The high cost of prescription drugs has everyone looking for ways to save. Hospitals, HMOs and insurance plans are as upset about their pharmacy bills as individual patients are.

One popular solution is to buy generic drugs. Doctors are encouraged to prescribe generic equivalents when possible. Patients may be penalized if they insist on a brand name. The co-pay for branded medications is often double or triple that for generics.

People without insurance often can't afford anything other than generic medicine. How good are these substitutes?

For 30 years we have defended generic drugs. The Food and Drug Administration assured us that its rigorous standards ensured quality. A few years ago, however, we started to get reports from readers about generic-drug failures.

Some parents claimed that when a child with ADHD was shifted from Ritalin to generic methylphenidate, his behavior and attention deteriorated. Patients whose epilepsy was well controlled on the anticonvulsant Dilantin reported seizures when switched to generic phenytoin.

An article in the journal Neurology (Oct. 26, 2004) confirmed that some generic phenytoin did not perform up to standards. The neurologists reported breakthrough seizures in patients under good control for years.

We also heard from people who had problems with irregular heartbeats, hypertension, acid reflux or pain when they were switched. Many found the generic version of their medication seemed less effective than the original.

We were puzzled by this spate of reported problems with generic medicines, so we contacted the FDA to find out how the agency monitors the quality of drugs after they are approved. We were not reassured by what we learned.

As far as we can tell, the pharmaceutical marketplace in the U.S. works on the honor system. The FDA relies on drug companies to be honest.

For such a profitable industry, there is remarkably little oversight. Airplanes, elevators and even restaurants are inspected on a regular basis. But more than 3 billion bottles of pills are dispensed in the U.S. each year, and only a relative handful are actually tested. The FDA says it pulls about 300 pill bottles off shelves to test for content and dosage strength. This amounts to 1 in 10 million.

Where do ingredients for generic drugs come from? More and more often, countries like China and India are getting into the game. The competitive nature of the generic-drug market makes low-cost source materials very attractive. Without constant quality surveillance, we worry that U.S. consumers may not always be getting what they expect.

We have examined the controversy over generic drugs in much greater depth in our new book, Best Choices From The People's Pharmacy (Rodale Books). It offers guidelines for using generic drugs safely. Tips include:

• Record numbers (blood pressure, blood sugar, etc.) that show if the drug is working.

• Monitor lab results (cholesterol, thyroid, INR).

• Observe your subjective response to antidepressants, pain medicine or sleeping pills.

With care, you can use generic drugs safely. If you suspect your medicine is not working properly, notify your doctor immediately. Switching back to the brand name might cost more, but it could preserve your health.

THE PEOPLE'S PHARMACY

Q. I have taken both Viagra and Cialis. They work well, but I do get sinus-pressure headaches when I take these drugs. I feel this has contributed to sinus infections that have required lengthy courses of antibiotics. Is this possible?

A. Nasal stuffiness is a relatively common reaction to drugs for erectile dysfunction like Viagra, Cialis and Levitra. People who experience chronic congestion may develop an infection and sinusitis as a consequence.

Please discuss this issue with your physician. There are other ways to treat erectile dysfunction.

Q. You have suggested that people should check prescriptions carefully to avoid pharmacy errors. How many people read Latin? Why aren't prescriptions written in English? Start a crusade!

A. We have been campaigning against Latin abbreviations in prescriptions for nearly 30 years. There is no excuse for physicians to use this archaic system in the 21st century.

This idea makes some doctors angry, though. One took us to task after we wrote a column calling for prescriptions to be written in legible English: "You do not have a right to tell us to change the standard format in which pharmacists provide service to physicians by saying that we should change the way prescriptions are written and have been forever. Pharmacists are here to serve, not to instruct."

Despite this objection, the leading pharmacology textbook used in medical schools is clear: "The directions to the patient should always be written in English. The use of Latin abbreviations serves no useful purpose."

Q. I have had weakness in my arms and legs, pain in my back, aching arms, loss of memory and fatigue. I have not been able to play golf for more than two years, and I totally lost the quality of life I enjoyed prior to undergoing angioplasty and starting on Lipitor.

If there is to be a class-action suit, I would like to be included. Your article helped me understand the pain and suffering I have endured.

A. Millions of people are able to take cholesterol-lowering drugs like atorvastatin (Lipitor), fluvastatin (Lescol), lovastatin (Mevacor), pravastatin (Pravachol), rosuvastatin (Crestor) and simvastatin (Zocor) without complications. But some experience debilitating muscle, nerve or joint pain, weakness, skin rash or memory problems.

The nutrient Coenzyme Q10 may help counteract some of these side effects. You can learn more about how to use it and alternative ways to control cholesterol in our new book, Best Choices From The People's Pharmacy (Rodale Books).

We cannot offer legal advice, though. Several lawsuits have been filed claiming deceptive marketing of statins.

Q. Do nitroglycerin heart tablets lose their potency once the bottle is opened for the first use, or can I go by the expiration date on the bottle? I have gotten conflicting answers from my doctors and my pharmacist. I'm not sure what to believe.

A. Nitroglycerin evaporates easily, which is why these pills should never be left out in the open or in a plastic pillbox. Store them in the original amber glass bottle with the cap screwed down tightly.

If there is cotton in the bottle, take it out and throw it away, as it can absorb the medicine. If you replace the cap firmly as soon as you remove a pill, you should be able to rely on the expiration date on the label.

THE PEOPLE'S HERBAL PHARMACY

Q. I suffer from gout from time to time. Have you ever heard of curry relieving the symptoms? My wife made a soup containing curry, and within one hour after eating it, I could feel the pain going away. I ate the soup the next two nights, and my gout was 95 percent gone. This worked much better than cherries for me.

A. Thanks for the tip. Gout is a painful inflammatory condition in which uric-acid crystals collect in the joints. The yellow spice in curry powder is turmeric. It has been used for centuries in the traditional medical system of India to treat inflammation. Research in animals confirms that turmeric extracts can reduce joint swelling from experimental arthritis (Journal of Natural Products, March 2006).

Q. I am taking a product that contains cascara sagrada to promote healthy digestion and relieve hemorrhoids. How often should I take it?

I took one dose of it at night, and the next afternoon experienced diarrhea. That has me a bit worried about taking it every day.

A. Cascara sagrada is a strong laxative, so we're not surprised it gave you diarrhea. We don't recommend taking stimulant laxatives on a regular basis since they can deplete the body of essential minerals. Daily use also may lead to dependence.

Q. My 8-year-old son has eczema. We have been alarmed by the recent studies about Elidel increasing the risk of cancer.

We also do not want to go back to topical steroids because they might thin his skin too much. Are there any other treatments that we can consider?

A. Besides a good moisturizer to keep the skin from drying out, you might want to consider DermaSmart undergarments and pajamas (www.dermasmart.com). This special fabric is super-soft and nonirritating.

A firefighter told us that he developed eczema after exposure to mold in an older fire station. When he put on his protective gear the itching nearly drove him crazy. The DermaSmart T-shirt and pants reduced the irritation and itching.

Another interesting product is CamoCare Soothing Cream (www.CamoCare.com). It contains a camomile-derived oil that is anti-inflammatory.

Q. I take prescription heart and blood-pressure medicine that keeps me awake. My doctor has prescribed Ambien, but my insurance company rations me so I can't take it every night. When I don't take Ambien I don't sleep.

What's the problem with this sleeping pill? What else can you suggest so I can get some sleep?

A. A surprising number of prescription and OTC medicines can cause insomnia. If your doctor could prescribe different drugs, your insomnia might disappear.

If that is not an option, ask your doctor to intervene with the insurance company. Some insurers restrict prescription sleep aids on the grounds that the Food and Drug Administration has not approved these drugs for daily use.

Labels: No Prescription, Online Pharmacy, Prescription Drugs