Availability and affordability of essential medicines for diabetes across high-income, middle-income, and low-income countries: a prospective epidemiological study

A retrospective cohort study of a community-based primary care program's effects on pharmacotherapy quality in low-income Peruvians with type 2 diabetes and hypertension

Little is known about the effects of the Chronic Care Model (CCM) and community health workers (CHWs) on pharmacotherapy of type 2 diabetes and hypertension in resource-poor settings. This retrospective cohort implementation study evaluated the effects of a community-based program consisting of CCM, CHWs, guidelines-based treatment protocols, and inexpensive freely accessible medications on type 2 diabetes and hypertension pharmacotherapy quality. A door-to-door household survey identified 856 adults 35 years of age and older living in a low-income Peruvian community, of whom 83% participated in screening for diabetes and hypertension. Patients with confirmed type 2 diabetes and/or hypertension participated in the program's weekly to monthly visits for < = 27 months. The program was implemented as two care periods employed sequentially. During home care, CHWs made weekly home visits and a physician made treatment decisions remotely. During subsequent clinic care, a physician attended patients in a centralized clinic. The study compared the effects of program (pre- versus post-) (N = 262 observations), and home versus clinic care periods (N = 211 observations) on standards of treatment with hypoglycemic and antihypertensive agents, angiotensin converting enzyme inhibitors, and low-dose aspirin. During the program, 80% and 50% achieved hypoglycemic and antihypertensive standards, respectively, compared to 35% and 8% prior to the program, RRs 2.29 (1.72-3.04, p <0.001) and 6.64 (3.17-13.9, p<0.001). Achievement of treatment standards was not improved by clinic compared to home care (RRs 1.0 +/- 0.08). In both care periods, longer retention in care (>50% of allowable time) was associated with achievement of all treatment standards. 85% compared to 56% achieved the hypoglycemic treatment standard with longer and shorter retention, respectively, RR 1.52 (1.13-2.06, p<0.001); 56% compared to 27% achieved the antihypertensive standard, RR 2.11 (1.29-3.45, p<0.001). In a dose-dependent manner, the community-based program was associated with improved guidelines-based pharmacotherapy of type 2 diabetes and hypertension.

Current type 2 diabetes guidelines: Individualized treatment and how to make the most of metformin

Evidence-based guidelines provide the premise for the delivery of quality care to preserve health and prevent disabilities and premature death. The systematic gathering of observational, mechanistic and experimental data contributes to the hierarchy of evidence used to guide clinical practice. In the field of diabetes, metformin was discovered more than 100 years ago, and with 60 years of clinical use, it has stood the test of time regarding its value in the prevention and management of type 2 diabetes. Although some guidelines have challenged the role of metformin as the first-line glucose-lowering drug, it is important to point out that the cardiovascular-renal protective effects of sodium-glucose co-transporter-2 inhibitors and glucagon-like peptide-1 receptor agonists were gathered from patients with type 2 diabetes, the majority of whom were treated with metformin. Most national, regional and international guidelines recommend metformin as a foundation therapy with emphasis on avoidance of therapeutic inertia and early attainment of multiple treatment goals. Moreover, real-world evidence has confirmed the glucose-lowering and cardiovascular-renal benefits of metformin accompanied by an extremely low risk of lactic acidosis. In patients with type 2 diabetes and advanced chronic kidney disease (estimated glomerular filtration rate 15-30 mL/min/1.73m2), metformin discontinuation was associated with an increased risk of cardiovascular-renal events compared with metformin persistence. Meanwhile, it is understood that microbiota, nutrients and metformin can interact through the gut-brain-kidney axis to modulate homeostasis of bioactive molecules, systemic inflammation and energy metabolism. While these biological changes contribute to the multisystem effects of metformin, they may also explain the gastrointestinal side effects and vitamin B12 deficiency associated with metformin intolerance. By understanding the interactions between metformin, foods and microbiota, healthcare professionals are in a better position to optimize the use of metformin and mitigate potential side effects. The United Kingdom Prospective Diabetes Study and the Da Qing Diabetes Prevention Program commenced 40 years ago provided the first evidence that type 2 diabetes is preventable and treatable. To drive real-world impact from this evidence, payors, practitioners and planners need to co-design and implement an integrated, data-driven, metformin-based programme to detect people with undiagnosed diabetes and prediabetes (intermediate hyperglycaemia), notably impaired glucose tolerance, for early intervention. The systematic data collection will create real-world evidence to bring out the best of metformin and make healthcare sustainable, affordable and accessible.

Access to essential medicines used in the management of noncommunicable diseases in Southern Ethiopia: Analysis using WHO/HAI methodology

Objectives

This study aims to assess access to essential medicines used in the management of noncommunicable diseases through analysis of the availability, prices, and affordability of these essential medicines in Arba Minch town, Gamo Zone, Southern Ethiopia.

Methods

A cross-sectional design was carried out using the World Health Organization/health action international methodology between 2 March and 2 May 2023, within public and private healthcare facilities located in Arba Minch town, Southern Ethiopia. The median price ratio served as a metric. Statistical tests like the Shapiro-Wilk and Kolmogorov-Smirnov were utilized to assess the normal distribution of price data. The Wilcoxon-Mann-Whitney U test was also employed to compare median buyer's prices (patient prices) between public and private healthcare institutions. Treatment affordability was determined by estimating the number of days' wages required by the lowest-paid government employee in Ethiopia to afford the prescribed medication regimen.

Results

Among 23 health facilities surveyed, the pooled availability of essential medicine used in the management of noncommunicable diseases was 18.7% (range: 0%-30.1%), with the public and private facilities contributing 16.3% and 38.3%, respectively. The overall percentage of availability originator brand versions was 1.1% for overall health sectors, 0.6% for public sectors, and 1.2% for private sectors. The overall percent availability of lowest price generics was 36.2% (range: 0%-26.2%; public: 32.0%; private: 37.1%). Only seven lowest price generics satisfied the World Health Organization target of 80% and above. The overall median price of lowest price generic medicines in private was two times higher than in public sectors. The top five median price scorers were amlodipine, furosemide, insulin, beclomethasone, and salbutamol. The Mann-Whitney U test showed that 11.6% of lowest price generics medicines had a statistically significant median price disparity between the public and private sectors (p < 0.05). The overall percent of unaffordability was found to be 100.0%, (public: 70.4; private: 100.0%).

Conclusions

This study revealed the limited availability and potential financial burdens on patients seeking essential noncommunicable disease medications. Limited availability suggests the need for better supply chain management and consistent stock availability. The price disparities and affordability challenges identified underscore the necessity for policy interventions such as price regulation and subsidized programs to ensure equitable access to essential noncommunicable disease medications in Arba Minch town, Southern Ethiopia.

Availability and pricing of insulin and related diagnostics in South Africa

Background

In South Africa (SA), most patients rely on the government for free healthcare. Some choose to subscribe to a medical insurance scheme. If insulin is unavailable in government or otherwise unaffordable, non-adherence may occur, which can increase complications of the disease.

Methods

Data on availability and pricing of insulin and related diagnostics was collected from SA pharmacies via an online survey. Co-payments levied on insulin by the biggest medical aids were extracted from formularies. Affordability of these items was then assessed. An adapted methodology from the World Health Organization/Health Action International tool was used.

Results

There was fairly high availability of insulin in the public sector, with the exception of long-acting insulin which respondents claimed was difficult to find; however, long-acting insulin glargine was available in most private sector pharmacies. Point-of-care (POC) blood glucose testing was free in the public sector but offered in only 31.25% of pharmacies. Patients pay a minimum of USD 40.4 (over 3 days' wages for the lowest paid government worker (LPGW)) for a months' supply of the cheapest insulin, needles and test strips. Insulin in SA was cheaper than 5 other countries, except Australia.

Conclusion

Overall, there is a good availability of insulin and related diagnostics in SA. Even though insulin is cheaper than other countries, it is unaffordable to the LPGW. This highlights the importance of ensuring a constant availability of insulin in the free public sector. Whilst human insulins are cheaper than newer analogue insulins and SA faces cost constraints, important variables in favour of newer insulins, such as ease-of-use, long term outcomes and value should be considered when treatment guidelines are updated. Annual POC testing should be available and offered free to all patients to detect diabetes early.

Global burden of type 2 diabetes in adolescents from 1990 to 2019

Purpose

To evaluate the burden of type 2 diabetes (T2D) among adolescents (15-24 years old) from 1990 to 2019.

Methods

The age-standardized incidence rate (ASIR) and disability-adjusted life years (DALYs) rate of adolescents were analyzed according to age, sex, geographical location, and sociodemographic index (SDI). The estimated annual percentage change (EAPC) was estimated to quantify the trends.

Results

From 1990 to 2019, the ASIR (EAPC = 1.07) and age-standardized DALY rate (EAPC = 2.01) of T2D in adolescents showed an increasing trend. The ASIR was higher in males than in females. The burden was greater in the 20-24-year age group. Of the five SDI regions, the highest ASIR and age-standardized DALY rate were found in low-middle-SDI regions, while the greatest increase in these rates was observed in high-SDI regions (EAPC = 3.28 and 3.55, respectively). Of the 21 regions analyzed, the highest ASIR and age-standardized DALY rate were found in Oceania. Of the 204 countries analyzed, the Marshall Islands (651.16) and Kiribati (277.42) had the highest ASIR and DALYs, respectively. The regions with the greatest increase in the ASIR from 1990 to 2019 were Western Europe (EAPC = 4.15), high-income North America (EAPC = 4.72).

Conclusions

The global burden of T2D in adolescents showed an overall upward trend from 1990 to 2019. It is necessary to strengthen prevention measures related to risk factors for T2D among young people, especially in areas with a low-to-medium SDI.

Delaying Renal Aging: Metformin Holds Promise as a Potential Treatment

Given the rapid aging of the population, age-related diseases have become an excessive burden on global health care. The kidney, a crucial metabolic organ, ages relatively quickly. While the aging process itself does not directly cause kidney damage, the physiological changes that accompany it can impair the kidney's capacity for self-repair. This makes aging kidneys more susceptible to diseases, including increased risks of chronic kidney disease and end-stage renal disease. Therefore, delaying the progression of renal aging and preserving the youthful vitality of the kidney are crucial for preventing kidney diseases. However, effective strategies against renal aging are still lacking due to the underlying mechanisms of renal aging, which have not been fully elucidated. Accumulating evidence suggests that metformin has beneficial effects in mitigating renal aging. Metformin has shown promising anti-aging results in animal models but has not been tested for this purpose yet in clinical trials. These findings indicate the potential of metformin as an anti-renal aging drug. In this review, we primarily discuss the characteristics and mechanisms of kidney aging and the potential effects of metformin against renal aging.

[Unfractionned heparin wastage at a French university hospital]

OBJECTIVES

In a context of heparin shortage, we studied the wasted quantities in three intensive care units (ICU) of a university hospital where two electric syringe pump (ESP) heparin protocols coexist (20,000UI/48mL used in the cardiology ICU and 25,000UI/50mL use in the medical and surgical ICUs).

METHOD

We performed a prospective observational study of patients treated with heparin ESP. We collected the information recorded in the prescription software connected to the ESP (dosage, start time, infusion rate, interruption times, date and time of end of treatment). We observed the ESPs, noted the time of start written on the label and the quantity remaining, and questioned nurses about the constraints that lead for changing the ESPs.

RESULTS

Between 23/03/23 and 19/05/23, 164 vials of 25,000UI/5mL were used. The wasted quantity was equivalent 42 vials: 18 vials (43%) of treatment stopped, nurses practices such as changing the ESP in advance 6 vials (14%), application of the rule "discard the ESP 24hours after preparation" 9 vials (21.5%) and 9 vials (21.5%) corresponding to the 45mL discarded for the 45 ESP prepared in the cardiology ICU.

CONCLUSION

More than a quarter of the heparin purchased is wasted. The results should lead to policy decisions concerning the medications supply chain, i.e. abandoning the 20,000UI/48mL protocol, supply of ready to use heparin syringes by industry or by the pharmacy. It is essential that these data be fed back to nurses' teams, in order to gather their suggestions before considering any changes of their practices.

The Current and Future Role of Insulin Therapy in the Management of Type 2 Diabetes: A Narrative Review

Early initiation of intensive insulin therapy has been demonstrated to be effective in controlling glycemia and possibly preserving beta-cell function. Innovations in insulin formulations and delivery systems continue. However, we have seen an acceleration in the development of new classes of diabetes medications for individuals with type 2 diabetes and obesity, such as, for example, glucagon-like peptide-1 receptor agonists (GLP-1 RAs). These formulations have been shown to confer significant benefits in achieving good glycemic control with reduced hypoglycemia risk, weight loss, and cardiorenal protection. Therefore, it is reasonable to question whether there is still a role for insulin therapy in the management of type 2 diabetes. However, there are clear limitations inherent to GLP-1 RA therapy, including high rates of suboptimal adherence and treatment discontinuation due to high cost and side effects, which diminish long-term efficacy, and supply issues. In addition, newer formulations have shown improvements in convenience and tolerability, and have been shown to be even more effective when used in conjunction with basal insulin. In this narrative review, we discuss current evidence that supports GLP-1 RA use in combination with insulin therapy and the potential pitfalls of reliance on GLP-1 RAs as a substitute for insulin therapy.

Application of machine learning in affordable and accessible insulin management for type 1 and 2 diabetes: A comprehensive review

Proper insulin management is vital for maintaining stable blood sugar levels and preventing complications associated with diabetes. However, the soaring costs of insulin present significant challenges to ensuring affordable management. This paper conducts a comprehensive review of current literature on the application of machine learning (ML) in insulin management for diabetes patients, particularly focusing on enhancing affordability and accessibility within the United States. The review encompasses various facets of insulin management, including dosage calculation and response, prediction of blood glucose and insulin sensitivity, initial insulin estimation, resistance prediction, treatment adherence, complications, hypoglycemia prediction, and lifestyle modifications. Additionally, the study identifies key limitations in the utilization of ML within the insulin management literature and suggests future research directions aimed at furthering accessible and affordable insulin treatments. These proposed directions include exploring insurance coverage, optimizing insulin type selection, assessing the impact of biosimilar insulin and market competition, considering mental health factors, evaluating insulin delivery options, addressing cost-related issues affecting insulin usage and adherence, and selecting appropriate patient cost-sharing programs. By examining the potential of ML in addressing insulin management affordability and accessibility, this work aims to envision improved and cost-effective insulin management practices. It not only highlights existing research gaps but also offers insights into future directions, guiding the development of innovative solutions that have the potential to revolutionize insulin management and benefit patients reliant on this life-saving treatment.

Out-of-pocket expenses and rationing of insulin and diabetes supplies: findings from the 2022 T1International cross-sectional web-based survey

Introduction

Continue investigating Out-of-Pocket Expenses (OoPEs) and rationing of insulin and diabetes supplies, including impacts of the COVID-19 pandemic, for people with type 1 diabetes (T1D).

Methods

A cross-sectional web-based survey was conducted in English and advertised by T1International's global network of patient advocates from May through September 2022. Participants provided monthly OoPEs and rationing frequency for insulin and supplies, impacts of the COVID-19 pandemic, and open-ended comments.

Results

In the seven most represented countries, mean monthly OoPEs were highest in the United States, followed by Panama, Canada, and India, and were much lower in the United Kingdom, Germany, and Sweden. OoPEs were highest for participants with partial healthcare coverage, followed by those with no healthcare coverage. The COVID-19 pandemic negatively impacted access and/or affordability of insulin and/or supplies for over half of participants. Globally, 19.5% reported insulin rationing and 36.6% reported rationing glucose testing supplies. Qualitative analysis of open-ended responses identified themes such as 'mental health impacts' and 'limits to life choices.'

Discussion

High OoPEs lead to rationing of insulin and supplies for many people with T1D globally. Healthcare systems improvements and price reductions of insulin and supplies are needed to ensure adequate, equitable access for all.

A systematic review of the economic burden of diabetes mellitus: contrasting perspectives from high and low middle-income countries

Introduction

Diabetes increases preventative sickness and costs healthcare and productivity. Type 2 diabetes and macrovascular disease consequences cause most diabetes-related costs. Type 2 diabetes greatly costs healthcare institutions, reducing economic productivity and efficiency. This cost of illness (COI) analysis examines the direct and indirect costs of treating and managing type 1 and type 2 diabetes mellitus.

Methodology

According to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, Cochrane, PubMed, Embase, CINAHL, Scopus, Medline Plus, and CENTRAL were searched for relevant articles on type 1 and type 2 diabetes illness costs. The inquiry returned 873 2011-2023 academic articles. The study included 42 papers after an abstract evaluation of 547 papers.

Results

Most articles originated in Asia and Europe, primarily on type 2 diabetes. The annual cost per patient ranged from USD87 to USD9,581. Prevalence-based cost estimates ranged from less than USD470 to more than USD3475, whereas annual pharmaceutical prices ranged from USD40 to more than USD450, with insulin exhibiting the greatest disparity. Care for complications was generally costly, although costs varied significantly by country and problem type.

Discussion

This study revealed substantial heterogeneity in diabetes treatment costs; some could be reduced by improving data collection, analysis, and reporting procedures. Diabetes is an expensive disease to treat in low- and middle-income countries, and attaining Universal Health Coverage should be a priority for the global health community.

The global burden of ischemic heart disease attributed to high fasting plasma glucose: Data from 1990 to 2019

Background

Ischemic heart disease (IHD) is the leading cause of death worldwide. High fasting plasma glucose (FPG) is an increasing risk factor for IHD. We aimed to explore the long-term trends of high FPG-attributed IHD mortality during 1990-2019.

Methods

Data were obtained from the Global Burden of Disease Study 2019 database. Deaths, disability-adjusted life-years (DALYs), the age-standardized mortality rate (ASMR) and age-standardized DALY rate (ASDR) of IHD attributable to high FPG were estimated by sex, socio-demographic index (SDI), regions and age. Estimated annual percentage changes (EAPCs) were calculated to assess the trends of ASMR and ASDR of IHD attributable to high FPG.

Results

IHD attributable to high FPG deaths increased from 1.04 million (0.62-1.63) in 1990 to 2.35 million (1.4-3.7) in 2019, and the corresponding DALYs rose from 19.82 million (12.68-29.4) to 43.3 million (27.8-64.2). In 2019, ASMR and ASDR of IHD burden attributable to high FPG were 30.45 (17.09-49.03) and 534.8 (340.7-792.2), respectively. The highest ASMR and ASDR of IHD attributable to high FPG occurred in low-middle SDI quintiles, with 39.28 (22.40-62.76) and 742.3 (461.5-1117.5), respectively, followed by low SDI quintiles and middle SDI quintiles. Males had higher ASMR and ASDR compared to females across the past 30 years. In addition, ASRs of DALYs and deaths were highest in those over 95 years old.

Conclusion

High FPG-attributed IHD mortality and DALYs have increased dramatically and globally, particularly in low, low-middle SDI quintiles and among the elderly. High FPG remains a great concern on the global burden of IHD and effective prevention and interventions are urgently needed to curb the ranking IHD burden, especially in lower SDI regions.

A systematic scoping review of medicine availability and affordability in Africa

BACKGROUND

The most recent World Medicines Situation Report published in 2011 found substantial medicine availability and affordability challenges across WHO regions, including Africa. Since publication of the 2011 report, medicine availability and affordability has risen on the international agenda and was included in the Sustainable Development Goals as Target 3.8. While numerous medicine availability and affordability studies have been conducted in Africa since the last World Medicines Situation Report, there has not been a systematic analysis of the methods used in these studies, measures of medicine availability and affordability, categories of medicines studied, or geographic distribution. Filling this knowledge gap can help inform future medicine availability and affordability studies, design systems to monitor progress toward Sustainable Development Goal Target 3.8 in Africa and beyond, and inform policy and program decisions to improve medicine availability and affordability.

METHODS

We conducted a systematic scoping review of studies assessing medicine availability or affordability conducted in the WHO Africa region published from 2009-2021.

RESULTS

Two hundred forty one articles met our eligibility criteria. 88% of the articles (213/241) reported descriptive studies, while 12% (28/241) reported interventional studies. Of the 198 studies measuring medicine availability, the most commonly used measure of medicine availability was whether a medicine was in stock on the date of a survey (124/198, 63%). We also identified multiple other availability methods and measures, including retrospective stock record reviews and self-reported medicine availability surveys. Of the 59 articles that included affordability measures, 32 (54%) compared the price of the medicine to the daily wage of the lowest paid government worker. Other affordability measures were patient self-reported affordability, capacity to pay measures, and comparing medicines prices with a population-level income standard (such as minimum wage, poverty line, or per capita income). The most commonly studied medicines were antiparasitic and anti-bacterial medicines. We did not identify studies in 22 out of 48 (46%) countries in the WHO Africa Region and more than half of the studies identified were conducted in Ethiopia, Kenya, Tanzania, and/or Uganda.

CONCLUSION

Our results revealed a wide range of medicine availability and affordability assessment methodologies and measures, including cross-sectional facility surveys, population surveys, and retrospective data analyses. Our review also indicated a need for greater focus on medicines for certain non-communicable diseases, greater geographic diversity of studies, and the need for more intervention studies to identify approaches to improve access to medicines in the region.

Prevalence and Overlap of Cardiac, Renal, and Metabolic Conditions in US Adults, 1999-2020

Importance

Individually, cardiac, renal, and metabolic (CRM) conditions are common and leading causes of death, disability, and health care-associated costs. However, the frequency with which CRM conditions coexist has not been comprehensively characterized to date.

Objective

To examine the prevalence and overlap of CRM conditions among US adults currently and over time.

Design, Setting, and Participants

To establish prevalence of CRM conditions, nationally representative, serial cross-sectional data included in the January 2015 through March 2020 National Health and Nutrition Examination Survey (NHANES) were evaluated in this cohort study. To assess temporal trends in CRM overlap, NHANES data between 1999-2002 and 2015-2020 were compared. Data on 11 607 nonpregnant US adults (≥20 years) were included. Data analysis occurred between November 10, 2020, and November 23, 2022.

Main Outcomes and Measures

Proportion of participants with CRM conditions, overall and stratified by age, defined as cardiovascular disease (CVD), chronic kidney disease (CKD), type 2 diabetes (T2D), or all 3.

Results

From 2015 through March 2020, of 11 607 US adults included in the analysis (mean [SE] age, 48.5 [0.4] years; 51.0% women), 26.3% had at least 1 CRM condition, 8.0% had at least 2 CRM conditions, and 1.5% had 3 CRM conditions. Overall, CKD plus T2D was the most common CRM dyad (3.2%), followed by CVD plus T2D (1.7%) and CVD plus CKD (1.6%). Participants with higher CRM comorbidity burden were more likely to be older and male. Among participants aged 65 years or older, 33.6% had 1 CRM condition, 17.1% had 2 CRM conditions, and 5.0% had 3 CRM conditions. Within this subset, CKD plus T2D (7.3%) was most common, followed by CVD plus CKD (6.0%) and CVD plus T2D (3.8%). The CRM comorbidity burden was disproportionately high among participants reporting non-Hispanic Black race or ethnicity, unemployment, low socioeconomic status, and no high school degree. Among participants with 3 CRM conditions, nearly one-third (30.5%) did not report statin use, and only 4.8% and 3.0% used glucagon-like peptide-1 receptor agonists and sodium-glucose cotransporter 2 inhibitors, respectively. Between 1999 and 2020, the proportion of US adults with multiple CRM conditions increased significantly (from 5.3% to 8.0%; P < .001 for trend), as did the proportion having all 3 CRM conditions (0.7% to 1.5%; P < .001 for trend).

Conclusions and Relevance

This cohort study found that CRM multimorbidity is increasingly common and undertreated among US adults, highlighting the importance of collaborative and comprehensive management strategies.

A national survey on registered products, availability, prices, and affordability of 100 essential medicines in community pharmacies across Sri Lanka

INTRODUCTION

Availability of essential medicines that meet the expected quality standards, in appropriate dosage forms at affordable prices is a fundamental prerequisite to fulfill healthcare needs of given a population. This study assessed available products, prices and affordability of essential medicines (EM) in community pharmacies in Sri Lanka with comparison of registration status from the National Medicines Regulatory Authority(NMRA).

METHODS

A cross-sectional island-wide survey of 80 pharmacies was conducted according to World Health Organization and Health Action International Manual (WHO/HAI). Hundred medicines were selected from the global core list(n = 14), regional core list(n = 16) and the Sri Lanka Essential Medicine List (SL-EML) (n = 70) based on healthcare needs. Number of registered products in 2015 and 2021 were compared.

FINDINGS

Average availability was 85.4%(± 12.31) and availability was lowest in the Northern province (69.38 ± 21.18%)(p = 0.008). Availability between the state owned, franchise and privately owned pharmacies was not significantly different (p > 0.05). 89.4% medicines were affordable except for amiodarone, hydroxychloroquine, sitagliptin, soluble insulin, isophane insulin, losartan, levodopa carbidopa combination, clonazepam and ceftriaxone. The median price ratio (MPR) of 33.7% of medicines was less than 1 and MPR of 37.1% originator brands (OB) was over 3. Median number of generic brands in the market was 8(range 2-44), 9% of medicines had 20 or more products in the market and 72.7% medicines had more products available than the number registered in 2015. The average number of registered products were similar in 2015 (8.27) and 2021(7.59) (p = 0.15).

CONCLUSION

The overall availability of EMs in Sri Lanka was high in all categories of community pharmacies. Medicines were largely affordable and reasonably priced in 2015, although OBs were generally more expensive. Majority of medicines had more products in the market than the number of registered products.

Financial burden of seeking diabetes mellitus care in India: Evidence from a Nationally Representative Sample Survey

Background

Diabetes mellitus (DM) is a major public health concern in India, and entails a severe burden in terms of disability, death, and economic cost. This study examined the out-of-pocket health expenditure (OOPE) and financial burden associated with DM care in India.

Methods

The study used data from the latest round of the National Sample Survey on health, which covered 555,115 individuals from 113,823 households in India. In the present study, data of 1216 individuals who sought inpatient treatment and 6527 individuals who sought outpatient care for DM were analysed.

Results

In India, 10.04 per 1000 persons reported having DM during the last 15 days before the survey date, varying from 6.94/1000 in rural areas to 17.45/1000 in urban areas. Nearly 38% of Indian households with diabetic members experienced catastrophic health expenditure (at the 10% threshold) and approximately 10% of DM-affected households were pushed below the poverty line because of OOPE, irrespective of the type of care sought. 48.5% of households used distressed sources to finance the inpatient costs of DM. Medicines constituted one of the largest proportion of total health expenditure, regardless of the type of care sought or type of healthcare facility visited. The average monthly OOPE was over 4.5-fold and 2.5-fold higher for households who sought inpatient and outpatient care, respectively, from private health facilities, compared with those treated at public facilities. Notably, the financial burden was more severe for households residing in rural areas, those in lower economic quintiles, those belonging to marginalised social groups, and those using private health facilities.

Conclusion

The burden of DM and its associated financial ramifications necessitate policy measures, such as prioritising health promotion and disease prevention strategies, strengthening public healthcare facilities, improved regulation of private healthcare providers, and bringing outpatient services under the purview of health insurance, to manage the diabetes epidemic and mitigate its financial impact.

Mobilizing morality: how caregivers in Vietnam handle the challenges of daily diabetes care

BACKGROUND

As a chronic disease, type 2 diabetes (T2D) often involves long-term care obligations for patients' family members. Understanding the socially and culturally specific challenges that family caregivers face and how they cope with them is crucial in developing targeted and effective interventions to support both caregivers and patients with T2D. This research examined family caregiving for people with T2D living in rural northern Vietnam. Although there is a growing literature on family support in Vietnam, little is known about the personal experiences of family caregivers for people with T2D. This paper seeks to fill this gap revealing some of the challenges and coping strategies of family caregivers to people with T2D.

METHODS

This qualitative study is based on ethnographic research using primarily semi-structured interviews with 21 caregivers to a person with T2D in Vietnam. The research was conducted in 2022 by a Vietnamese-Danish research team. Each interview was voice-recorded, transcribed verbatim and thematically coded.

RESULTS

Four major challenges emerged from the analysis: physical health concerns, psychological exhaustion, economic burdens, and lack of support. Caregivers expressed motivation to overcome these challenges as they felt a deep sense of responsibility towards their family member with diabetes. The primary caregiver's sense of responsibility toward their family would often cause them not to share the burdens from caregiving with other family members to avoid burdening them as well. However, negative experiences from caregiving were decreased and positive feelings increased in the instances where caregiving was shared between multiple family members.

CONCLUSION

While family members expressed motivation to take care of the patient because of moral obligations, some caregivers, specifically primary caregivers, did not want to burden other family members with care tasks and were reluctant to ask for assistance. For families who did share the caregiving tasks among several family members, some of the negative sentiments associated with caregiving were diminished. Having multiple members of a family forming a caregiving community thus motivated people in handling care challenges.

The Description and Prediction of Incidence, Prevalence, Mortality, Disability-Adjusted Life Years Cases, and Corresponding Age-Standardized Rates for Global Diabetes

OBJECTIVE

Diabetes is a life-long disease that poses a serious threat to safety and health. We aimed to assess the disease burden attributable to diabetes globally and by different subgroups, and to predict future disease burden using statistical models.

METHODS

This study was divided into three stages. Firstly, we evaluated the disease burden attributable to diabetes globally and by different subgroups in 2019. Second, we assessed the trends from 1990 to 2019. We estimated the annual percentage change of disease burden by applying a linear regression model. Finally, the age-period-cohort model was used to predict the disease burden from 2020 to 2044. Sensitivity analysis was performed with time-series models.

RESULTS

In 2019, the number of incidence cases of diabetes globally was 22239396 (95% uncertainty interval (UI): 20599519-24058945). The number of prevalence cases was 459875371 (95% UI 423474244-497980624) the number of deaths cases was 1551170 (95% UI 1445555-1650675) and the number of disability-adjusted life years cases was 70880155 (95% UI 59707574-84174005). The disease burden was lower in females than males and increased with age. The disease burden associated with type 2 diabetes mellitus was greater than that with type 1; the burden also varied across different socio-demographic index regions and different countries. The global disease burden of diabetes increased significantly over the past 30 years and will continue to increase in the future.

CONCLUSION

The disease burden of diabetes contributed significantly to the global disease burden. It is important to improve treatment and diagnosis to halt the growth in disease burden.

COVID-19 fear and its associated correlates among type-2 diabetes patients in Bangladesh: A hospital-based study

The outbreak of COVID-19 has caused widespread fear among people around the world, particularly those with underlying health conditions such as type-2 diabetes. This study aimed to investigate COVID-19 fear and its associated potential factors among type-2 diabetes patients in Bangladesh. A total of 1,036 type-2 diabetes patients residing in the Jashore district of Bangladesh were interviewed using the COVID-19 Fear Scale in Bengali language. A pre-validated questionnaire was used to collect data on sociodemographic, lifestyle-related characteristics, and COVID-19-related information. Logistic regression was performed to identify factors associated with perceived fear of COVID-19. The mean score of the COVID-19 fear was 18.1 ± 5.6. Approximately 45 and 39% were most afraid and uncomfortable thinking about COVID-19, respectively. Regression analysis revealed that gender, age, occupation, residence, physical activity, smoking, and dietary diversity score were associated with fear. Additionally, respondents who had limited self-care practice, unaffordable medicine, medicine shortages, a close friend or family member diagnosed with COVID-19, and financial problems during COVID-19 were significant predictors of COVID-19 fear. Healthcare providers should implement interventions, including appropriate education and counseling, to address the psychological impact of the COVID-19 pandemic on type-2 diabetes patients in Bangladesh.

Unilateral Phrenic Nerve Palsy as a Presentation of Diabetes Mellitus: A Rare Case Report

Diabetes mellitus is one of the most debilitating diseases, diabetic neuropathy happens to be the most common and perhaps the most serious complication of diabetes mellitus, often leading to morbidity and mortality. A 60 year old female presented with disorientation, history of vomiting, shortness of breath, respiratory failure initially. Blood reports revealed that she was positive for ketone bodies with elevated HbA1c and general random blood sugar. Chest radiogram revealed atelectasis of the right lung with prominent involvement of right middle and lower lobes. High-resolution computed tomography of chest confirmed the findings and unilateral diaphragmatic paralysis due to phrenic nerve neuropathy due to undetected type 2 diabetes was diagnosed. Although phrenic nerve paralysis is a rare occurrence with diabetes, the possibility shouldn't be overlooked as a presentation of diabetes mellitus.

Main drivers of diabetes pharmaceuticals expenditures: evidence from OECD countries and Iran

Purpose

This study aimed to identify the impact of prominent drivers on drug expenditure for diabetes.

Method

Following the examination of previous studies, this study identified possible factors contributing to diabetes pharmaceutical expenditures. The explanatory variables for the study were the median population age, access to innovative drugs, GDP per capita, prevalence, price, and consumption of diabetes drugs. Then, to estimate the per capita expenditure among diabetic patients, this study developed the panel data model and two time-series regression models for OECD countries and Iran, respectively.

Results

In the panel data regression model, R2 was 0.43. The influence of the age, prevalence, consumption volume and GDP per capita coefficients were + 1.79, + 0.704, + 3.86057, + 0.00054, respectively. Also, the probability level of all variables was less than 0.05. In Iran's comparative time-series regression model, R2 was 0.9, and the only significant influence coefficient was the age (β=+0.91). In the another model for Iran, R2 was 0.99, the influence coefficient of age was + 0.249, the prevalence was + 0.131, innovation was + 0.029, and the price was + 0.00054; all the probability levels were less than 0.05.

Conclusion

Pharmaceutical per capita expenditure is affected by several factors. These factors are not the same in various counties. Passing a judgment on drug utilization only based on pharmaceutical per capita expenditure cannot be perfect. Also, judging whether the per capita drug expenditure in one country is desirable without attention to the affecting factors and only relying on the value of utilized medicines is defective.

Time to reposition sulfonylureas in type 2 diabetes management in Indian context: A pragmatic practical approach

Sulfonylureas (SU) continue to be a vital therapeutic category of oral hypoglycemic agents (OHAs) for the management of type 2 diabetes mellitus (T2DM). Physicians consider modern SU (gliclazide and glimepiride) as "safe and smart" choices for T2DM management. The presence of multiple international guidelines and scarcity of a national guideline may contribute to the challenges faced by few physicians in choosing the right therapeutic strategy. The role of SU in diabetes management is explicit, and the present consensus aims to emphasize the benefits and reposition SU in India. This pragmatic, practical approach aims to define expert recommendations for the physicians to improve caregivers' knowledge of the management of T2DM, leading to superior patient outcomes.

Cardiovascular outcomes in type 1 and type 2 diabetes

Diabetes is one of the most prevalent cardiometabolic disorders on the planet. Type 1 diabetes accounts for only a minority of all cases (recently estimated to be ~2% globally); however, since this is a disorder with an early onset, many people live with type 1 diabetes for a long time. CVD and premature death are the main long-term outcomes for both types of diabetes; however, the type of diabetes that carries the highest risk of these outcomes is a controversial topic and has not been widely studied. Because of the association between diabetes and CVD, the rise in type 2 diabetes prevalence over the past decades has huge effects on global health. The excess risk in people with diabetes compared with those without depends, to a large extent, on the presence of other factors, such as general cardiovascular risk factors (e.g. elevated LDL-cholesterol, hypertension and smoking) and also factors that are more specific to diabetes (e.g. HbA1c, and micro- and macroalbuminuria). Some contributory factors are modifiable, while others are not, such as age, sex and type of diabetes. Older people with type 2 diabetes who have risk factors that are under control can achieve levels of CVD risk that are similar to that of the general population, while younger individuals with type 1 diabetes are mostly unable to achieve similar levels of risk, probably because of long and cumulative exposure to raised blood glucose levels. Despite reports of declining rates of CVD among people with type 1 and type 2 diabetes, rising rates of both types of diabetes lead to a continuing rise in the number of people with cardiometabolic disorders worldwide, offsetting the progress made in many countries. Comparison between individuals with type 1 and type 2 diabetes with respect to risk of CVD is fraught with difficulties and highly dependent on other, concomitant factors, some of which are modifiable and others not. Nonetheless, as a whole, what matters most in determining the management of diabetes is absolute risk and lifetime risk. Life-long efforts to achieve glycaemic control, control of lipids and hypertension, and not smoking are key to prevention, with a healthy lifestyle and pharmacological therapy to be implemented as needed.

Trajectory of glycated haemoglobin over time, using real-world data, in type 2 diabetes patients with obesity on a U-100 basal-bolus insulin regimen

AIMS

To identify patient clusters with poor glucose control among type 2 diabetes mellitus (T2DM) patients with obesity who are receiving basal-bolus insulin and to identify the potential therapeutic inertia factors associated with poor control.

METHODS

Glycated haemoglobin (HbA1c) trajectories across a 3-year period were structured at 6-month intervals for a retrospective cohort of T2DM patients with obesity on basal-bolus insulin from the Veterans' Health Administration database. Based on each patient's longitudinal HbA1c features, an unsupervised clustering procedure was used to determine the numbers of clusters and associated trajectory patterns. Multinomial logistic regression was used to examine the association between HbA1c trajectory clusters and patient characteristics/treatment patterns.

RESULTS

A total of 51 273 patients were included, of whom 11.2% were in a subgroup with persistent missingness of HbA1c values. For those with sufficient HbA1c observations, cluster analysis indicated six distinct HbA1c trajectories: stable low (35.8%); stable high (20.8%); descending low (10.5%); ascending low (10.2%); descending high (5.7%); and ascending high (5.7%). Being of Black ethnicity, not initiating noninsulin antihyperglycaemic agents (sodium-glucose cotransporter-2 inhibitors, glucagon-like peptide-1 receptor agonists or thiazolidinediones) or concentrated insulin, low adherence (measured by proportion of days covered), and reduced insulin prescription refills were factors associated with poorer HbA1c clusters; similar factors were associated with persistent HbA1c missingness.

CONCLUSION

The present study found the potential for therapeutic inertia among a significant proportion of T2DM patients with obesity on basal-bolus insulin. Subgrouping T2DM patients based on HbA1c missingness and HbA1c trajectories can inform disease management strategies.

Study protocol: Behavioral economics and self-determination theory to change diabetes risk (BEST Change)

BACKGROUND

The Diabetes Prevention Program (DPP) and metformin can prevent or delay the onset of type 2 diabetes mellitus (T2DM) among patients with prediabetes. Yet, even when these evidence-based strategies are accessible and affordable, uptake is low. Thus, there is a critical need for effective, scalable, and sustainable approaches to increase uptake and engagement in these interventions.

METHODS

In this randomized controlled trial, we will test whether financial incentives and automated messaging to promote autonomous motivation for preventing T2DM can increase DPP participation, metformin use, or both among adults with prediabetes. Participants (n = 380) will be randomized to one of four study arms. Control Arm participants will receive usual care and educational text messages about preventing T2DM. Incentives Arm participants will receive the Control Arm intervention plus financial incentives for DPP participation or metformin use. Tailored Messages Arm participants will receive the Control Arm intervention plus tailored messages promoting autonomous motivation for preventing T2DM. Combined Arm participants will receive the Incentives Arm and Tailored Messages Arm interventions plus messages to increase the personal salience of financial incentives. The primary outcome is change in hemoglobin A1c from baseline to 12 months. Secondary outcomes are change in body weight, DPP participation, and metformin use.

DISCUSSION

If effective, these scalable and sustainable approaches to increase patient motivation to prevent T2DM can be deployed by health systems, health plans, and employers to help individuals with prediabetes lower their risk for developing T2DM.

Treatment patterns and glycated haemoglobin levels over 36 months in individuals with type 2 diabetes initiating second-line glucose-lowering therapy: The global DISCOVER study

AIMS

To describe glucose-lowering treatment regimens and glycated haemoglobin (HbA1c) trajectories in individuals with type 2 diabetes (T2D) over 36 months of follow-up from the start of second-line therapy.

MATERIALS AND METHODS

This data analysis from the 3-year, observational DISCOVER study programme included 14 687 participants from 37 countries with T2D initiating second-line glucose-lowering therapy. Treatment and HbA1c data were collected at baseline (start of second-line therapy) and at 6, 12, 24 and 36 months. Treatment regimen changes over follow-up were analysed using the McNemar test, with carry-forward imputation for intermediate missing values.

RESULTS

A total of 11 592 participants had treatment data at baseline and 36 months, and 11 882 had HbA1c data at baseline. At baseline and 36 months, respectively, rates of oral monotherapy use were 12.1% and 12.4% (P = 0.22), rates of dual oral therapy use were 63.4% and 47.6% (P < 0.0001), rates of ≥ triple oral therapy use were 17.5% and 25.4% (P < 0.0001), and rates of injectable treatment use were 7.0% and 13.7% (P < 0.0001). Use of injectable drugs was most common among participants with an HbA1c level ≥64 mmol/mol (≥8.0%). Overall, 42.9% of participants changed treatment during follow-up. Mean HbA1c levels at baseline and 6 months were 67 mmol/mol (8.3%) and 55 mmol/mol (7.2%), respectively, remaining stable thereafter.

CONCLUSIONS

Dual oral therapy was the most common treatment regimen at the start of second-line treatment, and over half of the participants remained on the same treatment during follow-up.

Catastrophic pharmaceutical expenditure in patients with type 2 diabetes in Iran

OBJECTIVES

This study aimed to assess the financial burden of out-of-pocket (OOP) payments to purchase antidiabetic medicines for type 2 patients in Iran.

METHOD

The "budget share" and "capacity to pay" approaches were employed to assess the catastrophic pharmaceutical expenditures of antidiabetic medication therapies. The catastrophic thresholds were adjusted for pharmaceutical sectors. The data was 2019 monthly household expenditures in rural and urban areas, insurance coverages of antidiabetic medicines and patients' out-of-pocket (OOP) payments in 30-day treatment schedules.

RESULTS

The results show that expenditure on diabetes medication therapies in the form of mono-dual therapy and some cases triple oral therapies were not catastrophic even for rural households. Insulin puts patients at risk of catastrophic pharmaceutical expenditures when added to the treatment schedules, and lack of financial protection intensifies it. In general, the poorer households and those resistant to first-line treatments were at increased risk of catastrophic pharmaceutical expenditures. The number of treatments that put patients at risk of catastrophic pharmaceutical expenditure in "budget share" was higher than the "capacity to pay" approach.

CONCLUSIONS

Assessing medication treatment affordability instead of a single medicine assessment is needed. Assessment could be done by utilizing a macro-level data approach and applying adjusted pharmaceutical sector threshold values. Considering the variation between treatment schedules that put patients at risk of catastrophic pharmaceutical expenditures, targeted pharmaceutical policies and reimbursement decisions are recommended to promote Universal Health Coverage (UHC) and to protect vulnerable populations from hardship.

Sex-specific effects of maternal metformin intervention during glucose-intolerant obese pregnancy on body composition and metabolic health in aged mouse offspring

AIMS/HYPOTHESIS

Metformin is increasingly used to treat gestational diabetes (GDM) and pregnancies complicated by pregestational type 2 diabetes or polycystic ovary syndrome but data regarding long-term offspring outcome are lacking in both human studies and animal models. Using a mouse model, this study investigated the effects of maternal metformin intervention during obese glucose-intolerant pregnancy on adiposity, hepatic steatosis and markers of metabolic health of male and female offspring up to the age of 12 months.

METHODS

C57BL/6J female mice were weaned onto either a control diet (Con) or, to induce pre-conception obesity, an obesogenic diet (Ob). The respective diets were maintained throughout pregnancy and lactation. These obese dams were then randomised to the untreated group or to receive 300 mg/kg oral metformin hydrochloride treatment (Ob-Met) daily during pregnancy. In male and female offspring, body weights and body composition were measured from 1 month until 12 months of age, when serum and tissues were collected for investigation of adipocyte cellularity (histology), adipose tissue inflammation (histology and quantitative RT-PCR), and hepatic steatosis and fibrosis (histochemistry and modified Folch assay).

RESULTS

At 12 months of age, male Ob and Ob-Met offspring showed increased adiposity, adipocyte hypertrophy, elevated expression of proinflammatory genes, hyperleptinaemia and hepatic lipid accumulation compared with Con offspring. Male Ob-Met offspring failed to show hyperplasia between 8 weeks and 12 months, indicative of restricted adipose tissue expansion, resulting in increased immune cell infiltration and ectopic lipid deposition. Female Ob offspring were relatively protected from these phenotypes but Ob-Met female offspring showed increased adiposity, adipose tissue inflammation, hepatic lipid accumulation, hyperleptinaemia and hyperinsulinaemia compared with Con female offspring.

CONCLUSIONS/INTERPRETATION

Maternal metformin treatment of obese dams increased offspring metabolic risk factors in a sex- and age-dependent manner. These observations highlight the importance of following up offspring of both sexes beyond early adulthood after interventions during pregnancy. Our findings illustrate the complexity of balancing short-term benefits to mother and child vs any potential long-term metabolic effects on the offspring when prescribing therapeutic agents that cross the placenta.

The cost implications of a polypill for primary prevention in the TIPS-3 trial

AIMS

The International Polycap Study 3 (TIPS-3) trial demonstrated that a polypill containing cholesterol- and multiple blood-pressure-lowering drugs reduces cardiovascular events by 20% compared with placebo in people without cardiovascular disease. The polypill plus aspirin led to a 31% relative risk reduction in cardiovascular disease events compared with double placebo. We report regional variations in costs and affordability of a polypill based on the TIPS-3 trial.

METHODS AND RESULTS

Countries were categorized using World Bank economic groups: lower-middle-income, upper-middle-income, and high-income countries. Country-specific costs were obtained for hospitalization events, procedures, and non-study medications (2019 US dollars). Polypill price was based on the cheapest equivalent substitute (CES) for each component. For the polypill vs. placebo, the difference in cost over the 4.6 years of the trial was $291 [95% confidence interval (CI): $243-339] per participant in lower-middle-income countries, $1068 (95% CI: $992-1144) in upper-middle-income countries, and $48 (95% CI: -$271 to $367) in high-income countries. Results were similar for the polypill plus aspirin vs. a double placebo. In both cases, the polypill was affordable in all groups using monthly household capacity to pay or a threshold of 4% of the gross national income per capita.

CONCLUSION

The use of a polypill (CES) in TIPS-3 increases costs in lower-middle-income countries and upper-middle-income countries but is affordable in countries at various economic levels and is cost neutral (dominant) in high-income countries.

Current practice, attitude and views of providing pregnancy care for women with type 1 diabetes in China: a qualitative study

OBJECTIVE

Data are sparse on healthcare needs related to pregnancy among Chinese women with type 1 diabetes (T1D) or the gap between the needs and healthcare provision in China. We aimed to identify their needs and the gaps in pregnancy care provision.

DESIGN

This is a qualitative, face-to-face, one-to-one in-depth interview study. We recruited our participants using a purposive sampling strategy. Semistructural outlines were used to guide the interviews. The interviews were digitally recorded, transcribed and analysed using a thematic framework method with NVivo V.10.0.

SETTING

Guangdong Province in China.

PARTICIPANTS

This study involved three key stakeholders of pregnancy care for women with T1D: 29 women with T1D of childbearing age (aged 18-50 years), 16 family members (husbands, parents and parents-in-law of women with T1D) and 35 relevant healthcare providers (HCPs).

RESULTS

We found that women with T1D and the family members had a more pessimistic attitude towards pregnancy outcomes, which was different from the more positive view of HCPs. However, all three stakeholders shared the following perspectives regarding pregnancy-related care for women with T1D: (1) lack of knowledge and access to education, (2) lack of multidisciplinary cooperation, (3) education should be started earlier in adulthood, (3) positive role of peer support, and (4) hope for future training of HCPs for relevant knowledge and skills specified for T1D and pregnancy with T1D.

CONCLUSIONS

An immense gap was identified between the needs of women with T1D regarding pregnancy-related care and current care provision in China. These findings suggest that education be provided to patients and HCPs, and the role of professional and multidisciplinary support should be enhanced to optimise pregnancy care for women with T1D in China.

Association between the Diabetes Drug Cost and Cardiovascular Events and Death in Korea: A National Health Insurance Service Database Analysis

BACKGRUOUND

This study aimed to investigate the long-term effects of diabetes drug costs on cardiovascular (CV) events and death.

METHODS

This retrospective observational study used data from 2009 to 2018 from the National Health Insurance in Korea. Among the patients with type 2 diabetes, those taking antidiabetic drugs and who did not have CV events until 2009 were included. Patients were divided into quartiles (Q1 [lowest]-4 [highest]) according to the 2009 diabetes drug cost. In addition, the 10-year incidences of CV events (non-fatal myocardial infarction, stroke, hospitalization for heart failure, and coronary revascularization) and CV death (death due to CV events) were analyzed.

RESULTS

A total of 441,914 participants were enrolled (median age, 60 years; men, 57%). CV events and death occurred in 28.1% and 8.36% of the patients, respectively. The 10-year incidences of CV events and deaths increased from Q1 to 4. After adjusting for sex, age, income, type of diabetes drugs, comorbidities, and smoking and drinking status, the risk of CV events significantly increased according to the sequential order of the cost quartiles. In contrast, the risk of CV death showed a U-shaped pattern, which was the lowest in Q3 (hazard ratio [HR], 0.953; 95% confidence interval [CI], 0.913 to 0.995) and the highest in Q4 (HR, 1.266; 95% CI, 1.213 to 1.321).

CONCLUSION

Diabetes drug expenditure affects 10-year CV events and mortality. Therefore, affording an appropriate diabetes drug cost at a similar risk of CV is an independent protective factor against CV death.

Rural-Urban Differences in Diabetes Care and Control in 42 Low- and Middle-Income Countries: A Cross-sectional Study of Nationally Representative Individual-Level Data

OBJECTIVE

Diabetes prevalence is increasing rapidly in rural areas of low- and middle-income countries (LMICs), but there are limited data on the performance of health systems in delivering equitable and effective care to rural populations. We therefore assessed rural-urban differences in diabetes care and control in LMICs.

RESEARCH DESIGN AND METHODS

We pooled individual-level data from nationally representative health surveys in 42 countries. We used Poisson regression models to estimate age-adjusted differences in the proportion of individuals with diabetes in rural versus urban areas achieving performance measures for the diagnosis, treatment, and control of diabetes and associated cardiovascular risk factors. We examined differences across the pooled sample, by sex, and by country.

RESULTS

The pooled sample from 42 countries included 840,110 individuals (35,404 with diabetes). Compared with urban populations with diabetes, rural populations had ∼15-30% lower relative risk of achieving performance measures for diabetes diagnosis and treatment. Rural populations with diagnosed diabetes had a 14% (95% CI 5-22%) lower relative risk of glycemic control, 6% (95% CI -5 to 16%) lower relative risk of blood pressure control, and 23% (95% CI 2-39%) lower relative risk of cholesterol control. Rural women with diabetes had lower achievement of performance measures relating to control than urban women, whereas among men, differences were small.

CONCLUSIONS

Rural populations with diabetes experience substantial inequities in the achievement of diabetes performance measures in LMICs. Programs and policies aiming to strengthen global diabetes care must consider the unique challenges experienced by rural populations.

Strengthening Diabetes Care in Humanitarian Crises in Low- and Middle-income Settings

Amid the growing global diabetes epidemic, the scale of forced displacement resulting from armed conflict and humanitarian crises is at record-high levels. More than 80% of the displaced population lives in lower- and middle-income countries, which also host 81% of the global population living with diabetes. Most crises are protracted, often lasting decades, and humanitarian aid organizations are providing long-term primary care to both the local and displaced populations. Humanitarian crises are extremely varied in nature and occur in contexts that are diverse and dynamic. The scope of providing diabetes care varies depending on the phase of the crisis. This paper describes key challenges and possible solutions to improving diabetes care in crisis settings. It focuses on (1) ensuring a reliable supply of life preserving medications and diagnostics, (2) restoring and maintaining access to health care, and (3) adapting service design to the context. These challenges are illustrated through case studies in Ukraine, Mali, the Central African Republic, and Jordan.

Missed Opportunities for Screening and Management of Dysglycemia among Patients Presenting with Acute Myocardial Infarction in North India: The Prospective NORIN STEMI Registry

Background:

Dysglycemia is a major and increasingly prevalent cardiometabolic risk factor worldwide, but is often undiagnosed even in high-risk patients. We evaluated the impact of protocolized screening for dysglycemia on the prevalence of prediabetes and diabetes among patients presenting with ST-segment elevation myocardial infarction (STEMI) in North India.

Methods:

We conducted a prospective NORIN STEMI registry-based study of patients presenting with STEMI to two government-funded tertiary care medical centers in New Delhi, India, from January to November 2019. Hemoglobin A1c (HbA1c) was collected at presentation as part of the study protocol, irrespective of baseline glycemic status.

Results:

Among 3,523 participants (median age 55 years), 855 (24%) had known diabetes. In this group, baseline treatment with statins, sodium-glucose cotransporter 2 inhibitors, or glucagon-like peptide-1 receptor agonists was observed in 14%, <1%, and 1% of patients, respectively. For patients without known diabetes, protocolized inpatient screening identified 737 (28%) to have prediabetes (HbA1c 5.7–6.4%) and 339 (13%) to have newly detected diabetes (HbA1c ≥ 6.5%). Patients with prediabetes (49%), newly detected diabetes (53%), and established diabetes (48%) experienced higher rates of post-MI LV dysfunction as compared to euglycemic patients (42%). In-hospital mortality (5.6% for prediabetes, 5.1% for newly detected diabetes, 10.3% for established diabetes, 4.3% for euglycemia) and 30-day mortality (8.1%, 7.6%, 14.4%, 6.6%) were higher in patients with dysglycemia. Compared with euglycemia, prediabetes (adjusted odds ratio (aOR) 1.44 [1.12–1.85]), newly detected diabetes (aOR 1.57 [1.13–2.18]), and established diabetes (aOR 1.51 [1.19–1.94]) were independently associated with higher odds of composite 30-day all-cause mortality or readmission.

Conclusions:

Among patients presenting with STEMI in North India, protocolized HbA1c screening doubled the proportion of patients with known dysglycemia. Dysglycemia was associated with worse clinical outcomes at 30 days, and use of established pharmacotherapeutic risk-reduction strategies among patients with known diabetes was rare, highlighting missed opportunities for screening and management of dysglycemia among high-risk patients in North India.

The need for screening, early diagnosis, and prediction of chronic kidney disease in people with diabetes in low- and middle-income countries-a review of the current literature

Chronic kidney disease (CKD) in people with diabetes is becoming an increasing major public health concern, disproportionately burdening low- and middle-income countries (LMICs). This rising burden is due to various factors, including the lack of disease awareness that results in late referral and the cost of screening and consequent treatment of the comorbid conditions, as well as other factors endemic to LMICs relating to inadequate management of risk factors. We critically assessed the extant literature, by performing searches of Medline via PubMed, EBSCOhost, Scopus, and Web of Science, for studies pertaining to screening, diagnosis, and prediction of CKD amongst adults with diabetes in LMICs, using relevant key terms. The relevant studies were summarized through key themes derived from the Wilson and Jungner criteria. We found that screening for CKD in people with diabetes is generally infrequent in LMICs. Also, LMICs are ill-equipped to appropriately manage diabetes-associated CKD, especially its late stages, in which supportive care and kidney replacement therapy (KRT) might be required. There are acceptable and relatively simple tools that can aid diabetes-associated CKD screening in these countries; however, these tools come with limitations. Thus, effective implementation of diabetes-associated CKD screening in LMICs remains a challenge, and the cost-effectiveness of such an undertaking largely remains to be explored. In conclusion, for many compelling reasons, screening for CKD in people with diabetes should be a high policy priority in LMICs, as the huge cost associated with higher mortality and morbidity in this group and the cost of KRT offers a compelling economic incentive for improving early detection of diabetes in CKD.

Low- and middle-income countries demonstrate rapid growth of type 2 diabetes: an analysis based on Global Burden of Disease 1990-2019 data

AIMS/HYPOTHESIS

The study aims to quantify the global trend of the disease burden of type 2 diabetes caused by various risks factors by country income tiers.

METHODS

Data on type 2 diabetes, including mortality and disability-adjusted life years (DALYs) during 1990-2019, were obtained from the Global Burden of Disease Study 2019. We analysed mortality and DALY rates and the population attributable fraction (PAF) in various risk factors of type 2 diabetes by country income tiers.

RESULTS

Globally, the age-standardised death rate (ASDR) attributable to type 2 diabetes increased from 16.7 (15.7, 17.5)/100,000 person-years in 1990 to 18.5 (17.2, 19.7)/100,000 person-years in 2019. Similarly, age-standardised DALY rates increased from 628.3 (537.2, 730.9)/100,000 person-years to 801.5 (670.6, 954.4)/100,000 person-years during 1990-2019. Lower-middle-income countries reported the largest increase in the average annual growth of ASDR (1.3%) and an age-standardised DALY rate (1.6%) of type 2 diabetes. The key PAF attributing to type 2 diabetes deaths/DALYs was high BMI in countries of all income tiers. With the exception of BMI, while in low- and lower-middle-income countries, risk factors attributable to type 2 diabetes-related deaths and DALYs are mostly environment-related, the risk factors in high-income countries are mostly lifestyle-related.

CONCLUSIONS/INTERPRETATION

Type 2 diabetes disease burden increased globally, but low- and middle-income countries showed the highest growth rate. A high BMI level remained the key contributing factor in all income tiers, but environmental and lifestyle-related factors contributed differently across income tiers.

DATA AVAILABILITY

To download the data used in these analyses, please visit the Global Health Data Exchange at http://ghdx.healthdata.org/gbd-2019 .

Association of country economy and socioeconomic factors on risk factor control for primary prevention of cardiovascular disease in patients with diabetes mellitus: Insights from the DISCOVER Study

BACKGROUND

We sought to describe global patterns in achievement of risk factor control for primary prevention in patients with T2D and explore the association of country's GNI/capita with risk factor control.

METHODS

The DISCOVER study is a prospective, observational study of patients with T2D from 38 countries enrolled at initiation of second-line glucose-lowering therapy. We examined achievement of risk factor control (glycosylated hemoglobin <7%, blood pressure <140/90 mmHg, prescription of a statin) at 3 years among those without optimal control at baseline. Countries were stratified by gross national income (GNI)/capita, from 2017). We examined the impact of country GNI/capita with achievement of risk factor control.

FINDINGS

Our cohort included 9613 patients with T2D and without baseline cardiovascular disease (mean age 57.2 ± 8.7 years, 47.9% women). At baseline, 6354/7646 patients (83.1%) had suboptimal glucose control, 3449/9200 patients (37.5%) had suboptimal BP control, and 2800/4221 patients (66.7%) were not on an appropriate statin (sample sizes differed due to missing covariate data). Optimal control at 3 years of follow-up was achieved in 41% (glucose), 56% (blood pressure), and 29% (statins) of patients. There was significant variability in achievement of risk factor control across countries but no association between country GNI/capita with achievement of risk factor control (p>0.08 for all).

INTERPRETATION

In a global, prospective study of patients with T2D, we found that cardiovascular risk factor control achievement was suboptimal despite 3 years of follow-up in specialized health care systems. Neither country-level nor patient-level socioeconomic factors fully explained this finding.

2022 update to the position statement by Primary Care Diabetes Europe: a disease state approach to the pharmacological management of type 2 diabetes in primary care

Type 2 diabetes and its associated comorbidities are growing more prevalent, and the complexity of optimising glycaemic control is increasing, especially on the frontlines of patient care. In many countries, most patients with type 2 diabetes are managed in a primary care setting. However, primary healthcare professionals face the challenge of the growing plethora of available treatment options for managing hyperglycaemia, leading to difficultly in making treatment decisions and contributing to treatment and therapeutic inertia. This position statement offers a simple and patient-centred clinical decision-making model with practical treatment recommendations that can be widely implemented by primary care clinicians worldwide through shared-decision conversations with their patients. It highlights the importance of managing cardiovascular disease and elevated cardiovascular risk in people with type 2 diabetes and aims to provide innovative risk stratification and treatment strategies that connect patients with the most effective care.

Continuous glucose monitoring demonstrates low risk of clinically significant hypoglycemia associated with sulphonylurea treatment in an African type 2 diabetes population: results from the OPTIMAL observational multicenter study

INTRODUCTION

People living with diabetes in low-resource settings may be at increased hypoglycemia risk due to food insecurity and limited access to glucose monitoring. We aimed to assess hypoglycemia risk associated with sulphonylurea (SU) and insulin therapy in people living with type 2 diabetes in a low-resource sub-Saharan African setting.

RESEARCH DESIGN AND METHODS

This study was conducted in the outpatients' diabetes clinics of two hospitals (one rural and one urban) in Uganda. We used blinded continuous glucose monitoring (CGM) and self-report to compare hypoglycemia rates and duration in 179 type 2 diabetes patients treated with sulphonylureas (n=100) and insulin (n=51) in comparison with those treated with metformin only (n=28). CGM-assessed hypoglycemia was defined as minutes per week below 3mmol/L (54mg/dL) and number of hypoglycemic events below 3.0 mmol/L (54 mg/dL) for at least 15 minutes.

RESULTS

CGM recorded hypoglycemia was infrequent in SU-treated participants and did not differ from metformin: median minutes/week of glucose <3 mmol/L were 39.2, 17.0 and 127.5 for metformin, sulphonylurea and insulin, respectively (metformin vs sulphonylurea, p=0.6). Hypoglycemia risk was strongly related to glycated haemoglobin (HbA1c) and fasting glucose, with most episodes occurring in those with tight glycemic control. After adjusting for HbA1c, time <3 mmol/L was 2.1 (95% CI 0.9 to 4.7) and 5.5 (95% CI 2.4 to 12.6) times greater with sulphonylurea and insulin, respectively, than metformin alone.

CONCLUSIONS

In a low-resource sub-Saharan African setting, hypoglycemia is infrequent among people with type 2 diabetes receiving sulphonylurea treatment, and the modest excess occurs predominantly in those with tight glycemic control.

Access to Insulin Products in Pakistan: A National Scale Cross-Sectional Survey on Prices, Availability, and Affordability

Background: Diabetes is among the top ten most prevalent diseases in Pakistan, and the availability of medicines to treat the disease is vital for a great percentage of the country’s population. Insulin was discovered a century ago; however, its access in several parts of the globe remains an issue. This study aims to evaluate prices, availability, and affordability (access components) of insulin and five comparator medicine access in Pakistan.

Methods: A nationwide cross-sectional survey was conducted to evaluate the access to insulin and some comparator medicines in eight cities of Pakistan, using a modified WHO/HAI methodology. The survey included 80 medicine outlets, i.e., 40 private pharmacies and 40 public hospitals. Data for every unique insulin product available in the Pakistani market were obtained, including five comparator medicines. Percentage availability, median unit prices (MUPs), and affordability (the number of days’ wages (NDWs) required for a month’s course by the lowest-paid unskilled government worker) of all products were calculated, including originator brands (OBs) and biosimilar (BS) products.

Results: Of all insulin products surveyed (n = 320), 87.5% were manufactured by foreign multinational companies (MNCs). None of the insulin products had an ideal availability of 80% in any of the surveyed health facilities. In the public sector, none of the insulin products had an availability of more than 50%. In the public sector, the overall availability of human insulin was 70% (including OB and BS). While in the private sector, the overall availability of human insulin was 90% and that of analog insulin was 62.5%. The analog insulin products were 72.8% costlier than the human insulin products. The median prices of BS insulin were 25.4% lower than the OB products, indicating that almost one-fourth of the cost could be saved by switching to BS human insulin from OB human insulin. All oral anti-diabetic medicines were found to be affordable, whereas none of the insulin was affordable. The NDWs for human and analog insulin were 1.38 and 5.06.

Conclusion: In Pakistan, the insulin availability falls short of the WHO’s benchmark of 80%. Insulin continues to be unaffordable in both private and government sectors. To increase insulin access, the government should optimize insulin procurement at all levels, promote local production, enforce biosimilar prescribing, and provide financial subsidies for these products.

The availability of essential medicines for diabetes at health facilities in Bangladesh: evidence from 2014 and 2017 national surveys

BACKGROUND

Bangladesh ranks among the world's top ten countries in the number of diabetic patients. The prevention of this disease requires treating patients with essential medicines, and the first crucial step in the uptake of these medicines is availability. We aimed to assess the availability of essential medicines for diabetes (EM-Diabetes) and to explore health facility characteristics associated with the availability of those medicines.

METHODS

We performed the analysis using nationally representative data from the two waves of the cross-sectional Bangladesh Health Facility Survey (BHFS) in 2014 and 2017. Data are available for 1548 and 1524 health facilities in the 2014 and 2017 BHFS. Study samples of this study were 217 facilities (73 from 2014 and 144 from 2017) that offer diabetes diagnosis and treatment services. The outcome variable 'EM-Diabetes availability' was calculated as a counting score of the tracer medicines: metformin, glibenclamide, injectable insulin, and injectable glucose solution. A multivariable Poisson regression model was used to identify the health facility characteristics (such as, managing authority, location, external supervision, regular quality assurance activities, national guidelines for diagnosis and management of diabetes, etc.) associated with EM-Diabetes availability.

RESULTS

Since 2014, there have been minimal increases in Bangladeshi health facilities that provide diabetes screening and treatment services (from 4.7% to 9.4%). Among facilities offering diabetes services, 64.5% (BHFS 2014) and 55.7% (BHFS 2017) facilities had no EM-Diabetes on-site at all. Between 2014 and 2017, the availability of metformin increased (from 27.5% to 40.1%), but there was a decrease in the availability of glibenclamide (from 16.5% to 9.1%), injectable insulin (from 20.4% to 11.4%), and injectable glucose solution (from 20.4% to 19.2%). Furthermore, publicly owned facilities [relative risk (RR) = 0.44, 95% confidence interval (CI): 0.25-0.78 for 2014 and RR= 0.54, 95% CI: 0.41-0.71 for 2017] and facilities in rural settings [RR= 0.26, 95% CI: 0.12-0.55 for 2014 and RR= 0.60, 95% CI: 0.44-0.81 for 2017] were significantly associated with decreased availability of EM-Diabetes in both survey years. Moreover, routine user fees [RR=3.70, 95% CI: 1.86-7.38] and regular quality assurance activities [RR= 1.62, 95% CI: 1.12-2.34] were also significantly associated with increased EM-Diabetes availability in 2017 only.

CONCLUSIONS

Overall, the health facilities in Bangladesh had insufficient essential medicines for treating diabetes. In general, the availability of EM-Diabetes declined from 2014 to 2017, except for metformin. Policymakers should consider a wide range of policy implications, focusing on the management of public facilities, rural facilities, routine user fees, and quality assurance activities to improve the availability of EM-Diabetes at health facilities in Bangladesh.

Short-term effectiveness of nutrition therapy to treat type 2 diabetes in low-income and middle-income countries: systematic review and meta-analysis of randomised controlled trials

OBJECTIVES

This review examined the evidence arising from randomised controlled trials regarding the impact of nutrition therapy on glycaemic control in people living with type 2 diabetes mellitus (T2DM) in low/middle-income countries (LMICs).

DESIGN

Systematic review and meta-analysis using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) Approach.

DATA SOURCES

MEDLINE, EMBASE, Web of Science, OpenGrey and the International Clinical Trials Registry were searched (up to July 3 2020).

ELIGIBILITY CRITERIA

Trials were included if they evaluated nutrition therapy in adults diagnosed with T2DM, were conducted in LMICs, measured glycaemic control and the trial included a 3-month post-intervention assessment. Nutrition therapy was defined according to American Diabetes Association recommendations.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers screened the database. Study characteristics and outcome data were extracted using a data collection form. Meta-analyses were conducted for glycated haemoglobin (HbA1c) and fasting blood glucose. Trials were assessed for risk of bias (Cochrane Risk-of-Bias, Version 2.0) and overall certainty of evidence (GRADE).

RESULTS

Four trials met inclusion criteria (total n=463), conducted in Malaysia, Iran and South Africa. All trials focused on nutrition education with no direct prescription or manipulation of diet. Mean differences between intervention and standard care were -0.63% (95% CI -1.47% to 0.21%) for HbA1c and -13.63 mg/dL (95% CI -37.61 to 10.34) for fasting blood glucose in favour of the intervention. Given the small number of eligible trials, moderate to high risk of publication bias and serious concerns regarding consistency and precision of the evidence, certainty of evidence was deemed to be very low.

CONCLUSIONS

There is a lack of well-conducted randomised controlled trials that examine the long-term impact of nutrition therapy in LMICs, preventing firm conclusions to be made on their effectiveness. Further research is essential to discover realistic, evidence-based solutions.

PROSPERO REGISTRATION NUMBER

CRD42020188435.