Diabetes Drug Dollars: Money Well Spent   (October 30, 2008)

Diabetes mellitus is common (and becoming more prevalent), controllable, and costly. But are the new drugs worth the cost? A recent study in the medical journal Archives of Internal Medicine, titled National Trends in Treatment of Type 2 Diabetes Mellitus, 1994-2007 says maybe not: the authors conclude "Increasingly complex and costly diabetes treatments are being applied to an increasing population" and hint that they may not be worth the cost: "The magnitude of these rapid changes raises concerns about whether these more costly therapies will result in proportionately improved outcomes." And one of the authors told the Reuters news agency "Some of these drugs may represent valuable pharmaceutical innovation, but I think the need for greater evidence regarding their safety and effectiveness is important since they cost eight to 10 times more than some of the older, more time-tested alternatives."

Their study looked retrospectively at database data, and noted that diabetes drug spending nearly doubled as new medications came to market, and as the use of combination therapy (more than one drug at a time) has increased. They noted that increasing use of glitazones (Actos and Avandia), newer insulins, sitagliptin (Januvia), and exenatide (Byetta) largely accounted for recent increases in the mean cost per prescription ($56 in 2001 to $76 in 2007). On the other hand, they point out that the use of sulfonylureas (available as a cheap-as-dirt generic) decreased from 67% of treatment visits in 1994 to 34% in 2007.

It might be suggested by a skeptic that this paper was underwritten by a grant from the insurance industry; but of more concern, as I read the abstract, the authors seem unaware of the ability of physicians to propose (and patients to obtain and maintain) A1C levels as targets that would never have been possible with the older, more limited armamentarium of drugs. For clarification, metformin, which was the first of the modern non-SU pills for diabetes, wasn't available in the US until late 1994. And the first once-daily basal insulin that could give around-the-clock coverage was insulin glargine (Lantus), first marketed in the US in 2001.

Per the ADA, people with diabetes should target to get their A1C below 7; AACE and IDF use 6.5 as the target. Such tight targets were literally unthinkable in 1994, before these newer drugs and innovative combinations became available. And lower A1Cs are widely assumed to translate into better outcomes, which are certainly cost-saving to the health care financing system as well as decreasing morbidity: less blindness, less amputations, less heart attacks, etc., etc.

Certainly, new drugs are expensive. I can clearly recall telling a sales rep when a competing diabetes drug came on the market that it would have one positive effect for his slightly-older product: it would mean that his drug was now the second-most-expensive. They are expensive because research into safety and efficacy is expensive, because marketing is expensive, and because the pharmaceutical industry, like any other industry with exclusive but limited duration of patent protection for its products, does its best to keep its share-holders happy.

But these new drugs work. They allow physicians and patients a variety of tools to tackle a difficult problem: lowering blood sugar and preventing complications.

Therefore I think it's money well spent.