People’s Pharmacy: Problems with generic hydrocortisone could be dangerous

Q. As an endocrinologist, I treat patients who have adrenal insufficiency. They cannot make their own cortisol and rely on daily replacement with the synthetic cortisol, oral hydrocortisone.

Recently many patients have reported that the different generic forms of hydrocortisone (brand name Cortef) are not equally effective. Cortef is the brand name made by Pfizer.

One patient in this situation felt like a new person, and her labs improved to show it, after switching from one generic to the other. Differences in the content of hydrocortisone, absorption or pharmacokinetics could put patients at risk because this drug has a very narrow therapeutic window. Too little puts patients at risk of adrenal crisis and death, while too much puts them at risk for long-term side effects including weight gain, diabetes, heart disease and osteoporosis.

I have not seen anything about this problem with hydrocortisone and hope you have some recommendations.

A. Cortef (oral hydrocortisone) was first approved by the Food and Drug Administration in 1952. When the adrenal gland does not make enough cortisol (Addison’s disease), the hormone must be replaced. President John F. Kennedy suffered from this condition.

We have been concerned about generic drug quality for over 20 years. Both patients and health professionals have related problems with a variety of generic formulations.

According to GoodRx, the brand name Cortef costs over $300 for 90 tablets (20 milligrams). The generic is about one-tenth that cost. Patients could purchase brand name Cortef from a legitimate Canadian drugstore for about $80.

There is an authorized generic form of hydrocortisone from Greenstone in the U.S. It is far less expensive than brand-name Cortef.

To learn more about authorized generic drugs and how to access affordable brand name drugs from Canada, your patients may wish to read our “eGuide to Saving Money on Medicines.” This resource can be found under the Health eGuides tab at www.PeoplesPharmacy.com.

Q. I had COVID-19 a few months ago. My doctor prescribed Paxlovid.

I was on four kinds of blood pressure medications twice daily. Paxlovid interacted with my pills. As a consequence, my blood pressure dropped so low that I was not able to take three of them. I stuck with just half of my regular beta blocker. Has anyone else had this problem?

A. No one should take this antiviral medicine without having the prescriber and the pharmacist double check on potential drug interactions. Your experience is not unusual because so many medications can interact with this COVID-19 drug.

Q. I first bought Voltaren gel from a pharmacy at the airport in Rome over 10 years ago. It helped my joints so much that I started buying it every time we traveled abroad.

The label on the box I bought in New Zealand read “VOLTAREN Osteo Gel 12 Hourly 23.2 mg/g diclofenac diethylammonium. Apply once every 12 hours.”

The Voltaren now available over the counter in the U.S. is to be applied every six hours. Is what I bought overseas stronger? What is the difference?

A. The FDA first approved a prescription form of Voltaren Gel (diclofenac sodium) in 2007. It was a 1% topical NSAID formulation. The same strength was approved for OTC use in 2020.

This product contains 10 mg diclofenac per gram of gel. Some people get good relief from topical diclofenac without side effects, while others get less benefit. Side effects may include digestive upset, skin reactions and cardiovascular complications.

In their column, Joe and Teresa Graedon answer letters from readers. Write to them in care of King Features, 628 Virginia Drive, Orlando, Fla., 32803, or email them via their website: www.PeoplesPharmacy.com. Their newest book is “Top Screwups Doctors Make and How to Avoid Them.”