To the Editor—The study by Lee et al1 increases our understanding of people’s knowledge and acceptance of generic drugs. Several points warrant further discussion.

Public doctors, unlike those in the private sector, generally have little knowledge of the drug source. A choice of brands is rare. For example, the Clinical Management System of the Hospital Authority commonly uses the original brand name as an alias for a drug because these are better remembered. The final drug dispensed will depend on stock availability. On-screen support at the prescribing page may better inform doctors. Since the patient pays only according to the duration of use, it is not justifiable to routinely ask the patient’s consent when selecting a generic versus a branded medicine.

Relatively poor public knowledge about generic drugs might not be due to lower local literacy as Lee et al suggest.1 The adult literacy (primary education and above) rate in Hong Kong is quite good: 96% in 2015 and 2016.2 This is similar to that in the current study (96.4%).1 Japan implemented a generic drug policy in 2002. Patients pay less and their doctors and pharmacists are given financial incentives to use generic drugs. Hence, unsurprisingly, Japanese are more knowledgeable about generic drugs. A choice of branded and generic drugs has been explicit on the prescription since 2006.3 4 In contrast, Hong Kong has no policy or public information. On the consumer webpages of the Drug Office of the Department of Health, under “General Knowledge on the Use of Medicines”, generic drugs are not mentioned.5 The public would benefit from official views.

Health literacy on drugs can be improved by official healthcare programmes and by encouraging the public to read medical news, drug labels and to search official websites. Nevertheless individual counselling by healthcare professionals is essential. There are barriers for both healthcare professionals and patients but they should nonetheless become familiar with both the trade and generic names of prescribed drugs. A patient’s proficiency in English may be an advantage because most doctors know the English names of drugs but are not routinely taught the Chinese names. The Cantonese or Putonghua pronunciations are particularly challenging. The two local medical schools play a pivotal role in preparing new doctors in this regard.

The author had full access to the data, contributed to the study, approved the final version for publication, and takes responsibility for its accuracy and integrity.

The author has disclosed no conflicts of interest.

1. Lee VW, Cheng FW, Fong FY, et al. Branded versus generic drug use in chronic disease management in Hong Kong—perspectives of health care professionals and the general public. Hong Kong Med J 2018;24:554-60. Crossref

2. HK Council of Social Service. Adult literacy rate. Social Indicators of Hong Kong 2016. Available from: https://www.socialindicators.org.hk/en/indicators/education/7.7. Accessed 16 Jan 2019.

3. Hassali MA, Alrasheedy AA, McLachlan A, et al. The experiences of implementing generic medicine policy in eight countries: a review and recommendations for a successful promotion of generic medicine use. Saudi Pharm J 2014;22:491-503. Crossref

4. Kuribayashi R, Matsuhama M, Mikami K. Regulation of generic drugs in Japan: the current situation and future prospects. AAPS 2015;17:1312-6. Crossref

5. Drug Office, Department of Health. General Knowledge on the Use of Medicines. June 2017. Available from: https://www.drugoffice.gov.hk/eps/do/en/consumer/news_informations/knowledge_on_medicines/general_use_on_ medicine.html . Accessed 7 Jan 2019.

To the Editor—In our recently published study, we evaluated the understanding of generic substitution among healthcare professionals (HCPs) and members of the general public in Hong Kong. Our findings showed that the knowledge and perception of generic substitution among the general public and HCPs remain low. We thank Dr Poon for his comments and respond to each point raised.

We agree and acknowledge the point raised by Dr Poon about the awareness of HCPs in the Hospital Authority (HA) compared with private physicians who run their own clinic about drug source. Kumar et al1 have shown that most physicians at private hospitals in Malaysia have a negative perception of generic drugs with consequent limited use in the private sector. Public physicians have limited knowledge about or influence on the final drug dispensed. The drug formulary in each HA hospital is developed and overseen by various internal committees including the drug management committee (DMC), drug advisory committee (DAC), and drug formulary committee (DFC).2 The role of the DMC is to oversee the overall drug management of the HA whereas that of the DAC is to review new drugs and new indications for the HA drug formulary. Finally, the DFC reviews the existing drug lists to remove obsolete drugs and evaluate the indications for special drugs when necessary.2 The members of these three committees may include the chairman of the cluster service and the chief pharmacist of the HA, the Chief Nursing Manager, and two academics in healthcare-related disciplines from local universities.1 They are responsible for the centralised decision process for the drug formulary. We agree that we should better inform our HCPs about the choice of drugs available in the HA. In addition, we advise patients whether the drugs they are taking are a generic or branded product by appropriate labelling. Patients should be reminded to record any potential adverse drug reactions (ADRs)/side-effects or alert their physician if they feel unwell if any of their medications are switched.

Understandably, routinely obtaining patient consent could be challenging in the public sector, given the current workload of the HA and the funding of the healthcare system. Nonetheless with advances in technology and a higher level of education and awareness of the general public, it is not surprising that patients are increasingly aware of their health conditions and may be confused by generic substitution. To avoid any potential conflict among patients and HCPs, public and professional education to enable an understanding of drug quality as well as bioavailability and bioequivalence should not be delayed.

Undeniably, the adult literacy rate in Hong Kong has been improving but this may not apply to the existing elderly population. More than one-fifth of the current elderly did not attend primary school according to a report published in 2016.3 It may therefore be difficult for them to fully understand the concept of generic substitution and the need to alert HCPs about any potential ADRs. Our findings are in line with other published studies. In Malaysia, less than one-third of Malaysian consumers were aware of generic medicines.4 In India, over 60% of patients did not know the difference between branded and generic drugs.5

It was clearly emphasised by Dr Poon the need to train future doctors and other HCPs in health literacy on drugs as well as their trade and generic names. In the local pharmacy curriculum, we generally use generic names. We usually include the trade names in the supplementary information. Similar to Hong Kong, Australian pharmacology students may lack an in-depth understanding of generic medicines and need further teaching about the quality and safety of generic medicines versus branded products.6 In Ireland, general practitioners showed a lack of knowledge and problems with perception of generic medicines.7

The knowledge and perception of generic medicines remains low in many countries including Hong Kong. Prescribing behaviour with regard to generic drugs may vary between different sectors (public vs private) of the healthcare system. Education of both the general public and HCPs as well as HCP trainees is crucial to enable a better understanding of generic versus branded drug use.

Concept and design: VWY Lee.
Acquisition and analysis of data: FYH Fong, EEN Ng, LLH Lo, LYS Ngai, ASM Lam.
Interpretation of data and drafting the manuscript: FWT Cheng.
Critical revision for important intellectual content: VWY Lee.

All authors had full access to the data, contributed to the study, approved the final version for publication and take responsibility for its accuracy and integrity.

All authors have disclosed no conflicts of interest.

1. Kumar R, Hassali MA, Saleem F, et al. Knowledge and perceptions of physicians from private medical centres towards generic medicines: a nationwide survey from Malaysia. J Pharm Policy Pract 2015;8:11. Crossref

2. Hospital Authority Drug Formulary Management. Available from: http://www.ha.org.hk/hadf/en-us/Drug-Formulary-Management. Accessed 31 Jan 2019.

3. Census and Statistics Department, Hong Kong SAR Government. Thematic Report: Older Persons (2016). Available from: https://www.bycensus2016.gov.hk/data/16BC_Older_persons_report.pdf. Accessed 31 Jan 2019.

4. Al-Gedadi NA, Hassali MA, Shafie AA. A pilot survey on perceptions and knowledge of generic medicines among consumers in Penang, Malaysia. Pharm Pract (Malaysia) 2008;6:93-7. Crossref

5. Choulera MY, Amruta VD, Borkar AS, Date AP. Knowledge and perception about generic drugs in patients coming to outpatient department of tertiary care centre. Int J Basic Clin Pharmacol 2018;7:1024-7. Crossref

6. Hassali MA, Kong DC, Steward K. Knowledge and perceptions of recent pharmacy graduates about generic medicines. Pharm Educ 2007;7:89-95. Crossref

7. Dunne SS, Shannon B, Cullen W, Dunne CP. Beliefs, perceptions and behaviours of GPs towards generic medicines. Fam Pract 2014;31:467-74. Crossref