Tag Archives: diabetes

Cost of diabetes treatment has doubled in 6 years. Is anyone surprised?

Research out of Stanford USOM indicates that the total money spent on diabetes care went from $6.7bn in 2001 to $12.5bn in 2007. I can’t say I’m terribly surprised. Every time you turn around, someone’s hammering the dangers of monotherapy down your throat, especially when a comorbidity is present. (When isn’t there one?)

However, I am pleased to see that the Stanford researchers are interested in how much of this extra cost is due to costly new medications that may or may not be worth their price — a topic too rarely discussed in the Ivory Towers of academia. They cite Januvia and Byetta as potential cost centers, but I can’t help but think that they’re missing the mark just a little bit. In outpatient diabetes management — and I’m going to assume that institutions and hospitals are similar — Byetta and Januvia, while successful, aren’t what I would consider blockbusters. They aren’t super mainstream yet.

In terms of quantity and price, the TZDs — particularly Actos, since Avandia got thrown under the bus — are far more costly. Yeah, incretins, whether direct or indirect are the new CME hotness with the associated mindshare, but compared to your TZDs, biguanides, and sulfonylureas, they’re a distant a second/third/fourth fiddle in volume, if not cost.

Drug companies market these new drugs with claims of greater convenience and better control of blood sugar levels, and physicians have increasingly used them as alternatives to injected insulin, Alexander said. Insulin use has correspondingly dropped from 38 percent of treatment visits in 1994 to 28 percent in 2007.

This particular sentence bugs me because the implication is that insulin is cheaper than most oral medications. This just isn’t true, particularly with the modified human insulins that can be very costly indeed. At the very least, they’re on par with the cost of oral meds, and let’s not forget that most people with T2DM would prefer not to stick themselves with a needle, no matter how small.

Talk of direct costs aside, it is obvious that $1 spent in the name of public health has a greater marginal utility than $1 spent on a medical intervention — be that drug therapy, a procedure, or whatever. Ben Franklin was right, after all. Unfortunately, the long-run cost savings of public health programs are notoriously difficult to measure, and certainly nowhere near as sexy as a medical intervention. Perhaps that’s why public health gets shortchanged? I’ve spent some idle moments wondering how much money we could save if we spent a third or even a quarter as much combating things like poor nutrition and obesity as we do on direct healthcare itself.

It seems like the bulk of the money spent on prescription drugs is spent to offset the poor lifestyle choices that we Americans like to make. Unfortunately we pay dearly for that privilege. Any sort of nationalized healthcare will have to take this God-given right tendency into account.

Januvia is going to eat Byetta’s lunch

Januvia hit our shelves this past week, and I marveled at how inexpensive it was for a brand new drug. (~$300, if dim memory serves.) I think Merck’s going to have a runaway hit on their hands, and Amylin and Lilly are going to be the ones that lose out. I almost feel like I’m stating the obvious here — heck, maybe I am, I haven’t kept with any business news and speculation in several months.

Exenatide (Byetta) is a glucagon-like peptide analog that responds to glucose by stimulating insulin release and inhibiting glucagon release. It also slows gastric emptying, inhibits synthesis of glucagon, and stimulates beta cell neogenesis by preventing beta cell death. It only responds in the presence of glucose, which means there’s low risk for hypoglycemia.

Unfortunately, GLP-1 is broken down by DPP-IV, which limits native GLP-1 half-life to about 90 seconds. GLP-1 is also efficiently cleared by the kidneys. The other downside to Byetta is the fact that it’s injected.

Sitagliptin (Januvia) prevents the breakdown of the body’s own GLP-1 (and other incretin hormones) by inhibiting DPP-IV. As an oral tablet, patient compliance is likely to be higher, or at the very least, it’s more convenient than poking oneself.

Despite having entirely different mechanisms of action, the net effect is the same: higher levels of GLP-1 in the body, with low risk of hypoglycemia. Both Byetta and Januvia are likely to help patients lose weight as well. There’s been some talk about possibly getting Byetta approved as a weight-loss drug — I don’t know how far along this idea is, however.

It’s only a matter of time before we start getting insurance rejections for prior authorizations telling us that the doctor needs to try Januvia before they’ll approve Byetta. This is good news for those seniors on Medicare Part D plans as well — Januvia can save them a pile of money because it’s just so much cheaper than Byetta.

So to recap:

  • Easier to store (no refrigeration)
  • Oral tablet vs injection
  • Once a day dosing instead of twice a day poking
  • Cheaper

I think all the pieces are in place for Merck is going to eat Eli Lilly and Amylin’s lunch here. It seems one investment house is also predicting something similar. (PDF)