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Hussin SA, Mohamad NA, Othman MK, Wan Mohamed WMI. Evaluating the Impact of Intensifying Treatment from Human to Analogue Insulin on Glycaemic Control and Insulin Expenditure in Patients with Type 2 Diabetes: A Retrospective Cohort Study. Malays J Med Sci 2024; 31:159-169. [PMID: 38694591 PMCID: PMC11057824 DOI: 10.21315/mjms2024.31.2.14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 08/28/2023] [Indexed: 05/04/2024] Open
Abstract
Background Achieving good glycaemic control is essential to reducing the risk of diabetes complications. Insulin is the most effective therapy for achieving good glycaemic control; however, it is associated with a higher risk of hypoglycaemia, especially with human insulin. This study aimed to evaluate the efficacy of intensification from human to analogue insulin and its added cost. Methods This retrospective study was conducted at the Hospital Universiti Sains Malaysia (HUSM). Patients with type 2 diabetes mellitus (T2DM) who underwent intensification for at least 3 months from human to analogue insulin were included in this study. The patients' medical records, haemoglobin A1c (Hba1c) and fasting blood sugar (FBS) were retrieved. The total cost pre- and post-intensification of insulin was obtained from the pharmacy database. Differences in HbA1c, FBS and total insulin cost pre- and post-intensification were analysed. Results A total of 163 patients with T2DM who had intensification from human to analogue insulin were included in this study. HbA1c and FBS levels were significantly lower in analogue insulin. However, the differences were not clinically significant, as the mean reduction in HbA1c was less than 0.5%. Meanwhile, the total costs of analogue insulin for 3 months were higher. Conclusion There were no clinically significant improvements in patients' HbA1c and FBS after the intensification of insulin, despite the extra costs spent. Hence, it is vital to choose the right group of patients to receive an insulin analogue to maximise its benefit but at the most optimal cost.
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Affiliation(s)
- Siti Aisyah Hussin
- Department of Internal Medicine, School of Medical Sciences, Universiti Sains Malaysia, Kelantan, Malaysia
| | - Nur Aimi Mohamad
- Department of Pharmacy, Hospital Universiti Sains Malaysia, Kelantan, Malaysia
| | - Mohd Khairi Othman
- Department of Internal Medicine, School of Medical Sciences, Universiti Sains Malaysia, Kelantan, Malaysia
| | - Wan Mohd Izani Wan Mohamed
- Department of Internal Medicine, School of Medical Sciences, Universiti Sains Malaysia, Kelantan, Malaysia
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Toyoshima MTK, Brandes PHR, da Paz Lauterbach G, Moraes JRA, de Paiva EF, Umpierrez GE, Nery M, Kondo RH. InsulinAPP application protocol for the inpatient management of type 2 diabetes on a hospitalist-managed ward: a retrospective study. ARCHIVES OF ENDOCRINOLOGY AND METABOLISM 2022; 66:498-505. [PMID: 35758838 PMCID: PMC10697650 DOI: 10.20945/2359-3997000000496] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 04/09/2022] [Indexed: 06/15/2023]
Abstract
Introduction We assessed metrics related to inpatient glycemic control using InsulinAPP, an application available for free in Brazil, on the hospitalist-managed ward of our hospital. Subjects and methods We performed a retrospective study of patients with type 2 diabetes (T2D) admitted from November 2018 to October 2019. InsulinAPP recommends NPH and regular insulins three times a day, in bolus-correction or basal-bolus schemes. Parameters that included BG within range of 70-180 mg/dL, insulin treatment regimen and frequency of hypoglycemia were evaluated. Results A total of 147 T2D individuals (23% medicine and 77% surgery) were included (mean age 62.3 ± 12.7 years, HbA1c: 8.3 ± 3.0%). The initial insulin regimen was 50% bolus-correction, 47% basal-bolus and 3% with sliding scale insulin. During hospitalization, 71% patients required a bolus-basal regimen. In the first 10 days of the protocol, 71% BG measurements were between 70-180 mg/dL and 26% patients experienced one or more episodes of hypoglycemia < 70 mg/dL, and 5% with BG < 54 mg/dL. Conclusion The results of this retrospective study indicate the InsulinAPP application using human insulin formulations was effective and safe for the management of hyperglycemia on a hospitalist-managed ward, with more than 70% BG measurements within the therapeutic range and a low rate of hypoglycemia.
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Affiliation(s)
- Marcos Tadashi Kakitani Toyoshima
- Serviço de Onco-endocrinologia, Instituto do Câncer do Estado de São Paulo Octávio Frias de Oliveira, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil,
- Serviço de Endocrinologia e Metabologia, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
- Serviço de Medicina Hospitalar, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
| | - Pedro Henrique Ribeiro Brandes
- Serviço de Medicina Hospitalar, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
| | - Gerhard da Paz Lauterbach
- Serviço de Medicina Hospitalar, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
| | - Jéssica Ribeiro Andrade Moraes
- Serviço de Endocrinologia e Metabologia, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
- Serviço de Medicina Hospitalar, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
| | - Edison Ferreira de Paiva
- Serviço de Medicina Hospitalar, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
| | - Guillermo E Umpierrez
- Department of Medicine, Division of Endocrinology at Emory University, Atlanta, GA, USA
| | - Marcia Nery
- Serviço de Endocrinologia e Metabologia, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
| | - Rodrigo Hidd Kondo
- Serviço de Medicina Hospitalar, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
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Dogui S, Htira Y, Jemai C, Aloui K, Sfar Gandoura A, Echater W, Ben Mami F. Audit of glycemic control of diabetic patients on insulin analogues: about 2915 insured persons of the CNAM (Tunisia). LA TUNISIE MEDICALE 2022; 100:438-444. [PMID: 36206062 PMCID: PMC9585688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Insulin analogues are increasingly prescribed in Tunisia. These molecules, covered by the National Health Insurance Fund (CNAM) in Tunisia under certain conditions, have an important and constantly increasing cost. AIM To audit the diabetes control among insured in the Northern district of the CNAM (Tunisia), treated with insulin analogues in 2019 and to assess factors associated with good glycemic control. METHODS Retrospective observational study including patients with diabetes who applied for renewal of insulin analogues between March and April 2019 in the northern district of the CNAM. RESULTS Our study included 2915 diabetic insured. The sex ratio was 1.08. The mean age was 56.5 ±18.56 years. More than half of the diabetic insured were followed by a specialist physician (44% by endocrinologists, 7% by internists, 6% by nutritionists and 4% by other specialists). The average duration of treatment with insulin analogues was 5 years ± 1.41. Almost three quarters (74%) of the diabetic insured were type 2 diabetics. The mean daily dose of rapid-acting, short-acting and premixed insulin analogues were 30±15.49 IU/d, 38±18.36 IU/d and 65±19.38 IU/d respectively. HbA1c targets were achieved in 8% of the diabetic insured. In univariate analysis, the variables significantly associated with diabetes balance were follow-up by a physician specializing in endocrinology (OR=3.14, 95% CI [0.98-10.08]), internal medicine (OR=5.06, 95% CI [1.49-17.21]) or nutrition (OR=2.06, 95% CI [0.54-7.77]), type 1 diabetes (OR=1.67, 95% CI [1.26-2.22]) and basal insulin therapy regimen (OR=1.88, 95% CI [1.39-2.54]). In multivariate analysis, the independent and significant factors associated with glycemic control were type 1 diabetes (ORa=1.81, 95% CI [1.37-2.39]) and basal insulin therapy regimen (ORa= 1.77, 95% CI [1.30-2.40]). CONCLUSION This study showed that the majority of diabetic insured on insulin analogues had a poor controlled diabetes. Type 1 diabetes and basal insulin therapy regimen were the two factors associated with good glycemic control after multivariate analysis. A review of criteria for reimbursement of insulin analogues by the National Health Insurance Fund is necessary in order to rationalize the expenses related to these molecules.
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Affiliation(s)
| | - Yosra Htira
- 2. Service C, Institut National de Nutrition et de Technologies Alimentaires / Faculté de Médecine de Tunis
| | - Chaima Jemai
- 2. Service C, Institut National de Nutrition et de Technologies Alimentaires / Faculté de Médecine de Tunis
| | | | | | | | - Faika Ben Mami
- 2. Service C, Institut National de Nutrition et de Technologies Alimentaires / Faculté de Médecine de Tunis
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Dorati CM, Mordujovich Buschiazzo P, Marín GH, Buschiazzo HO, Rojas-Cortés R, Alfonso Arvez MJ, Cardozo JM, Marin D, Hernández de Hernández GI, Maldonado NL, Piva HM, Rego J, Dussault S, Velandia LP, Porrás A, Castro JL. [Indicators of rational prescription of medicines: feasibility of application in institutions in the AmericasIndicadores de prescrição racional de medicamentos: viabilidade de aplicação em instituições das Américas]. Rev Panam Salud Publica 2021; 45:e152. [PMID: 34987559 PMCID: PMC8699123 DOI: 10.26633/rpsp.2021.152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 09/20/2021] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Evaluate the feasibility of monitoring the quality of use of medicines in health institutions in countries of the Region of the Americas by means of rational prescription indicators. METHODOLOGY A quantitative study of the use of medicines was conducted during the period 2016-2018. Rational prescription indicators were developed and selected in accordance with international reference values and the best available evidence for: 1) anti-inflammatory drugs: prescription of ibuprofen and/or naproxen as a percentage of all prescribed non-steroidal anti-inflammatory drugs; 2) oral antidiabetics: metformin as a percentage of all prescribed antidiabetics, and metformin and/or sulfonylureas as a percentage of all prescribed antidiabetics; 3) insulins: crystalline insulin and NPH as a percentage of total prescribed insulins; and 4) antihypertensive drugs: angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor blockers (ARBs-II), and thiazide diuretics as a percentage of all prescribed antihypertensives. The defined daily dose (DDD) per 1 000 inhabitants was used as a measure of consumption per institution. RESULTS Prescription of metformin as a percentage of all antidiabetics was lower than the value of the reference indicator (27.9%-67.6% vs. 88%), while the prescription of metformin and/or a sulfonylurea was comparable with that value (80.9%-97.5% vs. 88%). The values of NPH, crystalline, and NPH/crystalline insulin in relation to all prescribed insulins were variable with respect to the reference indicator (37.1%-100% vs. 75%). Prescription of ibuprofen and naproxen was below the value of the indicator (20%-50% vs. 80%). The percentage of ACE inhibitors, ARBs, and thiazides with respect to all antihypertensives ranged from 65.2%-77.2% to 65%, consistent with the value of the proposed indicator. CONCLUSIONS The feasibility of applying the selected and constructed indicators of rational prescription was demonstrated. These indicators provide useful information for analyzing the quality of prescription in health institutions in countries in the Region and are a useful tool for periodically monitoring it.
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Affiliation(s)
- Cristian Matías Dorati
- Centro Universitario de Farmacología (CUFAR).Universidad Nacional de La PlataLa PlataArgentinaCentro Universitario de Farmacología (CUFAR). Universidad Nacional de La Plata, La Plata, Argentina.
| | - Perla Mordujovich Buschiazzo
- Centro Universitario de Farmacología (CUFAR).Universidad Nacional de La PlataLa PlataArgentinaCentro Universitario de Farmacología (CUFAR). Universidad Nacional de La Plata, La Plata, Argentina.
| | - Gustavo H. Marín
- Centro Universitario de Farmacología (CUFAR).Universidad Nacional de La PlataLa PlataArgentinaCentro Universitario de Farmacología (CUFAR). Universidad Nacional de La Plata, La Plata, Argentina.
| | - Héctor O. Buschiazzo
- Centro Universitario de Farmacología (CUFAR).Universidad Nacional de La PlataLa PlataArgentinaCentro Universitario de Farmacología (CUFAR). Universidad Nacional de La Plata, La Plata, Argentina.
| | - Robin Rojas-Cortés
- Organización Panamericana de la SaludWashington DCEstados Unidos de AméricaOrganización Panamericana de la Salud, Washington DC, Estados Unidos de América.
| | - María José Alfonso Arvez
- Dirección Nacional de Vigilancia SanitariaAsunciónParaguayDirección Nacional de Vigilancia Sanitaria, Asunción, Paraguay.
| | - José M. Cardozo
- Dirección Nacional de Vigilancia SanitariaAsunciónParaguayDirección Nacional de Vigilancia Sanitaria, Asunción, Paraguay.
| | - Danini Marin
- Ministerio de SaludBelmopánBeliceMinisterio de Salud, Belmopán, Belice.
| | - Gilda I. Hernández de Hernández
- Instituto Salvadoreño del Seguro SocialSan SalvadorEl SalvadorInstituto Salvadoreño del Seguro Social, San Salvador, El Salvador.
| | - Noemi Lugo Maldonado
- Secretaría de SaludCiudad de MéxicoMéxicoSecretaría de Salud, Ciudad de México, México.
| | - Hugo Marín Piva
- Caja Costarricense de Seguro SocialSan JoséCosta RicaCaja Costarricense de Seguro Social, San José, Costa Rica.
| | - José Rego
- Hospital Docente Dr. Salvador AllendeLa HabanaCubaHospital Docente Dr. Salvador Allende, La Habana, Cuba.
| | | | | | - Analía Porrás
- Organización Panamericana de la SaludWashington DCEstados Unidos de AméricaOrganización Panamericana de la Salud, Washington DC, Estados Unidos de América.
| | - José Luis Castro
- Organización Panamericana de la SaludWashington DCEstados Unidos de AméricaOrganización Panamericana de la Salud, Washington DC, Estados Unidos de América.
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Andrade TUD, Moreira FS, Cassaro KODS, Cruz MM, Brasil GA, Lima EMD, Lenz D, Endringer DC. Long-acting insulin in a public health system: analysis of compliance with clinical protocol in public pharmacies. CIENCIA & SAUDE COLETIVA 2021; 26:2301-2310. [PMID: 34231740 DOI: 10.1590/1413-81232021266.06592019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2019] [Accepted: 08/09/2019] [Indexed: 11/21/2022] Open
Abstract
Diabetes mellitus (DM) is a chronic disease marked by elevated blood glucose levels. Controlling DM involves adequate diet, physical exercises, medicines and monitoring the blood glucose and glycated hemoglobin (HbA1c) levels. This was a retrospective study of the process of dispensing long-acting insulin analogues to users with diabetes (types 1 and 2) who were registered at high-cost public pharmacies in public health system in a southeast state of Brazil, that sought to evaluate the fulfillment of the criteria of all the clinical protocol to provide these analogs. Of the 987 users registered in the health service, 315 met the inclusion criteria for the study. The evaluation of the dispensing processes of the long-acting insulin analogues revealed that the inclusion, exclusion, and suspension criteria of the protocol related with these insulin analogues were in some extend only partially fulfilled. Additionally, there was no difference between the initial and final fasting glycemic and HbA1c levels. It is concluded that the established criteria for dispensing long-acting insulin analogues were partly fulfilled by pharmacies, compromising the rational use of these analogues. It can directly impact the cost of maintaining the public health service and users' health.
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Affiliation(s)
- Tadeu Uggere de Andrade
- Departamento de Ciências Farmacêuticas, Universidade Vila Velha. Rua Comissário José Dantas de Melo 21, Boa Vista. 29102-770 Vila Velha ES Brasil.
| | - Fabrício Soares Moreira
- Departamento de Ciências Farmacêuticas, Universidade Vila Velha. Rua Comissário José Dantas de Melo 21, Boa Vista. 29102-770 Vila Velha ES Brasil.
| | - Karla Oliveira Dos Santos Cassaro
- Departamento de Ciências Farmacêuticas, Universidade Vila Velha. Rua Comissário José Dantas de Melo 21, Boa Vista. 29102-770 Vila Velha ES Brasil.
| | - Manuela Martins Cruz
- Departamento de Ciências Farmacêuticas, Universidade Vila Velha. Rua Comissário José Dantas de Melo 21, Boa Vista. 29102-770 Vila Velha ES Brasil.
| | - Girlandia Alexandre Brasil
- Departamento de Ciências Farmacêuticas, Universidade Vila Velha. Rua Comissário José Dantas de Melo 21, Boa Vista. 29102-770 Vila Velha ES Brasil.
| | - Ewelyne Miranda de Lima
- Departamento de Ciências Farmacêuticas, Universidade Vila Velha. Rua Comissário José Dantas de Melo 21, Boa Vista. 29102-770 Vila Velha ES Brasil.
| | - Dominik Lenz
- Departamento de Ciências Farmacêuticas, Universidade Vila Velha. Rua Comissário José Dantas de Melo 21, Boa Vista. 29102-770 Vila Velha ES Brasil.
| | - Denise Coutinho Endringer
- Departamento de Ciências Farmacêuticas, Universidade Vila Velha. Rua Comissário José Dantas de Melo 21, Boa Vista. 29102-770 Vila Velha ES Brasil.
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Evans M, Morgan AR, Bain SC. One Hundred Years of Insulin: Value Beyond Price in Type 2 Diabetes Mellitus. Diabetes Ther 2021; 12:1593-1604. [PMID: 33899150 PMCID: PMC8071610 DOI: 10.1007/s13300-021-01061-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 04/12/2021] [Indexed: 11/02/2022] Open
Abstract
Type 2 diabetes mellitus is a chronic, progressive disease that frequently necessitates treatment with basal insulin to maintain adequate glycaemic control. In considering the value of different basal insulin therapies, although acquisition costs are of increasing importance to budget-constrained healthcare systems, value beyond simple price considerations should be taken into account. Whilst human basal insulins are of lower acquisition cost compared to long-acting insulin analogues, this difference in price has the potential to be offset in terms of total healthcare system value through the ultra-long duration of action and low variability in glucose-lowering activity which have been translated into real clinical benefits, in particular a reduced risk of hypoglycaemic events. The maintenance of glycaemic targets and avoidance of hypoglycaemia that have been associated with insulin analogues represent a significant value consideration, beyond price, for the use of basal insulin analogues to manage type 2 diabetes mellitus from the perspective of all stakeholders within the healthcare system, including payers, healthcare professionals, patients and society.
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Affiliation(s)
- Marc Evans
- Diabetes Resource Centre, University Hospital Llandough, Cardiff, UK.
| | | | - Stephen C Bain
- Diabetes Research Unit, Swansea University Medical School, Swansea, UK
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Cromer SJ, Wexler DJ, Kazemian P. Correlates of analog vs human basal insulin use among individuals with type 2 diabetes: A cross-sectional study. Diabetes Res Clin Pract 2021; 175:108825. [PMID: 33887352 PMCID: PMC8217374 DOI: 10.1016/j.diabres.2021.108825] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 02/24/2021] [Accepted: 04/15/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND Given the shift from use of less expensive human to costlier analog insulins for treatment of type 2 diabetes (T2D), we examine characteristics and glycemic control associated with type of basal insulin use. METHODS We analyzed respondents with T2D in six consecutive National Health and Nutrition Examination Survey (NHANES) cycles (2005-2016). Logistic regression models examined associations between demographics, socioeconomic factors, and NHANES cycle with (1) type of basal insulin use and (2) hemoglobin A1c <8.0% and <7.0% according to basal insulin type. FINDINGS Basal insulin use increased from 9.6% to 17.2% of respondents with T2D between 2005 and 2016. Among 723 respondents meeting inclusion criteria, the proportion using analog basal insulin rose from 58% to 88%. African American (aOR 0.42, 95% CI 0.24-0.74) and Hispanic (aOR 0.54, 95% CI 0.30-0.96) respondents had lower odds of analog basal insulin use than non-Hispanic White respondents in adjusted and unadjusted models. Older age and having health insurance, but not type of basal insulin use, associated with meeting HbA1c targets. INTERPRETATION Non-White NHANES respondents were less likely to use analog basal insulin than White respondents. Increased analog basal insulin use between 2005 and 2016 was not associated with improved glycemic control.
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Affiliation(s)
- Sara J Cromer
- Massachusetts General Hospital, Boston, MA 02114, United States; Harvard Medical School, Boston, MA 02115, United States.
| | - Deborah J Wexler
- Massachusetts General Hospital, Boston, MA 02114, United States; Harvard Medical School, Boston, MA 02115, United States.
| | - Pooyan Kazemian
- Case Western Reserve University, Cleveland, OH 44106, United States.
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Almeida PHRF, Godman B, de Lemos LLP, Silva TBC, De Assis Acúrcio F, Guerra‑Junior AA, De Araújo VE, Almeida AM, Alvares-Teodoro J. A cross-sectional study of the quality of life of patients living with type 1 diabetes treated with insulin glargine and neutral protamine Hagedorn insulin and the implications. JOURNAL OF PHARMACEUTICAL HEALTH SERVICES RESEARCH 2021. [DOI: 10.1093/jphsr/rmab021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Abstract
Objectives
The study aim was to identify key factors associated with the health-related quality of life (HRQOL) of patients with type 1 diabetes mellitus (T1DM) treated with neutral protamine Hagedorn (NPH) insulin or human insulin analog glargine (IGLA).
Methods
We conducted two cross-sectional studies in Minas Gerais State, Brazil. One with 401 patients treated with IGLA, and the other with 179 T1DM patients treated with NPH. HRQOL was measured by Euroqol (EQ-5D-3L).
Key findings
Most participants were male (51%), aged between 18 and 40 years (47%), non-black (58%) and from the highest economic strata (A1-B2) (74%). Participants perceived their health as good/very good (51%), had one to three medical consultations in the previous year (51%), were not hospitalized in the previous year (74%), did not report angina (96%), diabetic neuropathy (90%), hearing loss (94%) or kidney disease (89%). Non-severe hypoglycaemia episodes in the last 30 days were reported by 17% of participants.
Conclusions
Higher HRQOL was associated with younger age (18–40 years), good/very good health self-perception, having had up to three medical consultations in the last year, not being hospitalized in the last year, having none to three comorbidities, not reporting angina, diabetic neuropathy, hearing loss or kidney disease and having had episodes of non-severe hypoglycaemia. In addition, the findings of our study demonstrated inequalities in access to treatment, which will be the subject of future research projects.
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Affiliation(s)
- Paulo H R F Almeida
- Graduate Program in Medicines and Pharmaceutical Services, Department of Social Pharmacy, Faculty of Pharmacy, Federal University of Minas Gerais (UFMG), Belo Horizonte, Minas Gerais, Brazil
| | - Brian Godman
- Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow, UK
- Division of Public Health Pharmacy and Management, School of Pharmacy, Sefako Makgatho Health Sciences University, Pretoria, South Africa
- Division of Clinical Pharmacology, Department of Laboratory Medicine, Karolinska Institutet, Karolinska University Hospital Huddinge, Stockholm, Sweden
- School of Pharmaceutical Sciences, Universiti Sains Malaysia, Penang, Malaysia
| | - Lívia L P de Lemos
- Graduate Program in Public Health, Faculty of Medicine, Department of Preventive and Social Medicine, Federal University of Minas Gerais (UFMG), Belo Horizonte, Minas Gerais, Brazil
| | - Thales B C Silva
- Graduate Program in Medicines and Pharmaceutical Services, Department of Social Pharmacy, Faculty of Pharmacy, Federal University of Minas Gerais (UFMG), Belo Horizonte, Minas Gerais, Brazil
| | - Francisco De Assis Acúrcio
- Graduate Program in Medicines and Pharmaceutical Services, Department of Social Pharmacy, Faculty of Pharmacy, Federal University of Minas Gerais (UFMG), Belo Horizonte, Minas Gerais, Brazil
- Graduate Program in Public Health, Faculty of Medicine, Department of Preventive and Social Medicine, Federal University of Minas Gerais (UFMG), Belo Horizonte, Minas Gerais, Brazil
- SUS Collaborating Centre for Technology Assessment and Excellence in Health (CCATES), Belo Horizonte, Brazil
| | - Augusto Afonso Guerra‑Junior
- Graduate Program in Medicines and Pharmaceutical Services, Department of Social Pharmacy, Faculty of Pharmacy, Federal University of Minas Gerais (UFMG), Belo Horizonte, Minas Gerais, Brazil
- SUS Collaborating Centre for Technology Assessment and Excellence in Health (CCATES), Belo Horizonte, Brazil
| | - Vânia E De Araújo
- Graduate Program in Medicines and Pharmaceutical Services, Department of Social Pharmacy, Faculty of Pharmacy, Federal University of Minas Gerais (UFMG), Belo Horizonte, Minas Gerais, Brazil
- SUS Collaborating Centre for Technology Assessment and Excellence in Health (CCATES), Belo Horizonte, Brazil
- Department of Dentistry, Pontifical Catholic University of Minas Gerais (PUCMG), Belo Horizonte, Brazil
| | - Alessandra M Almeida
- Graduate Program in Medicines and Pharmaceutical Services, Department of Social Pharmacy, Faculty of Pharmacy, Federal University of Minas Gerais (UFMG), Belo Horizonte, Minas Gerais, Brazil
- SUS Collaborating Centre for Technology Assessment and Excellence in Health (CCATES), Belo Horizonte, Brazil
| | - Juliana Alvares-Teodoro
- Graduate Program in Medicines and Pharmaceutical Services, Department of Social Pharmacy, Faculty of Pharmacy, Federal University of Minas Gerais (UFMG), Belo Horizonte, Minas Gerais, Brazil
- SUS Collaborating Centre for Technology Assessment and Excellence in Health (CCATES), Belo Horizonte, Brazil
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9
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Godman B, Basu D, Pillay Y, Almeida PHRF, Mwita JC, Rwegerera GM, Anand Paramadhas BD, Tiroyakgosi C, Patrick O, Niba LL, Sefah I, Oluka M, Guantai AN, Kibuule D, Kalemeera F, Mubita M, Fadare J, Ogunleye OO, Rampamba EM, Wing J, Mueller D, Alfadl A, Amu AA, Matsebula Z, Kalungia AC, Zaranyika T, Masuka N, Wale J, Hill R, Kurdi A, Timoney A, Campbell S, Meyer JC. Ongoing and planned activities to improve the management of patients with Type 1 diabetes across Africa; implications for the future. Hosp Pract (1995) 2020; 48:51-67. [PMID: 32196395 DOI: 10.1080/21548331.2020.1745509] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2020] [Accepted: 03/18/2020] [Indexed: 06/10/2023]
Abstract
BACKGROUND Currently about 19 million people in Africa are known to be living with diabetes, mainly Type 2 diabetes (T2DM) (95%), estimated to grow to 47 million people by 2045. However, there are concerns with early diagnosis of patients with Type 1 diabetes (T1DM) as often patients present late with complications. There are also challenges with access and affordability of insulin, monitoring equipment and test strips with typically high patient co-payments, which can be catastrophic for families. These challenges negatively impact on the quality of care of patients with T1DM increasing morbidity and mortality. There are also issues of patient education and psychosocial support adversely affecting patients' quality of life. These challenges need to be debated and potential future activities discussed to improve the future care of patients with T1DM across Africa. METHODOLOGY Documentation of the current situation across Africa for patients with T1DM including the epidemiology, economics, and available treatments within public healthcare systems as well as ongoing activities to improve their future care. Subsequently, provide guidance to all key stakeholder groups going forward utilizing input from senior-level government, academic and other professionals from across Africa. RESULTS Whilst prevalence rates for T1DM are considerably lower than T2DM, there are concerns with late diagnosis as well as the routine provision of insulin and monitoring equipment across Africa. High patient co-payments exacerbate the situation. However, there are ongoing developments to address the multiple challenges including the instigation of universal health care and partnerships with non-governmental organizations, patient organizations, and pharmaceutical companies. Their impact though remains to be seen. In the meantime, a range of activities has been documented for all key stakeholder groups to improve future care. CONCLUSION There are concerns with the management of patients with T1DM across Africa. A number of activities has been suggested to address this and will be monitored.
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Affiliation(s)
- Brian Godman
- Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde , Glasgow, UK
- Division of Public Health Pharmacy and Management, School of Pharmacy, Sefako Makgatho Health Sciences University , Pretoria, South Africa
- Division of Clinical Pharmacology, Karolinska Institute, Karolinska University Hospital Huddinge , Stockholm, Sweden
- Health Economics Centre, University of Liverpool Management School , Liverpool, UK
| | - Debashis Basu
- Department of Public Health Medicine, Steve Biko Academic Hospital and the University of Pretoria , Pretoria, South Africa
| | - Yogan Pillay
- National Department of Health, Pretoria, South Africa
| | - Paulo H R F Almeida
- School of Pharmacy, Postgraduate Program in Medicines and Pharmaceutical Services, Federal University of Minas Gerais (UFMG) , Belo Horizonte, Brazil
- Departamento de Gestão e Incorporação de Tecnologias e Inovação em Saúde, Secretaria de Ciência, Tecnologia, Inovação e Insumos Estratégicos em Saúde, Ministry of Health , Brasília, Brazil
| | - Julius C Mwita
- Department of Internal Medicine, Faculty of Medicine, University of Botswana , Gaborone, Botswana
| | - Godfrey Mutashambara Rwegerera
- Faculty of Medicine, Department of Internal Medicine, University of Botswana and Department of Medicine, Princess Marina Hospital , Gaborone, Botswana
| | - Bene D Anand Paramadhas
- Department of Pharmacy, Central Medical Stores, Ministry of Health and Wellness , Gaborone, Botswana
| | - Celda Tiroyakgosi
- Botswana Essential Drugs Action Program, Ministry of Health and Wellness , Gaborone, Botswana
| | - Okwen Patrick
- Effective Basic Services (Ebase) Africa , Bamenda, Africa
- Adelaide University , Adelaide, Australia
| | - Loveline Lum Niba
- Effective Basic Services (Ebase) Africa , Bamenda, Africa
- Department of Public Health, University of Bamenda , Bambili, Cameroon
| | - Israel Sefah
- Department of Pharmacy, Keta Municipal Hospital, Ghana Health Service , Keta, Ghana; Department of Pharmacy Practice, School of Pharmacy, University of Health and Allied Sciences, Ghana
| | - Margaret Oluka
- Department of Pharmacology and Pharmacognosy, School of Pharmacy, University of Nairobi , Nairobi, Kenya
| | - Anastasia N Guantai
- Department of Pharmacology and Pharmacognosy, School of Pharmacy, University of Nairobi , Nairobi, Kenya
| | - Dan Kibuule
- Department of Pharmacy Practice and Policy, Faculty of Health Sciences, University of Namibia , Windhoek, Namibia
| | - Francis Kalemeera
- Department of Pharmacy Practice and Policy, Faculty of Health Sciences, University of Namibia , Windhoek, Namibia
| | - Mwangana Mubita
- Department of Pharmacy Practice and Policy, Faculty of Health Sciences, University of Namibia , Windhoek, Namibia
| | - Joseph Fadare
- Department of Pharmacology and Therapeutics, Ekiti State University , Ado-Ekiti, Nigeria
- Department of Medicine, Ekiti State University Teaching Hospital , Ado-Ekiti, Nigeria
| | - Olayinka O Ogunleye
- Department of Pharmacology, Therapeutics and Toxicology, Lagos State University College of Medicine , Ikeja, Nigeria
- Department of Medicine, Lagos State University Teaching Hospital , Ikeja, Nigeria
| | - Enos M Rampamba
- Division of Public Health Pharmacy and Management, School of Pharmacy, Sefako Makgatho Health Sciences University , Pretoria, South Africa
- Department of Health, Tshilidzini Hospital, Department of Pharmacy , Shayandima, South Africa
| | - Jeffrey Wing
- Charlotte Maxeke Medical Research Cluster , Johannesburg, South Africa
| | - Debjani Mueller
- Department of Public Health Medicine, Steve Biko Academic Hospital and the University of Pretoria , Pretoria, South Africa
- Charlotte Maxeke Medical Research Cluster , Johannesburg, South Africa
| | - Abubakr Alfadl
- National Medicines Board, Federal Ministry of Health , Khartoum, Sudan
- Unaizah College of Pharmacy, Qassim University , Unaizah, Saudi Arabia
| | - Adefolarin A Amu
- Eswatini Medical Christian University , Swazi Plaza, Kingdom of Eswatini
| | | | | | - Trust Zaranyika
- Department Of Medicine, University of Zimbabwe College of Health Sciences , Harare, Zimbabwe
| | - Nyasha Masuka
- Independent Health Systems Consultant , Harare, Zimbabwe
| | - Janney Wale
- Independent Consumer Advocate , Brunswick, Australia
| | - Ruaraidh Hill
- Liverpool Reviews and Implementation Group, Whelan Building, University of Liverpool , Liverpool, UK
| | - Amanj Kurdi
- Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde , Glasgow, UK
- Department of Pharmacology, College of Pharmacy, Hawler Medical University , Erbil, Iraq
| | - Angela Timoney
- Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde , Glasgow, UK
- NHS Lothian Director of Pharmacy, NHS Lothian , Edinburgh, UK
| | - Stephen Campbell
- Centre for Primary Care, Division of Population Health, Health Services Research and Primary Care, University of Manchester , Manchester, UK
- NIHR Greater Manchester Patient Safety Translational Research Centre, School of Health Sciences, University of Manchester , Manchester, UK
| | - Johanna C Meyer
- Division of Public Health Pharmacy and Management, School of Pharmacy, Sefako Makgatho Health Sciences University , Pretoria, South Africa
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10
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Beran D, Laing RO, Kaplan W, Knox R, Sharma A, Wirtz VJ, Frye J, Ewen M. A perspective on global access to insulin: a descriptive study of the market, trade flows and prices. Diabet Med 2019; 36:726-733. [PMID: 30888075 PMCID: PMC6593686 DOI: 10.1111/dme.13947] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/15/2019] [Indexed: 01/23/2023]
Abstract
AIM To describe the global insulin market. METHODS Market intelligence data, United Nations Commodity Trade Statistics for insulin trade, the International Medical Products Price Guide for prices of human insulin and additional web searches were used as data sources. These sources were combined to gain further insight into possible links among market, trade flows and prices. Descriptive statistics and Spearman's rank order correlation were used for the analysis. RESULTS A total of 34 insulin manufacturers were identified. Most countries and territories are reliant on a limited number of supplying countries. The overall median (interquartile range) government procurement price for a 10-ml, 100-IU/ml vial during the period 1996-2013 equivalent was US$4.3 (US$ 3.8-4.8), with median prices in Africa (US$ 4.7) and low- (US$ 6.9) and low- to middle- (US$ 4.7) income countries being higher over this period. The relationships between price and quantity of insulin (Spearman's r=0.046; P>0.1) and number of import links (Spearman's r=0.032; P>0.1) were weak. The links between price and percentage of total insulin from a country where a 'big three' manufacturer produces insulin (Spearman's r=0.294; P<0.05) and total insulin from the main import link (Spearman's r=-0.392; P<0.05) were stronger. CONCLUSIONS This research shows the high variability of insulin prices and the reliance on a few sources, both companies and countries, for global supply. In addressing access to insulin, countries need to use existing price data to negotiate prices, and mechanisms need to be developed to foster competition and security of supply of insulin, given the limited number of truly global producers.
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Affiliation(s)
- D. Beran
- Division of Tropical and Humanitarian MedicineUniversity of Geneva and Geneva University HospitalsGenevaSwitzerland
| | - R. O. Laing
- Boston University School of Public HealthBostonMAUSA
- Faculty of Community Health SciencesSchool of Public HealthUniversity of the Western CapeCape TownSouth Africa
| | - W. Kaplan
- Boston University School of Public HealthBostonMAUSA
| | - R. Knox
- Boston University School of Public HealthBostonMAUSA
| | - A. Sharma
- Boston University School of Public HealthBostonMAUSA
- Precision Health EconomicsBostonMAUSA
| | - V. J. Wirtz
- Boston University School of Public HealthBostonMAUSA
| | - J. Frye
- Management Sciences for HealthMedfordMAUSA
| | - M. Ewen
- Health Action InternationalAmsterdamThe Netherlands
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11
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Almeida PHRF, Silva TBC, de Assis Acurcio F, Guerra Júnior AA, Araújo VE, Diniz LM, Godman B, Almeida AM, Alvares J. Quality of Life of Patients with Type 1 Diabetes Mellitus Using Insulin Analog Glargine Compared with NPH Insulin: A Systematic Review and Policy Implications. PATIENT-PATIENT CENTERED OUTCOMES RESEARCH 2019; 11:377-389. [PMID: 29322308 PMCID: PMC6019415 DOI: 10.1007/s40271-017-0291-3] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Insulin analog glargine (GLA) has been available as one of the therapeutic options for patients with type 1 diabetes mellitus to enhance glycemic control. Studies have shown that a decrease in the frequency of hypoglycemic episodes improves the quality of life (QoL) of diabetic patients. However, there are appreciable acquisition cost differences between different insulins. Consequently, there is a need to assess their impact on QoL to provide future guidance to health authorities. METHOD A systematic review of multiple databases including Medline, LILACS, Cochrane, and EMBASE databases with several combinations of agreed terms involving randomized controlled trials and cohorts, as well as manual searches and gray literature, was undertaken. The primary outcome measure was a change in QoL. The quality of the studies and the risk of bias was also assessed. RESULTS Eight studies were eventually included in the systematic review out of 634 publications. Eight different QoL instruments were used (two generic, two mixed, and four specific), in which the Diabetes Treatment Satisfaction Questionnaire (DTSQ) was the most used. The systematic review did not consistently show any significant difference overall in QoL scores, whether as part of subsets or combined into a single score, with the use of GLA versus neutral protamine Hagedorn (NPH) insulin. Only in patient satisfaction measured by DTSQ was a better result consistently seen with GLA versus NPH insulin, but not using the Well-being Inquiry for Diabetics (WED) scale. However, none of the cohort studies scored a maximum on the Newcastle-Ottawa scale for quality, and they generally were of moderate quality with bias in the studies. CONCLUSION There was no consistent difference in QoL or patient-reported outcomes when the findings from the eight studies were collated. In view of this, we believe the current price differential between GLA and NPH insulin in Brazil cannot be justified by these findings.
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Affiliation(s)
- Paulo H R F Almeida
- Postgraduate Program in Medicines and Pharmaceutical Assistance, School of Pharmacy, Federal University of Minas Gerais (UFMG), Belo Horizonte, Minas Gerais, Brazil.,SUS Collaborating Centre for Technology Assessment and Excellence in Health (CCATES), Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - Thales B C Silva
- Postgraduate Program in Medicines and Pharmaceutical Assistance, School of Pharmacy, Federal University of Minas Gerais (UFMG), Belo Horizonte, Minas Gerais, Brazil.,SUS Collaborating Centre for Technology Assessment and Excellence in Health (CCATES), Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - Francisco de Assis Acurcio
- Postgraduate Program in Medicines and Pharmaceutical Assistance, School of Pharmacy, Federal University of Minas Gerais (UFMG), Belo Horizonte, Minas Gerais, Brazil.,SUS Collaborating Centre for Technology Assessment and Excellence in Health (CCATES), Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - Augusto A Guerra Júnior
- Postgraduate Program in Medicines and Pharmaceutical Assistance, School of Pharmacy, Federal University of Minas Gerais (UFMG), Belo Horizonte, Minas Gerais, Brazil.,SUS Collaborating Centre for Technology Assessment and Excellence in Health (CCATES), Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - Vania E Araújo
- Postgraduate Program in Medicines and Pharmaceutical Assistance, School of Pharmacy, Federal University of Minas Gerais (UFMG), Belo Horizonte, Minas Gerais, Brazil.,SUS Collaborating Centre for Technology Assessment and Excellence in Health (CCATES), Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - Leonardo M Diniz
- School of Medicine, Federal University of Minas Gerais (UFMG), Belo Horizonte, Minas Gerais, Brazil
| | - Brian Godman
- Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow, G4 0RE, UK. .,Division of Clinical Pharmacology, Department of Laboratory Medicine, Karolinska Institutet, Karolinska University Hospital Huddinge, 141 86, Stockholm, Sweden. .,Health Economics Centre, University of Liverpool Management School, Liverpool, UK.
| | - Alessandra M Almeida
- Postgraduate Program in Medicines and Pharmaceutical Assistance, School of Pharmacy, Federal University of Minas Gerais (UFMG), Belo Horizonte, Minas Gerais, Brazil.,SUS Collaborating Centre for Technology Assessment and Excellence in Health (CCATES), Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - Juliana Alvares
- Postgraduate Program in Medicines and Pharmaceutical Assistance, School of Pharmacy, Federal University of Minas Gerais (UFMG), Belo Horizonte, Minas Gerais, Brazil.,SUS Collaborating Centre for Technology Assessment and Excellence in Health (CCATES), Federal University of Minas Gerais, Belo Horizonte, Brazil
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12
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Sharma A, Bhandari PM, Neupane D, Kaplan WA, Mishra SR. Challenges constraining insulin access in Nepal-a country with no local insulin production. Int Health 2019; 10:182-190. [PMID: 29617832 DOI: 10.1093/inthealth/ihy012] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2017] [Indexed: 11/15/2022] Open
Abstract
Background Nepal is facing an increasing burden of diabetes and relies almost entirely on insulin imported through India. Methods We employed a modified version of the WHO/Health Action International standard survey to assess insulin availability and prices, along with qualitative interviews with insulin retailers (pharmacists) and wholesalers in the Kathmandu Valley, Nepal. Results The mean availability of the two human insulins listed on the 2011 Nepal Essential Medicine List were 14.3% and 42.85% in the surveyed private- and public-sector pharmacies, respectively, compared with the WHO target of 80% availability. The median consumer price of human insulin cartridges, analogue insulin cartridges and pens was, respectively, 2.1, 4.6 and 5.3 times that of human insulin vials (US$5.54). The insulin cartridges made in India were less expensive (p<0.001) than those made elsewhere. The lowest-paid worker would need to spend between 3 and 17 days' wages to purchase a monthly insulin supply out of pocket. Conclusion Insulin access is limited in Kathmandu owing to low availability and the highly unaffordable price. Insulin access could improve with the government exploring additional suppliers, pooling insulin tenders, auditing insulin utilization and developing independent prescribing guidelines. Furthermore, there is a need to educate physicians and develop a consensus statement on insulin initiation to curb the growing analogue use and promote rational use.
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Affiliation(s)
- Abhishek Sharma
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA.,Precision Health Economics, Boston, Massachusetts, USA
| | | | | | - Warren A Kaplan
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
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13
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Jones SM, Chennupati S, Nguyen T, Fedorenko C, Ramsey SD. Comorbidity is associated with higher risk of financial burden in Medicare beneficiaries with cancer but not heart disease or diabetes. Medicine (Baltimore) 2019; 98:e14004. [PMID: 30608446 PMCID: PMC6344147 DOI: 10.1097/md.0000000000014004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
The aim of the study was to examine how multimorbidity influences the prevalence of financial burden among older adults with heart disease, diabetes, or cancer.The study was a cross-sectional analysis of prospective observational cohort survey study.Older adults (age 65 or older) who did not report 1/6 major chronic illnesses (n = 2773; reference group), reported 1/3 major chronic illnesses without comorbidity (heart disease n = 206; diabetes n = 460; cancer n = 417), and reported 1/3 major chronic illnesses with comorbidity (heart disease n = 232; diabetes n = 202; cancer n = 109).The measures were presence of chronic diseases (heart disease, diabetes, cancer), comorbid chronic diseases (stroke, lung disease, dementia), medical-related financial burden (credit card debt due to medical costs, paying medical bills over time), and overall financial burden (financial help from family, credit card debt, help with food, utilities, and other necessities).The proportion reporting financial burden ranged from 15% to 27% across samples. Heart disease was unrelated to medical or overall financial burden, regardless of comorbidity. Diabetes was unrelated to financial burden except diabetes without comorbidity was associated with lower odds of overall financial burden compared to healthy older adults (odds ratio [OR] = 0.655, 95% confidence interval [CI]: 0.468-0.917). Cancer with comorbidity, but not cancer without comorbidity, was associated with greater odds of medical related (OR = 1.678, 95% CI: 1.057-2.664) and overall financial burden (OR = 1.748, 95% CI: 1.064-2.872).The association of multimorbidity with financial burden likely varies based on specific diseases. Future research on financial burden should focus on specific disease combinations such as cancer with comorbidity.
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14
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Fullerton B, Siebenhofer A, Jeitler K, Horvath K, Semlitsch T, Berghold A, Gerlach FM. Short-acting insulin analogues versus regular human insulin for adult, non-pregnant persons with type 2 diabetes mellitus. Cochrane Database Syst Rev 2018; 12:CD013228. [PMID: 30556900 PMCID: PMC6517032 DOI: 10.1002/14651858.cd013228] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND The use of short-acting insulin analogues (insulin lispro, insulin aspart, insulin glulisine) for adult, non-pregnant people with type 2 diabetes is still controversial, as reflected in many scientific debates. OBJECTIVES To assess the effects of short-acting insulin analogues compared to regular human insulin in adult, non-pregnant people with type 2 diabetes mellitus. SEARCH METHODS For this update we searched CENTRAL, MEDLINE, Embase, the WHO ICTRP Search Portal, and ClinicalTrials.gov to 31 October 2018. We placed no restrictions on the language of publication. SELECTION CRITERIA We included all randomised controlled trials with an intervention duration of at least 24 weeks that compared short-acting insulin analogues to regular human insulin in the treatment of people with type 2 diabetes, who were not pregnant. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data and assessed the risk of bias. We assessed dichotomous outcomes by risk ratios (RR), and Peto odds ratios (POR), with 95% confidence intervals (CI). We assessed continuous outcomes by mean differences (MD) with 95% CI. We assessed trials for certainty of the evidence using the GRADE approach. MAIN RESULTS We identified 10 trials that fulfilled the inclusion criteria, randomising 2751 participants; 1388 participants were randomised to receive insulin analogues and 1363 participants to receive regular human insulin. The duration of the intervention ranged from 24 to 104 weeks, with a mean of about 41 weeks. The trial populations showed diversity in disease duration, and inclusion and exclusion criteria. None of the trials were blinded, so the risk of performance bias and detection bias, especially for subjective outcomes, such as hypoglycaemia, was high in nine of 10 trials from which we extracted data. Several trials showed inconsistencies in the reporting of methods and results.None of the included trials defined all-cause mortality as a primary outcome. Six trials provided Information on the number of participants who died during the trial, with five deaths out of 1272 participants (0.4%) in the insulin analogue groups and three deaths out of 1247 participants (0.2%) in the regular human insulin groups (Peto OR 1.66, 95% CI 0.41 to 6.64; P = 0.48; moderate-certainty evidence). Six trials, with 2509 participants, assessed severe hypoglycaemia differently, therefore, we could not summarise the results with a meta-analysis. Overall, the incidence of severe hypoglycaemic events was low, and none of the trials showed a clear difference between the two intervention arms (low-certainty evidence).The MD in glycosylated haemoglobin A1c (HbA1c) change was -0.03% (95% CI -0.16 to 0.09; P = 0.60; 9 trials, 2608 participants; low-certainty evidence). The 95% prediction ranged between -0.31% and 0.25%. The MD in the overall number of non-severe hypoglycaemic episodes per participant per month was 0.08 events (95% CI 0.00 to 0.16; P = 0.05; 7 trials, 2667 participants; very low-certainty evidence). The 95% prediction interval ranged between -0.03 and 0.19 events per participant per month. The results provided for nocturnal hypoglycaemic episodes were of questionable validity. Overall, there was no clear difference between the two short-acting insulin analogues and regular human insulin. Two trials assessed health-related quality of life and treatment satisfaction, but we considered the results for both outcomes to be unreliable (very low-certainty evidence).No trial was designed to investigate possible long term effects (all-cause mortality, microvascular or macrovascular complications of diabetes), especially in participants with diabetes-related complications. No trial reported on socioeconomic effects. AUTHORS' CONCLUSIONS Our analysis found no clear benefits of short-acting insulin analogues over regular human insulin in people with type 2 diabetes. Overall, the certainty of the evidence was poor and results on patient-relevant outcomes, like all-cause mortality, microvascular or macrovascular complications and severe hypoglycaemic episodes were sparse. Long-term efficacy and safety data are needed to draw conclusions about the effects of short-acting insulin analogues on patient-relevant outcomes.
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Affiliation(s)
- Birgit Fullerton
- Goethe UniversityInstitute of General PracticeTheodor‐Stern‐Kai 7Frankfurt am MainGermany60590
| | - Andrea Siebenhofer
- Graz, Austria / Institute of General Practice, Goethe UniversityInstitute of General Practice and Evidence‐Based Health Services Research, Medical University of GrazFrankfurt am MainAustria
| | - Klaus Jeitler
- Medical University of GrazInstitute of General Practice and Evidence‐Based Health Services Research / Institute for Medical Informatics, Statistics and DocumentationAuenbruggerplatz 2/9GrazAustria8036
| | - Karl Horvath
- Medical University of GrazInstitute of General Practice and Evidence‐Based Health Services Research / Department of Internal Medicine, Division of Endocrinology and MetabolismAuenbruggerplatz 2/9GrazAustria8036
| | - Thomas Semlitsch
- Medical University of GrazInstitute of General Practice and Evidence‐Based Health Services ResearchAuenbruggerplatz 2/9GrazAustria8036
| | - Andrea Berghold
- Medical University of GrazInstitute for Medical Informatics, Statistics and DocumentationAuenbruggerplatz 2GrazAustria8036
| | - Ferdinand M Gerlach
- Goethe UniversityInstitute of General PracticeTheodor‐Stern‐Kai 7Frankfurt am MainGermany60590
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15
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Li Z, Feng Q, Kabba JA, Yang C, Chang J, Jiang M, Zhao M, Yu J, Xu S, Li Q, Zhai P, Fang Y. Prices, availability and affordability of insulin products: a cross-sectional survey in Shaanxi Province, western China. Trop Med Int Health 2018; 24:43-52. [PMID: 30307681 DOI: 10.1111/tmi.13167] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To evaluate price, availability and affordability of insulin products in Shaanxi Province, western China. METHODS We used a simplified and adapted WHO/Health Action International method to obtain the availability and prices of insulin products and five oral anti-diabetic medicines as comparators in public general hospitals and private retail outlets. In addition, we investigated the price components of eight selected insulin products by tracing the supply chain. RESULTS All three kinds of insulin products, prandial, basal and premixed insulin, are 100% available in public hospitals, and have fairly high availability in the private sector (62.5-68.8%). The prices of most insulin products were higher than international reference prices in both sectors (ranging from 0.95 times to 2.33 times). All insulin products were unaffordable as they would cost 3.5-17.1 days' wage of the lowest-paid government workers in Shaanxi. The manufacturer's markup (selling price), which comprised more than 60% of the final price of all insulin products surveyed, was the largest price component. CONCLUSIONS Although availability of insulin products was high in public general hospitals and private retail pharmacies, their high price made them unaffordable to diabetes patients, especially low-income patients. The government should increase insurance compensation for those who need these life-saving medicines or decrease the cost of insulin products through negotiation with suppliers.
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Affiliation(s)
- Zongjie Li
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmacy, Xi'an Jiaotong University, Xi'an, China.,Center for Drug Safety and Policy Research, Xi'an Jiaotong University, Xi'an, China.,Shaanxi Center for Health Reform and Development Research, Xi'an, China
| | - Qinqin Feng
- Department of Drug and Equipment, No. 521 Hospital of Ordnance Industry, Xi'an, China
| | - John Alimamy Kabba
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmacy, Xi'an Jiaotong University, Xi'an, China.,Center for Drug Safety and Policy Research, Xi'an Jiaotong University, Xi'an, China.,Shaanxi Center for Health Reform and Development Research, Xi'an, China
| | - Caijun Yang
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmacy, Xi'an Jiaotong University, Xi'an, China.,Center for Drug Safety and Policy Research, Xi'an Jiaotong University, Xi'an, China.,Shaanxi Center for Health Reform and Development Research, Xi'an, China
| | - Jie Chang
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmacy, Xi'an Jiaotong University, Xi'an, China.,Center for Drug Safety and Policy Research, Xi'an Jiaotong University, Xi'an, China.,Shaanxi Center for Health Reform and Development Research, Xi'an, China
| | - Minghuan Jiang
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmacy, Xi'an Jiaotong University, Xi'an, China.,Center for Drug Safety and Policy Research, Xi'an Jiaotong University, Xi'an, China.,Shaanxi Center for Health Reform and Development Research, Xi'an, China
| | - Mingyue Zhao
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmacy, Xi'an Jiaotong University, Xi'an, China.,Center for Drug Safety and Policy Research, Xi'an Jiaotong University, Xi'an, China.,Shaanxi Center for Health Reform and Development Research, Xi'an, China
| | - Jiale Yu
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmacy, Xi'an Jiaotong University, Xi'an, China.,Center for Drug Safety and Policy Research, Xi'an Jiaotong University, Xi'an, China.,Shaanxi Center for Health Reform and Development Research, Xi'an, China
| | - Sen Xu
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmacy, Xi'an Jiaotong University, Xi'an, China.,Center for Drug Safety and Policy Research, Xi'an Jiaotong University, Xi'an, China.,Shaanxi Center for Health Reform and Development Research, Xi'an, China
| | - Qian Li
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmacy, Xi'an Jiaotong University, Xi'an, China.,Center for Drug Safety and Policy Research, Xi'an Jiaotong University, Xi'an, China.,Shaanxi Center for Health Reform and Development Research, Xi'an, China
| | - Panpan Zhai
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmacy, Xi'an Jiaotong University, Xi'an, China.,Center for Drug Safety and Policy Research, Xi'an Jiaotong University, Xi'an, China.,Shaanxi Center for Health Reform and Development Research, Xi'an, China
| | - Yu Fang
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmacy, Xi'an Jiaotong University, Xi'an, China.,Center for Drug Safety and Policy Research, Xi'an Jiaotong University, Xi'an, China.,Shaanxi Center for Health Reform and Development Research, Xi'an, China
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16
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Silva TBC, Almeida PHRF, Araújo VE, Acurcio FDA, Guerra Júnior AA, Godman B, Alvares J. Effectiveness and safety of insulin glargine versus detemir analysis in patients with type 1 diabetes: systematic review and meta-analysis. Ther Adv Endocrinol Metab 2018; 9:241-254. [PMID: 30181850 PMCID: PMC6116758 DOI: 10.1177/2042018818781414] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2018] [Accepted: 05/16/2018] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Diabetes mellitus type 1 (DM1) is an autoimmune disease characterized by metabolic destruction of pancreatic cells responsible for insulin production, with treatment based on replacing insulin. Long-acting insulin analogs are indicated for patients with DM1 who exhibit important oscillations of their daily glycemia, despite its higher cost. Our study objective was to evaluate the effectiveness and safety of two long-acting insulins, insulin glargine and detemir, in treating patients with DM1. METHODS We undertook a systematic review with meta-analysis of observational studies (cohort and registry) available in the databases and the gray literature, and a complementary search in the Diabetes Care journal. Outcomes assessed were: glycated hemoglobin concentration; fasting plasma or capillary glucose; occurrence of episodes of severe hypoglycemia and occurrence of nocturnal hypoglycemia. The assessment of methodological quality was performed using the Newcastle score. The meta-analyses were performed on software Review Manager® 5.2. RESULTS Out of 705 publications, 8 cohort studies were included. The quality of these studies was classified as high. In the meta-analysis, results regarding episodes of severe hypoglycemia (p = 0.02) and fasting glucose (p = 0.01) were in favor of detemir. The glycated hemoglobin (p = 0.49; I2 = 89) showed high heterogeneity and no statistically significant difference between the two. The meta-analysis of total insulin dose favored glargine (p = 0.006; I2 = 75). The rates of nocturnal hypoglycemia (NH) were evaluated only for one study and showed a significant reduction of NH after therapy with detemir, (p < 0.0001). CONCLUSION Although some outcomes were favorable to detemir insulin analog, it has not been possible to identify important differences of effectiveness and safety between the two analogs. These results can help in the current debate on the inclusion of long-acting analogs on the list of reimbursed medicines in Brazil, especially with the recent introduction of an insulin glargine biosimilar at a considerably lower price.
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Affiliation(s)
- Thales B. C. Silva
- School of Pharmacy, Federal University of Minas Gerais (UFMG), Minas Gerais, Brazil
- SUS Collaborating Center for Technology Assessment and Excellence in Health (CCATES), Federal University of Minas Gerais (UFMG), Minas Gerais, Brazil
| | - Paulo H. R. F. Almeida
- School of Pharmacy, Federal University of Minas Gerais (UFMG), Minas Gerais, Brazil
- SUS Collaborating Center for Technology Assessment and Excellence in Health (CCATES), Federal University of Minas Gerais (UFMG), Minas Gerais, Brazil
| | - Vania E. Araújo
- School of Pharmacy, Federal University of Minas Gerais (UFMG), Minas Gerais, Brazil
- SUS Collaborating Center for Technology Assessment and Excellence in Health (CCATES), Federal University of Minas Gerais (UFMG), Belo Horizonte, Minas Gerais Brazil
- School of Dentistry, Pontifícia Universidade Católica de Minas Gerais (PUCMG), Minas Gerais, Brazil
| | - Francisco de Assis Acurcio
- School of Pharmacy, Federal University of Minas Gerais (UFMG), Minas Gerais, Brazil
- SUS Collaborating Center for Technology Assessment and Excellence in Health (CCATES), Federal University of Minas Gerais (UFMG), Minas Gerais, Brazil
| | - Augusto A. Guerra Júnior
- School of Pharmacy, Federal University of Minas Gerais (UFMG), Minas Gerais, Brazil
- SUS Collaborating Center for Technology Assessment and Excellence in Health (CCATES), Federal University of Minas Gerais (UFMG), Minas Gerais, Brazil
| | | | - Juliana Alvares
- School of Pharmacy, Federal University of Minas Gerais (UFMG), Minas Gerais, Brazil
- SUS Collaborating Center for Technology Assessment and Excellence in Health (CCATES), Federal University of Minas Gerais (UFMG), Minas Gerais, Brazil
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17
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Cazarim MDS, Rodrigues JPV, Cruz-Cazarim ELCD, Ayres LR, Pereira LRL. Cost-effectiveness of insulin analogs from the perspective of the Brazilian public health system. BRAZ J PHARM SCI 2017. [DOI: 10.1590/s2175-97902017000300178] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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18
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Marra LP, Araújo VE, Oliveira GC, Diniz LM, Guerra Júnior AA, Acurcio FDA, Godman B, Álvares J. The clinical effectiveness of insulin glargine in patients with Type I diabetes in Brazil: findings and implications. J Comp Eff Res 2017; 6:519-527. [PMID: 28960085 DOI: 10.2217/cer-2016-0099] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
AIM Published studies have challenged the cost-effectiveness of insulin glargine versus neutral protamine hagedorn (NPH) insulins in Brazil with limited evidence of increased effectiveness despite considerably higher acquisition costs. However, still a controversy. Consequently, there is a need to address this. MATERIALS & METHODS Retrospective cohort study of Type I diabetes patients receiving insulin glargine in Brazil following NPH insulin who met the criteria. RESULTS 580 patients were enrolled. HbA1c varied from 8.80 ± 1.98% in NPH insulin users to 8.54 ± 1.88% after insulin glargine for 6 months, which is not clinically significant. Frequency of glycemic control varied from 22.6% with NPH insulin to 26.2% with insulin glargine. No statistically significant difference was observed between controlled and still uncontrolled groups for all analyzed factors including type and frequency of insulin use and carbohydrate counting. CONCLUSION Limited differences between NPH insulins and insulin analogs in routine clinical care do not justify an appreciable cost difference.
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Affiliation(s)
- Lays P Marra
- Department of Social Pharmacy, School of Pharmacy, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - Vânia E Araújo
- Department of Social Pharmacy, School of Pharmacy, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - Gerusa Cc Oliveira
- Department of Social Pharmacy, School of Pharmacy, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - Leonardo M Diniz
- School of Medicine, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - Augusto A Guerra Júnior
- Department of Social Pharmacy, School of Pharmacy, Federal University of Minas Gerais, Belo Horizonte, Brazil.,SUS Collaborating Centre - Technology Assessment & Excellence in Health, College of Pharmacy, Federal University of Minas Gerais, Minas Gerais, Brazil
| | - Francisco de Assis Acurcio
- Department of Social Pharmacy, School of Pharmacy, Federal University of Minas Gerais, Belo Horizonte, Brazil.,School of Medicine, Federal University of Minas Gerais, Belo Horizonte, Brazil.,SUS Collaborating Centre - Technology Assessment & Excellence in Health, College of Pharmacy, Federal University of Minas Gerais, Minas Gerais, Brazil
| | - Brian Godman
- Strathclyde Institute of Pharmacy & Biomedical Sciences, University of Strathclyde, Glasgow, UK.,Department of Laboratory Medicine, Division of Clinical Pharmacology, Karolinska Institutet, Karolinska University Hospital Huddinge, Stockholm, Sweden.,Health Economics Centre, Liverpool University Management School, Liverpool University, UK
| | - Juliana Álvares
- Department of Social Pharmacy, School of Pharmacy, Federal University of Minas Gerais, Belo Horizonte, Brazil.,SUS Collaborating Centre - Technology Assessment & Excellence in Health, College of Pharmacy, Federal University of Minas Gerais, Minas Gerais, Brazil
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Śliwczyński A, Brzozowska M, Jacyna A, Iltchev P, Iwańczuk T, Wierzba W, Marczak M, Orlewska K, Szymański P, Orlewska E. Drug-class-specific changes in the volume and cost of antidiabetic medications in Poland between 2012 and 2015. PLoS One 2017; 12:e0178764. [PMID: 28582404 PMCID: PMC5459444 DOI: 10.1371/journal.pone.0178764] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Accepted: 05/18/2017] [Indexed: 02/02/2023] Open
Abstract
Aim to investigate the drug-class-specific changes in the volume and cost of antidiabetic medications in Poland in 2012–2015. Methods This retrospective analysis was conducted based on the National Health Fund database covering an entire Polish population. The volume of antidiabetic medications is reported according to ATC/DDD methodology, costs—in current international dollars, based on purchasing power parity. Results During a 4-year observational period the number of patients, consumption of antidiabetic drugs and costs increased by 17%, 21% and 20%, respectively. Biguanides are the basic diabetes medication with a 39% market share. The insulin market is still dominated by human insulins, new antidiabetics (incretins, thiazolidinediones) are practically absent. Insulins had the largest share in diabetes medications expenditures (67% in 2015). The increase in antidiabetic medications costs over the analysed period of time was mainly caused by the increased use of insulin analogues. Conclusions The observed tendencies correspond to the evidence-based HTA recommendations. The reimbursement status, the ratio of cost to clinical outcomes and data on the long-term safety have a deciding impact on how a drug is used.
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Affiliation(s)
- Andrzej Śliwczyński
- Division of Quality Services, Procedures and Medical Standards, Medical University in Lodz, Lodz, Poland
- National Health Fund, Warsaw, Poland
| | - Melania Brzozowska
- Division of Quality Services, Procedures and Medical Standards, Medical University in Lodz, Lodz, Poland
- National Health Fund, Warsaw, Poland
| | | | - Petre Iltchev
- Health Care Policy Department, Medical University of Lodz, Lodz, Poland
| | - Tymoteusz Iwańczuk
- The Agency for Health Technology Assessment and Tariff System, Warsaw, Poland
| | | | - Michał Marczak
- Division of Quality Services, Procedures and Medical Standards, Medical University in Lodz, Lodz, Poland
| | | | | | - Ewa Orlewska
- Jan Kochanowski University in Kielce, Kielce, Poland
- * E-mail:
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20
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Laranjeira FO, da Silva EN, Pereira MG. Budget Impact of Long-Acting Insulin Analogues: The Case in Brazil. PLoS One 2016; 11:e0167039. [PMID: 27907034 PMCID: PMC5132224 DOI: 10.1371/journal.pone.0167039] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Accepted: 11/08/2016] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Long-acting insulin analogues for type 1 diabetes (T1D) treatment have been available on the Brazilian market since 2002. However, the population cannot access the analogues through the public health system. OBJECTIVE To estimate the incremental budget impact of long-acting insulin analogues coverage for T1D patients in the Brazilian public health system compared to NPH insulin. METHODS We performed a budget impact analysis of a five-year period. The eligible population was projected using epidemiological data from the International Diabetes Federation estimates for patients between 0-14 and 20-79 years old. The prevalence of T1D was estimated in children, and the same proportion was applied to the 15-19-year-old group due to a gap in epidemiological information. We considered 4,944 new cases per year and a 34.61/100,000 inhabitants mortality rate. Market share for long-acting insulin analogues was assumed as 20% in the first year, reaching 40% in the fifth year. The mean daily dose was taken from clinical trials. We calculated the bargaining power of the Ministry of Health by dividing the price paid for human insulin in the last purchase by the average regulated price. We performed univariate and multivariate sensitivity analyses. RESULTS The incremental budget impact of long-acting insulin analogues was US$ 28.6 million in the first year, and reached US$ 58.7 million in the fifth year. The total incremental budget impact was US$ 217.9 million over the five-year period. The sensitivity analysis showed that the percentage of T1D among diabetic adults and the insulin analogue price were the main factors that affected the budget impact. CONCLUSIONS The cost of the first year of long-acting insulin analogue coverage would correspond to 0.03% of total public health expenditure. The main advantage of this study is that it identifies potential bargaining power because it features more realistic profiles of resource usage, once centralized purchasing is established as an economically sustainable strategy. Clinical guidelines restricting the use of insulin analogues would make the decision towards insulin analogue coverage more affordable.
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21
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Sharma A, Kaplan WA. Challenges constraining access to insulin in the private-sector market of Delhi, India. BMJ Glob Health 2016; 1:e000112. [PMID: 28588966 PMCID: PMC5321364 DOI: 10.1136/bmjgh-2016-000112] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Accepted: 09/09/2016] [Indexed: 11/06/2022] Open
Abstract
Objective India's majority of patients—including those living with diabetes—seek healthcare in the private sector through out-of-pocket (OOP) payments. We studied access to insulin in the private-sector market of Delhi state, India. Methods A modified World Health Organization/Health Action International (WHO/HAI) standard survey to assess insulin availability and prices, and qualitative interviews with insulin retailers (pharmacists) and wholesalers to understand insulin market dynamics. Results In 40 pharmacy outlets analysed, mean availability of the human and analogue insulins on the 2013 Delhi essential medicine list was 44.4% and 13.1%, respectively. 82% of pharmacies had domestically manufactured human insulin phials, primarily was made in India under licence to overseas pharmaceutical companies. Analogue insulin was only in cartridge and pen forms that were 4.42 and 5.81 times, respectively, the price of human insulin phials. Domestically manufactured human phial and cartridge insulin (produced for foreign and Indian companies) was less expensive than their imported counterparts. The lowest paid unskilled government worker in Delhi would work about 1.5 and 8.6 days, respectively, to be able to pay OOP for a monthly supply of human phial and analogue cartridge insulin. Interviews suggest that the Delhi insulin market is dominated by a few multinational companies that import and/or license in-country production. Several factors influence insulin uptake by patients, including doctor's prescribing preference. Wholesalers have negative perceptions about domestic insulin manufacturing. Conclusions The Delhi insulin market is an oligopoly with limited market competition. Increasing competition from Indian companies is going to require some additional policies, not presently in place. As more Indian companies produce biosimilars, brand substitution policies are needed to be able to benefit from market competition.
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Affiliation(s)
- Abhishek Sharma
- Department of Global Health, Center for Global Health and Development, Boston University School of Public Health, Boston, Massachusetts, USA.,Precision Health Economics, Boston, Massachusetts, USA
| | - Warren A Kaplan
- Department of Global Health, Center for Global Health and Development, Boston University School of Public Health, Boston, Massachusetts, USA
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22
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Walicka M, Jóźwiak J, Rzeszotarski J, Zarzycka-Lindner G, Zonenberg A, Bijoś P, Masierek M, Franek E. PROGENS-HbA 1c study: safety and effectiveness of premixed recombinant human insulin (Gensulin M30). Arch Med Sci 2016; 12:985-991. [PMID: 27695488 PMCID: PMC5016585 DOI: 10.5114/aoms.2016.61910] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2016] [Accepted: 06/05/2016] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Insulin analogues have gained widespread popularity. However, in many countries the use of these drugs is limited by their relatively high cost, so there is still a need for more cost-effective human insulin therapies. The aim of the study was to assess the effectiveness and safety of the premixed recombinant human insulin (rhuI) Gensulin M30 in a real-life setting. MATERIAL AND METHODS The study group consisted of 4257 patients (2196 female, 2061 male) with type 2 diabetes, aged 63.7 ±9.4, with body mass index (BMI) 30.3 ±4.5 kg/m2 and diabetes duration 9 ±5.5 years. All patients were treated with premixed rhuI Gensulin M30. In 91.7% of patients, insulin was used in combination with metformin. In 3.7% of patients, it was used with sulphonylureas. The patients were observed for a period of 6 months. RESULTS The total insulin dose on visit 1 was 36.1 ±18.7 U (0.42 ±0.22 U/kg), and by the end of the study it reached 40.3 ±18.9 U (0.48 ±0.22 U/kg). A significant, continuous decrease of the levels of glycated hemoglobin (HbA1c), along with fasting and postprandial plasma glucose, was observed during the study period. The frequency of hypoglycemia increased slightly during the study, although these figures remained low, especially with regard to severe hypoglycemic episodes (0.02 episodes/patient/year). The lowest number of hypoglycemic episodes occurred in patients treated with insulin and metformin, while the highest number of episodes was observed in patients treated with insulin alone. No weight changes were noted in the patients during the study. CONCLUSIONS This study shows rhuI Gensulin M30 to be effective and safe in a real-life setting.
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Affiliation(s)
- Magdalena Walicka
- Department of Internal Diseases, Endocrinology and Diabetology, MSW Central Clinical Hospital, Warsaw, Poland
| | - Jacek Jóźwiak
- Department of Public Health, Czestochowa University of Technology, Czestochowa, Poland
- Silesian Analytical Laboratories, Katowice, Poland
| | - Jacek Rzeszotarski
- Clinical Department of Internal Diseases and Diabetology, 10th Military Hospital, Bydgoszcz, Poland
| | | | - Anna Zonenberg
- ZA Medical Institute, Higher School of Computer Science and Business Administration, Lomza, Poland
| | | | | | - Edward Franek
- Department of Internal Diseases, Endocrinology and Diabetology, MSW Central Clinical Hospital, Warsaw, Poland
- Department of Human Epigenetics, Mossakowski Medical Research Centre, Polish Academy of Sciences, Warsaw, Poland
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Kaplan WA, Beall RF. The global intellectual property ecosystem for insulin and its public health implications: an observational study. J Pharm Policy Pract 2016; 10:3. [PMID: 27446593 PMCID: PMC4955122 DOI: 10.1186/s40545-016-0072-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Accepted: 06/07/2016] [Indexed: 11/10/2022] Open
Abstract
Background Lack of access to insulin and poor health outcomes are issues for both low and high income countries. This has been accompanied by a shift from relatively inexpensive human insulin to its more expensive analogs, marketed by three to four main global players. Nonetheless, patent-based market exclusivities are beginning to expire there for the first generation insulin analogs. This paper adds a global dimension to information on the U.S. patent landscape for insulin by reviewing the patent status of insulins with emphasis on the situation outside the US and Europe. Methods Using the term “insulin”, we searched for patents listed on the United States Food and Drug Administration’s (USFDA) Orange Book and the Canadian Online Drug Product Database Online Query and its Patent Register. With this information, we expanded the search globally using the World Intellectual Property Organization (WIPO) PatentScope database, the European Patent Office’s INPADOC database and various country-specific Patent Offices. Results Patent protected insulins marketed in the U.S. and other countries are facing an imminent patent-expiration “cliff’ yet the three companies that dominate the global insulin market are continuing to file for patents in and outside the U.S, but very rarely in Africa. Only a few local producers in the so-called "pharmerging" markets (e.g., Brazil, India, China) are filing for global patent protection on their own insulins. There is moderate, but statistically significant association between patent filings and diabetes disease burden. Conclusions The global market dominance by a few companies of analog over human insulin will likely continue even though patents on the current portfolio of insulin analogs will expire very soon. Multinationals are continuing to file for more insulin patents in the bigger markets with large disease burdens and a rapidly emerging middle class. Off-patent human insulins can effectively manage diabetes. A practical way forward would be find (potential) generic manufacturers globally and nudge them towards opportunities to diversify their national insulin markets with acceptable off-patent products for export. Electronic supplementary material The online version of this article (doi:10.1186/s40545-016-0072-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Warren A Kaplan
- Department of Global Health, Boston University School of Public Health, Boston, MA 02118 USA
| | - Reed F Beall
- Population Health Program, Faculties of Medicine and of Law, University of Ottawa, One Stewart St, Ottawa, ON K1N 6N5 Canada
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Fullerton B, Siebenhofer A, Jeitler K, Horvath K, Semlitsch T, Berghold A, Plank J, Pieber TR, Gerlach FM. Short-acting insulin analogues versus regular human insulin for adults with type 1 diabetes mellitus. Cochrane Database Syst Rev 2016; 2016:CD012161. [PMID: 27362975 PMCID: PMC6597145 DOI: 10.1002/14651858.cd012161] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Short-acting insulin analogue use for people with diabetes is still controversial, as reflected in many scientific debates. OBJECTIVES To assess the effects of short-acting insulin analogues versus regular human insulin in adults with type 1 diabetes. SEARCH METHODS We carried out the electronic searches through Ovid simultaneously searching the following databases: Ovid MEDLINE(R), Ovid MEDLINE(R) In-Process & Other Non-Indexed Citations, Ovid MEDLINE(R) Daily and Ovid OLDMEDLINE(R) (1946 to 14 April 2015), EMBASE (1988 to 2015, week 15), the Cochrane Central Register of Controlled Trials (CENTRAL; March 2015), ClinicalTrials.gov and the European (EU) Clinical Trials register (both March 2015). SELECTION CRITERIA We included all randomised controlled trials with an intervention duration of at least 24 weeks that compared short-acting insulin analogues with regular human insulins in the treatment of adults with type 1 diabetes who were not pregnant. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data and assessed trials for risk of bias, and resolved differences by consensus. We graded overall study quality using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) instrument. We used random-effects models for the main analyses and presented the results as odds ratios (OR) with 95% confidence intervals (CI) for dichotomous outcomes. MAIN RESULTS We identified nine trials that fulfilled the inclusion criteria including 2693 participants. The duration of interventions ranged from 24 to 52 weeks with a mean of about 37 weeks. The participants showed some diversity, mainly with regard to diabetes duration and inclusion/exclusion criteria. The majority of the trials were carried out in the 1990s and participants were recruited from Europe, North America, Africa and Asia. None of the trials was carried out in a blinded manner so that the risk of performance bias, especially for subjective outcomes such as hypoglycaemia, was present in all of the trials. Furthermore, several trials showed inconsistencies in the reporting of methods and results.The mean difference (MD) in glycosylated haemoglobin A1c (HbA1c) was -0.15% (95% CI -0.2% to -0.1%; P value < 0.00001; 2608 participants; 9 trials; low quality evidence) in favour of insulin analogues. The comparison of the risk of severe hypoglycaemia between the two treatment groups showed an OR of 0.89 (95% CI 0.71 to 1.12; P value = 0.31; 2459 participants; 7 trials; very low quality evidence). For overall hypoglycaemia, also taking into account mild forms of hypoglycaemia, the data were generally of low quality, but also did not indicate substantial group differences. Regarding nocturnal severe hypoglycaemic episodes, two trials reported statistically significant effects in favour of the insulin analogue, insulin aspart. However, due to inconsistent reporting in publications and trial reports, the validity of the result remains questionable.We also found no clear evidence for a substantial effect of insulin analogues on health-related quality of life. However, there were few results only based on subgroups of the trial populations. None of the trials reported substantial effects regarding weight gain or any other adverse events. No trial was designed to investigate possible long-term effects (such as all-cause mortality, diabetic complications), in particular in people with diabetes related complications. AUTHORS' CONCLUSIONS Our analysis suggests only a minor benefit of short-acting insulin analogues on blood glucose control in people with type 1 diabetes. To make conclusions about the effect of short acting insulin analogues on long-term patient-relevant outcomes, long-term efficacy and safety data are needed.
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Affiliation(s)
- Birgit Fullerton
- Goethe UniversityInstitute of General PracticeTheodor‐Stern‐Kai 7Frankfurt am MainHesseGermany60590
| | - Andrea Siebenhofer
- Graz, Austria / Institute of General Practice, Goethe UniversityInstitute of General Practice and Evidence‐Based Health Services Research, Medical University of GrazFrankfurt am MainAustria
| | - Klaus Jeitler
- Medical University of GrazInstitute of General Practice and Evidence‐Based Health Services Research / Institute for Medical Informatics, Statistics and DocumentationAuenbruggerplatz 2/9GrazAustria8036
| | - Karl Horvath
- Medical University of GrazInstitute of General Practice and Evidence‐Based Health Services Research / Department of Internal Medicine, Division of Endocrinology and MetabolismAuenbruggerplatz 2/9GrazAustria8036
| | - Thomas Semlitsch
- Medical University of GrazInstitute of General Practice and Evidence‐Based Health Services ResearchAuenbruggerplatz 2/9GrazAustria8036
| | - Andrea Berghold
- Medical University of GrazInstitute for Medical Informatics, Statistics and DocumentationAuenbruggerplatz 2GrazAustria8036
| | - Johannes Plank
- Medical University of GrazDepartment of Internal MedicineAuenbruggerplatz 15GrazAustria8036
| | - Thomas R Pieber
- Medical University of GrazDepartment of Internal MedicineAuenbruggerplatz 15GrazAustria8036
| | - Ferdinand M Gerlach
- Goethe UniversityInstitute of General PracticeTheodor‐Stern‐Kai 7Frankfurt am MainHesseGermany60590
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Beran D, Ewen M, Laing R. Constraints and challenges in access to insulin: a global perspective. Lancet Diabetes Endocrinol 2016; 4:275-285. [PMID: 26857998 DOI: 10.1016/s2213-8587(15)00521-5] [Citation(s) in RCA: 114] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2015] [Revised: 12/14/2015] [Accepted: 12/17/2015] [Indexed: 12/17/2022]
Abstract
Substantial attention has been given to the issue of access to medicines for communicable diseases; however, access to essential medicines for diabetes, especially insulin, has had insufficient focus. Although insulin was discovered in 1921, the drug is unattainable to many globally, and this Review aims to highlight the range and complexity of factors that contribute to this unattainability. Manufacturers' selling prices of various insulin formulations and presentations, duties, taxes, mark-ups, and other supply chain costs affect the price of insulin and hence the drug's affordability to health systems and individuals. Unlike drugs for HIV and AIDS, the production of generic or biosimilar insulin has not had an effect on the overall market. Other factors contributing to poor availability of insulin include its quantification at the national level, in-country distribution, and determination of needs at lower levels of the health system. Although insulin is essential for the survival of people with type 1 diabetes and is needed for improved management of diabetes for some people with type 2 diabetes, very little has been done globally to address the issue of access, despite the UN's political commitment to address non-communicable diseases and ensure universal access to drugs for these disorders.
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Affiliation(s)
- David Beran
- Division of Tropical and Humanitarian Medicine, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
| | | | - Richard Laing
- Boston University School of Public Health, Boston University, Boston, MA, USA
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Parfitt C, Church D, Armston A, Couchman L, Evans C, Wark G, McDonald TJ. Commercial insulin immunoassays fail to detect commonly prescribed insulin analogues. Clin Biochem 2015; 48:1354-7. [PMID: 26171976 DOI: 10.1016/j.clinbiochem.2015.07.017] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2015] [Revised: 07/09/2015] [Accepted: 07/10/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVES Blood insulin and C-peptide are key investigations in the differential diagnosis of hypoglycaemia. Analogues of insulin have modified primary-sequences compared to native human insulin, as such may not cross react with insulin assays. This has important implications in detecting surreptitious or malicious insulin administration. The aim of this study is to assess the cross-reactivity of all insulins currently listed in the British National Formulary (BNF65, 2013) in clinical insulin assays currently used in UK clinical laboratories. DESIGN AND METHODS Sample sets were prepared for all 15 exogenous insulin classes listed in the BNF, at concentrations of 1000 pmol/L and 300 pmol/L, using pooled human serum. Samples were sent blinded to 5 participating analytical laboratories to cover analysis on the 10 major clinical insulin assays used in the UK. RESULTS The ability of insulin assays to detect exogenous insulin preparations was highly variable and ranged from 0% to >140% for a single exogenous insulin. Four assays were highly specific for the human insulin sequence and had no cross-reactivity with any synthetic analogue insulin. Two detected all insulin types (human sequence, animal and synthetic analogue), with the remaining having variable cross-reactivity. CONCLUSION The cross-reactivity of the 15 exogenous insulin preparations is highly variable in the assays used in clinical laboratories around the UK. It is important that laboratories and clinicians are aware of the limitations of their local assays to avoid missing the important diagnosis of hypoglycaemia secondary to excessive exogenous insulin. Where necessary, samples should be referred to specialist centres for insulin analysis and ideally by a validated and fully-quantitative mass spectrometry-based method.
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Affiliation(s)
- C Parfitt
- Blood Sciences, Royal Devon and Exeter Foundation Trust, UK
| | - D Church
- Department of Clinical Biochemistry, Addenbrooke's Hospital, UK; University of Cambridge Metabolic Research Laboratories, UK
| | - A Armston
- Department of Laboratory Medicine, University Hospital Southampton, UK
| | - L Couchman
- Viapath, Department of Clinical Biochemistry, King's College Hospital, London, UK
| | - C Evans
- Department of Medical Biochemistry & Immunology, University Hospital of Wales, UK
| | - G Wark
- Surrey Pathology Services, Royal Surrey County Hospital, UK
| | - T J McDonald
- Blood Sciences, Royal Devon and Exeter Foundation Trust, UK; NIHR Exeter Clinical Research Facility, University of Exeter, UK.
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Valentine WJ, Curtis BH, Pollock RF, Van Brunt K, Paczkowski R, Brändle M, Boye KS, Kendall DM. Is the current standard of care leading to cost-effective outcomes for patients with type 2 diabetes requiring insulin? A long-term health economic analysis for the UK. Diabetes Res Clin Pract 2015; 109:95-103. [PMID: 25989713 DOI: 10.1016/j.diabres.2015.04.023] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2014] [Revised: 03/14/2015] [Accepted: 04/15/2015] [Indexed: 12/18/2022]
Abstract
AIMS The aim of the analysis was to investigate whether insulin intensification, based on the use of intensive insulin regimens as recommended by the current standard of care in routine clinical practice, would be cost-effective for patients with type 2 diabetes in the UK. METHODS Clinical data were derived from a retrospective analysis of 3185 patients with type 2 diabetes on basal insulin in The Health Improvement Network (THIN) general practice database. In total, 48% (614 patients) intensified insulin therapy, defined by adding bolus or premix insulin to a basal regimen, which was associated with a reduction in HbA1c and an increase in body mass index. Projections of clinical outcomes and costs (2011 GBP) over patients' lifetimes were made using a recently validated type 2 diabetes model. RESULTS Immediate insulin intensification was associated with improvements in life expectancy, quality-adjusted life expectancy and time to onset of complications versus no intensification or delaying intensification by 2, 4, 6, or 8 years. Direct costs were higher with the insulin intensification strategy (due to the acquisition costs of insulin). Incremental cost-effectiveness ratios for insulin intensification were GBP 32,560, GBP 35,187, GBP 40,006, GBP 48,187 and GBP 55,431 per QALY gained versus delaying intensification 2, 4, 6 and 8 years, and no intensification, respectively. CONCLUSIONS Although associated with improved clinical outcomes, insulin intensification as practiced in the UK has a relatively high cost per QALY and may not lead to cost-effective outcomes for patients with type 2 diabetes as currently defined by UK cost-effectiveness thresholds.
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Affiliation(s)
- W J Valentine
- Ossian Health Economics and Communications, Basel, Switzerland.
| | - B H Curtis
- Eli Lilly and Company, Indianapolis, IN, USA
| | - R F Pollock
- Ossian Health Economics and Communications, Basel, Switzerland
| | - K Van Brunt
- Lilly Research Center, Windlesham, Surrey, UK
| | | | - M Brändle
- Division of Endocrinology and Diabetes, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - K S Boye
- Eli Lilly and Company, Indianapolis, IN, USA
| | - D M Kendall
- Eli Lilly and Company, Indianapolis, IN, USA
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Beran D, Yudkin JS. In defence of NICE draft type 2 diabetes guidelines. Lancet Diabetes Endocrinol 2015; 3:406. [PMID: 26003753 DOI: 10.1016/s2213-8587(15)00131-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2015] [Accepted: 04/29/2015] [Indexed: 11/24/2022]
Affiliation(s)
- David Beran
- Division of Tropical and Humanitarian Medicine, Geneva University Hospitals and University of Geneva, CH-1211 Geneva 14, Switzerland; International Insulin Foundation, Liverpool School of Tropical Medicine, Liverpool, UK.
| | - John S Yudkin
- International Insulin Foundation, Liverpool School of Tropical Medicine, Liverpool, UK; University College London, London, UK
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Idris I, Gordon J, Tilling C, Vora J. A cost comparison of long-acting insulin analogs vs NPH insulin-based treatment in patients with type 2 diabetes using routinely collected primary care data from the UK. J Med Econ 2015; 18:273-82. [PMID: 25422990 DOI: 10.3111/13696998.2014.991788] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
AIM The aim of this analysis was to investigate total healthcare costs, HbA1c, and weight changes over a 36-month period in patients with type 2 diabetes initiated on NPH or long-acting insulin analogs. METHODS Electronic patient data from 479 general practices in the UK (THIN database) were examined for new users of glargine (n = 794), detemir (n = 252), or NPH insulin (n = 430). Annualized healthcare costs and clinical outcomes in years 1, 2, and 3 following insulin initiation were quantified and compared with baseline, using ANOVA and linear regression models. RESULTS A significant difference (p < 0.05) in total healthcare costs increases at year 1 vs baseline was observed between glargine and detemir, detemir and NPH, but not between glargine and NPH (increase: +£486, +£635, and +£420 for glargine, detemir, and NPH users, respectively). However, increases by year 3 were not significantly different between the insulins. A propensity score analysis comparing analog and NPH insulin showed that, following insulin initiation, increases in costs were higher with insulin analogs at year one (+£220), but this difference decreased over time in each year following insulin initiation (+£168 and +£146, respectively, for years 2 and 3). HbA1c reductions were not significantly different between the groups at all time points. Differences in weight gain between glargine and NPH were statistically significant at year 1 (0.87 kg vs 1.11 kg) and year 3 (1.15 kg vs 1.57 kg), but other estimates of between-group differences in weight gain were non-significant. CONCLUSIONS Following insulin initiation, the difference in healthcare costs of long-acting analogs compared to NPH insulin was transient. By year 3, the cost differences were not significantly different between the two cohorts, driven by an observed reduction in the cost of self-monitoring of blood glucose (SMBG) in the analog group and an increase in the cost of bolus insulin in the NPH group.
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MESH Headings
- Body Mass Index
- Body Weight/drug effects
- Comorbidity
- Costs and Cost Analysis
- Diabetes Mellitus, Type 2/drug therapy
- Diabetes Mellitus, Type 2/economics
- Electronic Health Records/statistics & numerical data
- Female
- Glycated Hemoglobin/drug effects
- Health Care Costs/statistics & numerical data
- Humans
- Hypoglycemia/chemically induced
- Hypoglycemic Agents/adverse effects
- Hypoglycemic Agents/economics
- Hypoglycemic Agents/therapeutic use
- Insulin Glargine/adverse effects
- Insulin Glargine/economics
- Insulin Glargine/therapeutic use
- Insulin, Isophane/adverse effects
- Insulin, Isophane/economics
- Insulin, Isophane/therapeutic use
- Insulin, Long-Acting/adverse effects
- Insulin, Long-Acting/economics
- Insulin, Long-Acting/therapeutic use
- Male
- Middle Aged
- Multivariate Analysis
- Outcome Assessment, Health Care/economics
- Outcome Assessment, Health Care/statistics & numerical data
- Propensity Score
- United Kingdom
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Affiliation(s)
- Iskandar Idris
- Division of Medical Sciences & Graduate Entry Medicine, University of Nottingham , Derby , UK
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Holden SE, Jenkins-Jones S, Morgan CL, Schernthaner G, Currie CJ. Glucose-lowering with exogenous insulin monotherapy in type 2 diabetes: dose association with all-cause mortality, cardiovascular events and cancer. Diabetes Obes Metab 2015; 17:350-62. [PMID: 25399739 DOI: 10.1111/dom.12412] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2014] [Revised: 11/04/2014] [Accepted: 11/09/2014] [Indexed: 12/16/2022]
Abstract
AIMS To evaluate the association between insulin exposure and all-cause mortality, incident major adverse cardiovascular events (MACE) and incident cancer in people with type 2 diabetes treated with insulin monotherapy. METHODS For this retrospective study, people with type 2 diabetes who progressed to insulin monotherapy from the year 2000 were identified from the UK Clinical Practice Research Datalink. The risks of progression to serious adverse outcomes were compared using Cox proportional hazards models. In the main analysis, insulin exposure was introduced into the model as prescribed international units per kilogram per day, as a cumulative, continuous, annually updated, time-dependent covariable. RESULTS A total of 6484 subjects with type 2 diabetes who progressed to treatment with insulin monotherapy from the year 2000 onwards were followed for a mean of 3.3 years. The event numbers were as follows: deaths, n = 1110; incident MACE, n = 342; incident cancers, n = 382. Unadjusted event rates were 61.3 deaths per 1000 person-years, 26.4 incident MACE per 1000 person-years and 24.6 incident cancers per 1000 person-years. The adjusted hazard ratios in relation to 1-unit increases in insulin dose were 1.54 [95% confidence interval (CI) 1.32-1.78] for all-cause mortality, 1.37 (95% CI 1.05-1.81) for MACE and 1.35 (95% CI 1.04-1.75) for cancer. CONCLUSIONS There was an association between increasing exogenous insulin dose and increased risk of all-cause mortality, MACE and cancer in people with type 2 diabetes. The limitations of observational studies mean that this should be further investigated using an interventional study design.
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Affiliation(s)
- S E Holden
- Cochrane Institute of Primary Care and Public Health, School of Medicine, Cardiff University, The Pharma Research Centre, Cardiff Medicentre, Cardiff, UK
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31
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Schaan BD, Scheffel RS. Modern insulins, old paradigms and pragmatism: choosing wisely when deciding how to treat type 1 diabetes. Diabetol Metab Syndr 2015; 7:35. [PMID: 25964802 PMCID: PMC4426553 DOI: 10.1186/s13098-015-0033-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2015] [Accepted: 04/13/2015] [Indexed: 11/10/2022] Open
Abstract
There is a clinical imperative to improve metabolic control in the treatment of patients with type 1 diabetes, but in doing so, hypoglycemia should be avoided at all costs. Insulin analogues and the assumption they would better mimic the pharmacokinetic profile of endogenous insulin secretion emerged as a magic bullet in the treatment of patients with type 1 diabetes. However, although insulin analogues have pharmaceutical properties, such as pharmacodynamic stability, reproducibility of action, and a more physiological timing of action, which could possibly facilitate insulin use, the results obtained in clinical practice have not been as good as expected. Like all clinical decisions, the decision regarding which insulin would be better for the patient should be, if possible, evidence based. Here, we briefly discuss evidence for the use of insulin analogues and the different views with respect to the available evidence that lead to different interpretations and decisions regarding the use of this new technology.
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Affiliation(s)
- Beatriz D Schaan
- />Endocrine Division, Hospital de Clínicas de Porto Alegre and Medical Faculty, Universidade Federal do Rio Grande do Sul, Rua Ramiro Barcelos 2350, prédio 12, 4° andar, Porto Alegre, RS 90035-003 Brazil
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de Souza ALC, Acurcio FDA, Guerra Júnior AA, do Nascimento RCRM, Godman B, Diniz LM. Authors' reply to Dr. Malerbi: "Insulin glargine in a Brazilian state: should the government disinvest?". APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2014; 12:561-563. [PMID: 25119850 DOI: 10.1007/s40258-014-0113-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Affiliation(s)
- Ana Luísa Caires de Souza
- Medical College, Federal University of Minas Gerais (UFMG), Av. Antônio Carlos, 6627, Bloco 02, sl 1048, Belo Horizonte, MG, CEP 31270-901, Brazil,
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Bazargani YT, de Boer A, Leufkens HGM, Mantel-Teeuwisse AK. Selection of essential medicines for diabetes in low and middle income countries: a survey of 32 national essential medicines lists. PLoS One 2014; 9:e106072. [PMID: 25259517 PMCID: PMC4178014 DOI: 10.1371/journal.pone.0106072] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2014] [Accepted: 07/22/2014] [Indexed: 11/19/2022] Open
Abstract
AIM Diabetes is a growing burden especially in low and middle income countries (LMICs). Inadequate access to diabetes care is of particular concern and selection of appropriate diabetes medicines on national essential medicines lists (NEMLs) is a first step in achieving adequate access. This selection was studied among LMICs and influences of various factors associated with selection decisions were assessed. METHODS Countries were studied if they employed NEMLs for reimbursement or procurement purposes. Presence and number of essential diabetes medicines from different classes, both insulins and oral blood glucose lowering medicines, were surveyed and calculated. Data were also analyzed by country income level, geographic region, year of last update of the NEML and purpose of NEML employment. The effect of prevalence and burden of disease on the number of essential diabetes medicines was also studied. Non parametric tests and univariate linear regression analysis were used. RESULTS Nearly all countries (n = 32) had chosen fast (97%) and intermediate acting insulin (93%), glibenclamide and metformin (100% both) as essential medicines. The median number of essential diabetes medicines was 6, equally divided between insulins and oral medicines. 20% of the countries had selected insulin analogues as essential medicines. Among all the studied factors, an increase in burden of diabetes and wealth of countries were associated with selection of higher numbers of essential diabetes medicines (p = 0.02 in both cases). CONCLUSIONS Nearly all the studied LMICs had included the minimum required medicines for diabetes management in their NEMLs. Selection can still be improved (e.g. exclusion of insulin analogues and replacement of glibenclamide by gliclazide). Nevertheless, the known suboptimal and inconsistent availability of essential diabetes medicines in LMICs cannot be explained by inadequate selection of essential medicines. Countries should therefore be encouraged to give precedence to implementation of NEMLs to make essential diabetes medicines more accessible.
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Affiliation(s)
- Yaser T. Bazargani
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, the Netherlands
| | - Anthonius de Boer
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, the Netherlands
| | - Hubert G. M. Leufkens
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, the Netherlands
| | - Aukje K. Mantel-Teeuwisse
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, the Netherlands
- * E-mail:
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Lipska KJ, Ross JS, Van Houten HK, Beran D, Yudkin JS, Shah ND. Use and out-of-pocket costs of insulin for type 2 diabetes mellitus from 2000 through 2010. JAMA 2014; 311:2331-3. [PMID: 24915266 PMCID: PMC4133975 DOI: 10.1001/jama.2014.6316] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Kasia J Lipska
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Joseph S Ross
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Holly K Van Houten
- Division of Health Care Policy and Research, Mayo Clinic, Rochester, Minnesota
| | - David Beran
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | | | - Nilay D Shah
- Division of Health Care Policy and Research, Mayo Clinic, Rochester, Minnesota
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Roumie CL, Greevy RA, Grijalva CG, Hung AM, Liu X, Murff HJ, Elasy TA, Griffin MR. Association between intensification of metformin treatment with insulin vs sulfonylureas and cardiovascular events and all-cause mortality among patients with diabetes. JAMA 2014; 311:2288-96. [PMID: 24915260 PMCID: PMC4149288 DOI: 10.1001/jama.2014.4312] [Citation(s) in RCA: 120] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
IMPORTANCE Preferred second-line medication for diabetes treatment after metformin failure remains uncertain. OBJECTIVE To compare time to acute myocardial infarction (AMI), stroke, or death in a cohort of metformin initiators who added insulin or a sulfonylurea. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort constructed with national Veterans Health Administration, Medicare, and National Death Index databases. The study population comprised veterans initially treated with metformin from 2001 through 2008 who subsequently added either insulin or sulfonylurea. Propensity score matching on characteristics was performed, matching each participant who added insulin to 5 who added a sulfonylurea. Patients were followed through September 2011 for primary analyses or September 2009 for cause-of-death analyses. MAIN OUTCOMES AND MEASURES Risk of a composite outcome of AMI, stroke hospitalization, or all-cause death was compared between therapies with marginal structural Cox proportional hazard models adjusting for baseline and time-varying demographics, medications, cholesterol level, hemoglobin A1c level, creatinine level, blood pressure, body mass index, and comorbidities. RESULTS Among 178,341 metformin monotherapy patients, 2948 added insulin and 39,990 added a sulfonylurea. Propensity score matching yielded 2436 metformin + insulin and 12,180 metformin + sulfonylurea patients. At intensification, patients had received metformin for a median of 14 months (IQR, 5-30), and hemoglobin A1c level was 8.1% (IQR, 7.2%-9.9%). Median follow-up after intensification was 14 months (IQR, 6-29 months). There were 172 vs 634 events for the primary outcome among patients who added insulin vs sulfonylureas, respectively (42.7 vs 32.8 events per 1000 person-years; adjusted hazard ratio [aHR], 1.30; 95% CI, 1.07-1.58; P = .009). Acute myocardial infarction and stroke rates were statistically similar, 41 vs 229 events (10.2 and 11.9 events per 1000 person-years; aHR, 0.88; 95% CI, 0.59-1.30; P = .52), whereas all-cause death rates were 137 vs 444 events, respectively (33.7 and 22.7 events per 1000 person-years; aHR, 1.44; 95% CI, 1.15-1.79; P = .001). There were 54 vs 258 secondary outcomes: AMI, stroke hospitalizations, or cardiovascular deaths (22.8 vs 22.5 events per 1000 person-years; aHR, 0.98; 95% CI, 0.71-1.34; P = .87). CONCLUSIONS AND RELEVANCE Among patients with diabetes who were receiving metformin, the addition of insulin vs a sulfonylurea was associated with an increased risk of a composite of nonfatal cardiovascular outcomes and all-cause mortality. These findings require further investigation to understand risks associated with insulin use in these patients.
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Affiliation(s)
- Christianne L. Roumie
- Veterans Health Administration-Tennessee Valley Healthcare System Geriatric Research Education Clinical Center (GRECC), HSR&D Center, Nashville, TN
- Department of Medicine, Vanderbilt University, Nashville, TN
| | - Robert A. Greevy
- Veterans Health Administration-Tennessee Valley Healthcare System Geriatric Research Education Clinical Center (GRECC), HSR&D Center, Nashville, TN
- Department of Biostatistics, Vanderbilt University, Nashville TN
| | - Carlos G. Grijalva
- Veterans Health Administration-Tennessee Valley Healthcare System Geriatric Research Education Clinical Center (GRECC), HSR&D Center, Nashville, TN
- Department of Health Policy, Vanderbilt University, Nashville, TN
| | - Adriana M. Hung
- Veterans Health Administration-Tennessee Valley Healthcare System Geriatric Research Education Clinical Center (GRECC), HSR&D Center, Nashville, TN
- Department of Medicine, Vanderbilt University, Nashville, TN
| | - Xulei Liu
- Veterans Health Administration-Tennessee Valley Healthcare System Geriatric Research Education Clinical Center (GRECC), HSR&D Center, Nashville, TN
- Department of Biostatistics, Vanderbilt University, Nashville TN
| | - Harvey J. Murff
- Veterans Health Administration-Tennessee Valley Healthcare System Geriatric Research Education Clinical Center (GRECC), HSR&D Center, Nashville, TN
- Department of Medicine, Vanderbilt University, Nashville, TN
| | - Tom A. Elasy
- Veterans Health Administration-Tennessee Valley Healthcare System Geriatric Research Education Clinical Center (GRECC), HSR&D Center, Nashville, TN
- Department of Medicine, Vanderbilt University, Nashville, TN
| | - Marie R. Griffin
- Veterans Health Administration-Tennessee Valley Healthcare System Geriatric Research Education Clinical Center (GRECC), HSR&D Center, Nashville, TN
- Department of Medicine, Vanderbilt University, Nashville, TN
- Department of Health Policy, Vanderbilt University, Nashville, TN
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Holden SE, Gale EAM, Jenkins-Jones S, Currie CJ. How many people inject insulin? UK estimates from 1991 to 2010. Diabetes Obes Metab 2014; 16:553-9. [PMID: 24410846 DOI: 10.1111/dom.12260] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2013] [Revised: 08/01/2013] [Accepted: 01/05/2014] [Indexed: 11/30/2022]
Abstract
AIMS We set out to estimate the prevalence rate of insulin use in the UK population, the total number of people in the UK who use insulin, the proportion of users with type 1 and type 2 diabetes and changes between 1991 and 2010. METHODS Patients receiving prescriptions for insulin were identified in the Clinical Practice Research Datalink and attributed a diagnosis of type 1 or type 2 diabetes. The annual prevalence of insulin use was calculated and applied to population data. RESULTS The crude prevalence rate of insulin use increased from 2.43 (95% CI 2.38-2.49) per 1000 population in 1991 to 6.71 (6.64-6.77) per 1000 in 2010. The largest change was an increase in the prevalence of insulin users with a diagnosis of type 2 diabetes from 0.67 (0.64-0.70) to 4.34 (4.29-4.39) per 1000 population. The absolute number using insulin increased from 137 000 people (121 000-155 000) in 1991 to 421 000 (400 000-444 000) in 2010. The proportion taking insulin alone (as against combination with oral agents) decreased from 97% in the first decade to 37% in the second. CONCLUSION The number of people using insulin trebled between 1991 and 2010, largely due to a considerable increase in the number of people with type 2 diabetes using insulin.
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Affiliation(s)
- S E Holden
- Cochrane Institute of Primary Care and Public Health, School of Medicine, Cardiff University, The Pharma Research Centre, Cardiff Medicentre, Cardiff, UK
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Joseph F. ‘Just do it, ’cos I've got your back!’ Diabetes care: the West Cheshire Way. PRACTICAL DIABETES 2014. [DOI: 10.1002/pdi.1857] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Frank Joseph
- Consultant Physician in Diabetes and Endocrinology; Countess of Chester Hospital NHS Foundation Trust; West Cheshire UK
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Caires de Souza AL, de Assis Acurcio F, Guerra Júnior AA, Rezende Macedo do Nascimento RC, Godman B, Diniz LM. Insulin glargine in a Brazilian state: should the government disinvest? An assessment based on a systematic review. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2014; 12:19-32. [PMID: 24385261 DOI: 10.1007/s40258-013-0073-6] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
INTRODUCTION AND OBJECTIVE The costs of the insulin analogue (insulin glargine) have been growing appreciably in the State of Minas Gerais in Brazil, averaging 291% per year in recent years. This growth has been driven by an increasing number of successful law suits and a 536% price difference between insulin glargine and neutral protamine Hagedorn (NPH) insulin. One potential way to address this is to undertake a systematic review assessing the efficacy and safety of insulin glargine analogue compared with NPH insulin in patients with type 1 diabetes mellitus (T1DM), and, as a result, provide published data to support future recommended activities by the State of Minas Gerais. These could include maintaining it on the list of the Public Health System (SUS) provided there is a price reduction. Alternatively, the review could provide potential arguments to defend against future law suits should the authorities decide to delist insulin glargine. METHODS A systematic review of published studies researching the effectiveness of insulin glargine in patients with T1DM between January 1970 and July 2009 in MEDLINE (PubMed), the Latin American and Caribbean Centre on Health Sciences Information, the Cochrane Controlled Trials Databases and the National Health Service Centre for Reviews and Dissemination. Inclusion criteria included insulin glargine on its own or combined with other insulin formulations. Only randomised controlled clinical trials were included. Initially, the titles of all studies were assessed by two independent reviewers before being potentially discarded, with the quality of papers assessed using a modified Jadad scale. The outcome measures included blood levels of glycated haemoglobin, episodes of hypoglycaemia, adverse effects and the reduction of microvascular and macrovascular end-organ complications of T1DM. RESULTS Out of 803 studies found in the selected databases, only eight trials met the inclusion criteria. Most of the studies were of poor methodological quality or had a high risk of bias, with a mean score of 2.125 on the Jadad scale. No study could be classified as double-blind, and only one study documented the increased efficacy of insulin glargine in relation to both glycaemic control and hypoglycaemic episodes. Typically, there was no significant difference between insulin glargine and NPH insulins. CONCLUSIONS This systematic review showed no therapeutic benefit of insulin glargine over other insulin formulations studied when analysing together glycaemic control and the frequency and severity of hypoglycaemia. We therefore recommend to the State Authority to delist insulin glargine or renegotiate a price reduction with the manufacturer. This systematic review provides support for this decision as well as documentation to combat potential law suits if discussions are unsatisfactory.
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Affiliation(s)
- Ana Luísa Caires de Souza
- Medical College, Federal University of Minas Gerais (UFMG), Av. Antônio Carlos, 6627, Bloco 02, sl 1048, CEP 31270-901, Belo Horizonte, MG, Brazil,
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Gordon J, Evans M, McEwan P, Bain S, Vora J. Evaluation of insulin use and value for money in type 2 diabetes in the United kingdom. Diabetes Ther 2013; 4:51-66. [PMID: 23296753 PMCID: PMC3687091 DOI: 10.1007/s13300-012-0018-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2012] [Indexed: 01/29/2023] Open
Abstract
INTRODUCTION It is unclear as to whether human or long-acting analog insulins represent the most efficient use of health and non-healthcare resources in the management of type 2 diabetes mellitus (T2DM). The aim of this study was to evaluate the value for money relationship associated with the use of these insulins in the UK setting. METHODS A literature search was performed for studies reporting expenditure associated with the use of human and analog insulins. Data from this review informed a budget impact assessment model. Costs were converted to a common currency and results are reported in 2011 British pounds sterling (GBP) values. RESULTS Annual diabetes-related medication expenditure and patients total expenditure associated with the management of T2DM were estimated to be £397 million and £3,901 million, respectively. Substitution of human insulin for analog insulins was associated with a drug acquisition cost saving of between £5 million and £23 million each year. Overall, though, total expenditure increased significantly with increased use of human insulin by £34 million to £136 million each year depending on the degree of substitution. CONCLUSIONS On the face of it, analog insulins are more expensive, prompting questions about potential cost savings to health services in the UK from direct substitution to the less expensive human preparation. The current analysis illustrates that the increased use of human insulin and decreased use of analog insulin would, however, increase the overall net societal cost of managing insulin-treated patients with T2DM. Governments and decision makers should consider that total healthcare expenditure would not necessarily fall when decisions are based solely on the use of cheaper products.
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Affiliation(s)
- Jason Gordon
- Department of Public Health, University of Adelaide, Level 7, 178 North Terrace, Adelaide, SA, 5005, Australia,
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A UK analysis of the cost-effectiveness of Humalog Mix75/25 and Mix50/50 versus long-acting basal insulin. Adv Ther 2012. [PMID: 23179373 DOI: 10.1007/s12325-012-0065-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
INTRODUCTION As healthcare spending on diabetes and its complications continues to rise, the optimization of prescribed insulin regimens is becoming increasingly important from both clinical and economic perspectives. The aim of the present study was to evaluate the cost-effectiveness of 75/25 biphasic insulin lispro and 50/50 biphasic insulin lispro (Humalog® Mix75/25 and Humalog® Mix50/50, respectively; Eli Lilly and Company, Indianapolis, IN, USA) compared with a long-acting analog insulin regimen in patients with type 2 diabetes. METHODS A published and validated computer simulation model of diabetes was used to evaluate the cost-effectiveness of 75/25 and 50/50 biphasic insulin lispro versus a long-acting analog insulin (insulin glargine) from the perspective of a healthcare payer in the UK. Treatment effects in terms of glycated hemoglobin (HbA1c) benefits were taken from a recent meta-analysis. Direct medical costs including pharmacy, complication, and patient management costs were obtained from published sources. All costs were expressed in 2008 British pounds sterling (GBP), and future costs and clinical benefits were discounted at 3.5% per annum. Sensitivity analyses were performed. RESULTS 75/25 and 50/50 biphasic insulin lispro were associated with improvements in life expectancy of 0.09 and 0.13 years, respectively, improvements in quality-adjusted life expectancy of 0.09 quality-adjusted life years (QALYs) and 0.12 QALYs, respectively, and reductions in cost of GBP 1,217 and GBP 430, respectively, when compared with long-acting analog insulin. CONCLUSION Based on a recently published meta-analysis, biphasic analog insulins are likely to improve clinical outcomes and reduce costs versus long-acting analog insulins in the longterm treatment of patients with type 2 diabetes in the UK.
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Holden SE, Currie CJ. Do the benefits of analog insulins justify their costs? ACTA ACUST UNITED AC 2012. [DOI: 10.2217/dmt.12.17] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Savage MW, Malik I, Dang CN. The case for basal analogue insulins as first-line insulins: back to the future? PRACTICAL DIABETES 2011. [DOI: 10.1002/pdi.1628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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