Diabetes Bigwigs Spar on Costs, Benefits of New vs Old Drugs

Christine Wiebe

April 03, 2017

ORLANDO, Florida ― "This is going to be really huge, it's going to be spectacular, you're going to enjoy this!" announced David M Nathan, MD, of Massachusetts General Hospital, Boston, setting the tone for a debate here at ENDO 2017: The Endocrine Society Annual Meeting on the relative benefits of older type 2 diabetes drugs compared with newer medications.

The crowd erupted in laughter, anticipating a bout of verbal jousting that has become popular at medical conferences in recent years.

But it soon became clear that this was going to be less than jovial as Dr Nathan reported that he had no financial interests to disclose, "and you'll soon see why."

His counterpart, Daniel Drucker, MD, of the University of Toronto, listened dispassionately on the dais as Dr Nathan spent the next 20 minutes criticizing the pharmaceutical industry for promoting newer, more expensive drugs that he said were not better than older drugs.

For 73 years after insulin was introduced, only two other drugs were available to treat type 2 diabetes: sulfonylureas and biguanides (eg, metformin), Dr Nathan said. During the next 20 years, four times as many classes of drugs became available, along with numerous combination products.

He presented a slide with a bar graph showing the most commonly used drugs and each one's potency for lowering HbA1c. He then superimposed the cost for each one, creating an image that suggested the less effective drugs were also the most expensive.

"Medication costs have gone up faster for diabetes than for any other disease, including cancer," Dr Nathan asserted. And any benefits, he concluded, are not worth the cost, especially considering "a host" of new adverse effects associated with the newer drugs.

With a parting shot at the pharmaceutical industry — the only ones to have benefited from all the new drugs, he maintained — Dr Nathan declared himself the winner as he turned the floor over to his colleague.

The View From the Other Side

"First of all," said Dr Drucker, "I have disclosures."

Despite a few snickers in the audience, he explained that he works with industry to help bring scientific advances to the market. And he set out to make the case that newer drugs represent significant advances in diabetes treatment.

When analyzing the cost/benefit ratio of drugs, all costs should be considered, he stressed, and not just that of the product itself.

With insulin, for example, the cost is really double that of the product itself, because of the additional costs involved with testing and monitoring. In addition, costs associated with hypoglycemia events should be considered, because insulin carries a higher risk for that.

Addressing his "opponent" directly, Dr Drucker repeated Dr Nathan's claim that insulin is the most effective injectable type 2 diabetes drug.

"And it is, except if you look at the data, which I'm now going to show you," he said to a round of laughter.

Pointing to randomized, controlled trials, he noted that long-acting subcutaneously injected glucagonlike peptide-1 (GLP-1) receptor agonists were "as effective or more effective" than insulin.

"So the concept that insulin is superior to GLP-1 receptor agonists is simply not borne out by the data," Dr Drucker said. "If you want to practice evidence-based medicine, I would suggest we stick to the data."

He then discussed the EMPA-REG study, which demonstrated a mortality benefit with the sodium glucose cotransporter-2 (SGLT-2) inhibitor empagliflozin (Jardiance, Boehringer Ingelheim) in patients with type 2 diabetes who were at high cardiovascular risk. "It's hard to argue with death as an outcome," Dr Drucker asserted.

Furthermore, the number needed to treat for many of the newer diabetes drugs is lower than for many other common medications, such as statins.

"We are facing a huge challenge as a community," Dr Drucker said. "We need as many options as we can have to treat diabetes, because all of our patients are different."

Physicians also need to work on improving access to the newer drugs, he noted, because if they are too expensive, they can't help patients.

In conclusion, he reiterated the many benefits of the newer drugs: effective at lowering HbA1c; less hypoglycemia; weight loss; and reduced need for blood glucose monitoring. In addition, certain drugs have been shown to reduce the risk for nephropathy, strokes, and cardiovascular death.

"To diminish the importance of these new drugs for our patients is malfeasance," he declared, prompting murmurs and even low whistles from the audience. He continued, "To counsel against using them is intellectual malpractice."

Rebuttles, Anyone?

Dr Nathan was quick to approach the podium to respond.

"Talk about alternative facts!" he said playfully. He dismissed the notion that recent trial data make it possible to "personalize" diabetes treatment and again insisted that the only one to benefit from the recent surge of new drugs is the pharmaceutical industry.

In addition to advertising directly to consumers about the benefits of their new products, drug companies have bombarded physicians with information and "guidance" on how to use the agents, Dr Nathan said.

Dr Drucker took offense at the suggestion that physicians are being influenced by drug companies: "I do not think my primary-care colleagues make decisions based on advertising," he said, to which Dr Nathan quickly responded, "I think that's naïve."

Opening the debate to the audience, Dr Drucker soon found himself defending his opinions to another critic, who insisted that the findings from the EMPA-REG trial might not be as robust as reported and that physicians were now being encouraged to use empagliflozin in patients who did not match the study criteria.

Dr Nathan jumped on the bandwagon, putting his colleague on the spot by asking if he agreed the SGLT-2 inhibitors should be prescribed only to men who had previously experienced a myocardial infarction, because the increased risk for yeast infections seen as a side effect with these agents mostly affects women.

After deflecting a bit, Dr Drucker responded that he thought it would be "disrespectful" to deny a woman who wants to take the drug "to avoid death."

"The conversation has to be unique to the patient in the room," Dr Drucker said, adding that the days of just prescribing something without involving the patient are long gone.

Although the irate questioner in the audience had to be ushered away from the microphone, the two presenters were able to end on a more positive note, embracing as the audience applauded their appreciation of the spirited and important discussion.

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Listen to the full session here.

ENDO 2017. The diabetes dilemma: How to treat type 2 diabetes;  April 2, 2017; Orlando, Florida.


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