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May 1, 2010 (Vol. 30, No. 9)

Treating T2DM with Early Insulin Therapy

Lack of Comprehensive Patient Education Has Stymied Adoption of Beneficial Treatment Option

  • Insulin in Emerging Economies

    Diabetes will continue to have a severely negative economic impact on healthcare in India and China. Obesity-related health expenses in China are expected to grow from $50 billion in 2000 to over $110 billion by 2025. In India, the total cost of diet-related, noncommunicable diseases (NCDs) is nearly $3.4 billion, or roughly 1.1% of India’s GDP. Even more troubling is that mortality due to diet-related NCDs in India is expected to account for over 43% of all deaths by 2020, where T2DM is a major contributor.

    Although the monetary and human costs associated with T2DM’s proliferation will continue to devastate these countries if the status quo is maintained, significant opportunities exist for cost-effective therapies. To be successful, these therapies must be coupled with far-reaching educational programs to foster the two-pronged effect of decreasing disease incidence and treating those already living with the disease.

    In India, the launch of large-scale health-intervention programs encouraging increased physical activity and healthier eating habits are working to slow the T2DM growth rate, with the latter program aiming to reach over 500,000 children in northern India alone. These programs are limited to reducing the number of new diabetics in these countries, therefore, modifications to the treatment paradigm should be considered to reduce disease mortality while controlling costs.

    Not all insulin types will achieve widespread success, especially in the early stages of T2DM treatment. Significant adoption will be limited to those specific subcategories of insulins that require the least amount of patient education, have support from leading diabetic organizations like the American Diabetes Association, and provide cost advantages over other treatments.

    Insulin determir (Levemir, Novo Nordisk) and insulin glargine (Lantus, Sanofi-Aventis) are best  positioned to capitalize on the need for early, more effective treatments due to their ease of use and existing endorsements. Unfortunately, these products do not offer much of a cost advantage until later in the progression of the disease when several OADs are prescribed concomitantly. For example, treatment via generic metformin and sulfonylurea can cost as little as $10 per month, whereas one 10 mL vial of Lantus, which lasts for 30–45 days, typically costs over $100, as much as ten times that of treatment via these generic OADs. However, when drugs like metformin are combined with OADs in emerging classes (e.g., GLP-1 agonists and DPP-IVs), which themselves can cost over $200 per month, the cost advantages of these basal insulin analogs become more apparent.

    Although the worldwide market for long-acting insulins is likely to grow from $2.5 billion in 2007 to $4.6 billion in 2012, a reduction in the cost of these drugs will likely accelerate growth beyond these initial projections. The introduction of effective, low-cost insulin analogs to populations in India and China is occurring.

    Biocon launched its version of insulin glargine, Basalog, in India earlier this year at a 40% discount compared to its peers, a considerable difference that may facilitate its adoption earlier in the treatment paradigm, encourage its coverage by the state, and accelerate access. Biocon also plans to introduce Basalog outside India.

    Although in no way localized to emerging economies, countries such as India and China are positioned to suffer from the epidemic growth of T2DM more severely than most developed countries due to greater cost sensitivity, inconsistent patient access to adequate healthcare, and insufficient—or nonexistent—educational programs encouraging healthy lifestyles aiming to deter the onset of the disease.

    Early insulin use has the potential to greatly improve patient outcomes in the form of sustained prevention of hyperglycemic episodes and, with newly diagnosed patients, to foster euglycemia for extended periods via intensive administration without therapeutic intervention.

    Furthermore, long-acting insulins may see less patient resistance than other forms of insulin, which require more closely monitored blood glucose levels and a greater degree of patient education. In developing countries, the emergence of less costly basal insulin analogs like Basalog is critical to facilitating earlier use of insulin.

    Thus, we believe that the emergence of novel, low-cost insulins, combined with more widespread patient information regarding diabetes, will not only temper the devastating effects of T2DM on developing countries, but also usher in a hugely disruptive force in the treatment algorithm for the disease, one of which marketers of OADs must remain highly alert.

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