Costly Diabetes Drugs-Are They Worth It?

Keeping it simple, can reduce the cost to treat diabetes significantly.

How fitting that in these cost-conscious times, some experts are questioning whether pricey new diabetes drugs like Actos and Byetta actually provide more bang for the buck than older, cheaper ones. Their research dovetails nicely with new diabetes treatment guidelines that support trying less expensive drugs to lower blood sugar levels first and only moving on to more expensive drugs if the cheaper ones don’t do the trick.

Researchers at Stanford University and the University of Chicago reported that spending on diabetes drugs nearly doubled between 2001 and 2007, to $12.5 billion. They concluded that the use of newer diabetes drugs was largely responsible for the rise in the mean cost per prescription from $56 in 2001 to $76 in 2007. More patients also received prescriptions for more than one medication. In 1994, 82 percent of patients took just one drug; by 2007, that number had dropped to just 47 percent.

To evaluate these trends, G. Caleb Alexander, M.D., M.S., of the University of Chicago Hospitals, and colleagues gathered diabetes prescription information and costs from national databases. The researchers analyzed prescription data from U.S. patients age 35 and older with type 2 diabetes who visited a physician’s office between 1994 and 2007. Information about medication costs was available from 2001 to 2007.

The analysis revealed that, between 1994 and 2007:

• The estimated number of yearly patient visits to treat diabetes increased from 25 million to 36 million
• The average number of medications prescribed per treated patient increased from 1.14 to 1.63
• Among visits in which any treatment was given, the number in which only one drug was prescribed decreased from 82 percent to 47 percent
• Insulin use decreased from 38 percent in 1994 to a low of 25 percent in 2000, and then increased again to 28 percent
• The types of medications prescribed shifted-the use of sulfonylurea drugs decreased from 67 percent to 34 percent of treatment visits, while use of newer drugs such as biguanides and glitazones increased, so that by 2007 these agents were prescribed at 54 percent and 28 percent of treatment visits, respectively

Some of the newer, costlier drugs have been touted because they’re more convenient, have fewer side effects, or provide better control over blood sugar levels. But they’re also up to 11 times as expensive as the typical $29 per 30-day prescription for metformin, a generic version of Glucophage, which was approved in 1995. The benefits may not outweigh the costs in some cases, these researchers argue, particularly since it’s not clear that the new drugs improve heart or kidney function in the long term.

The Stanford study, comes on the heels of new diabetes treatment guidelines issued last week by the American Diabetes Association and the European Association for the Study of Diabetes. The guidelines suggest a stepped approach to treatment, starting with metformin and lifestyle changes immediately after diagnosis.

Checklist of what do after being diagnosed: If after three months blood sugar levels are still too high, then insulin or a sulfonylurea drug, both older generic drugs, should be the preferred next step. If blood sugar is still too high after an additional three months, then the ADA says, OK, now try Actos, a brand-name drug with a $160 price tag per 30-day prescription, or some of the other new drugs. The guidelines no longer recommend the use of Avandia, a drug in the same class as Actos, following reports that link it to higher heart attack risk.

“In our considered opinion, these newer drugs don’t have any particular advantage,” says David Nathan, the director of the Diabetes Center at Massachusetts General Hospital who chaired the panel that developed the recommendations.

Nathan discussed Byetta as an example. Approved by the FDA in 2005, Byetta has received plenty of attention because it not only improves glycemic control but also helps patients lose weight. At $202 per month, though, it’s nearly 10 times as expensive as metformin. According to Nathan, typical weight loss with Byetta is just 4 to 6 pounds, and 40 percent of people complain of nausea when taking it. It requires twice-daily injections, he says, and doesn’t lower blood glucose levels as much as some other drugs.

I’ve written in the past about. doctors’ cluelessness when it comes to the cost of the treatments they prescribe. That’s got to change, says Nathan. “Many physicians don’t like to think about costs,” he explains. “But we all have a responsibility to think about the bottom line.”

Archives of Internal Medicine, Oct. 27, 2008