are, say, 100 times the cost of the generic. So how can that happen; how is that sustainable? Presumably nearly everyone starts on the generic, and then switches to the brand name if they have problems with the generic. So there is actually not competition so much as price discrimination! You can't tell someone who the generic has failed that they are equivalent, because their only hope is that they are not! Not only is the generic no longer an alternative, but psychologically, it's easier to put your hope in a super-expensive option because of the cliche "you get what you pay for".

So I think telling people continually that generics are identical is not helpful, because it's not information. It's an assumption, which might be true or it might not be, but is essentially never helpful to any individual in making a decision.

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