Pharma's Influence on Diabetes Prescribing: Good or Bad?

Laurie Scudder, DNP, NP;  Matthew L. Mintz, MD

Disclosures

September 20, 2017

Most physicians know about the Open Payments system, commonly referred to as the Sunshine Act, which requires pharmaceutical companies to report any payments they make to physicians. In Washington, DC, drug makers are forced to be even more transparent, reporting money given to all healthcare professionals as well as that spent on advertising. In a recent interview, Susan Wood, PhD, a health policy analyst at George Washington University, reported on an analysis of data from that system, AccessRx, which found a correlation between pharma spending and a dramatic rise in the use of newer, more expensive drugs to treat patients with diabetes.

But what do clinicians in DC think about the law? To find out, we spoke with Matthew Mintz, MD, an internist and clinical associate professor, also at the George Washington University School of Medicine. Dr Mintz writes frequently about the drug industry and trends in prescribing.

Medscape: You were practicing in the District prior to this 2004 law and for the 13 years since its implementation. How has it influenced prescribing in the city?

Matthew L. Mintz, MD

Dr Mintz: I suspect that most physicians in the District have no idea about this law. Because data reported to the city are anonymized, it likely does not affect the practice of even those physicians who are familiar with the law. That is very different from the Sunshine Act, which I think many physicians do care about and which has made a difference in the willingness of many to interact with pharmaceutical representatives. Not to imply that the Sunshine Act has had a major impact but rather that it has had some impact.

So we have these great new drugs that are not only working better with fewer side effects, but they also might be saving lives... I think that's a good thing. Does it cost money? Yes.

Medscape: In your opinion, are the data reported to the DC government clinically relevant?

Dr Mintz: I think that these data are meaningful and important because they look into the spending patterns of the pharmaceutical industry and the products that the industry promotes. However, I'm not sure that the information is clinically relevant. Basically, the data demonstrate that companies spend money on marketing their products, and that marketing is actually effective. What they do not tell you is whether the increased use of those products is appropriate or not. The data found that substantial money was spent both in marketing and in the actual use of the newer insulin analogs. The fact is that the insulins available today are far superior to the older insulins. They are more effective or just as effective with fewer side effects. That has been documented in numerous studies.

Drug companies are telling clinicians about these newer insulin products that are at least as effective, easier to use, and/or safer. The doctor can decide if what they are being told makes sense and decide to start using these products. Is that a good thing or a bad thing? The data about pharmaceutical spending in DC don't answer that question. I can give you my clinical opinion, which is that, yes, increased use of the newer insulins is a good thing. Administration is via a pen, which is easier to use; they only need to be administered once a day; and hypoglycemia is less of a concern.

Now, the downside is that these newer insulins cost more money. So, is the increased spending on better insulins worth it? I would argue that it is. I think the true problem is that the cost of healthcare, including premiums and out-of-pocket costs, has skyrocketed. There's a perception that the pharmaceutical industry, and the prices of drugs, are the biggest driver of that rise. That is a false perception. More drugs become generic virtually every day. And so the rising cost of drugs as a contributor to total healthcare spending is far less of a factor now than in years past—and that trend will likely continue despite the introduction of blockbuster, expensive new agents.

This first report produced as a result of the AccessRx law looked at spending in patients with diabetes. And yes, particularly with the prevalence of diabetes, spending on this disease state is a big driver of overall spending. When you look at the diseases most often treated in primary care—conditions like diabetes, hypertension, hyperlipidemia—you'll find that diabetes is one of the most common conditions that continues to be treated with a large number of branded agents. That is really in contrast to the use of and spending on agents used to treat cardiovascular disease. There are almost no branded hypertension or hypercholesterolemia drugs. Most of the branded agents used for those disease states are now generic. That's not true of the newer diabetes drugs.

There are some exceptions when treating diabetes. Metformin is a great drug that is very safe and very effective, and every guideline suggests that it be used first line. However, metformin does not work 100% of the time in all patients with diabetes. In fact, most of these patients will need more than one drug. The only other generic diabetes drugs on the market are the sulfonylureas. This class of drugs causes weight gain and hypoglycemia, and most diabetes experts have suggested that we should no longer be using them. The result then is that when metformin is just not enough, you are left with one of these newer expensive agents that are not yet generic.

The AccessRx data on the impacts of pharmaceutical marketing on spending for patients with diabetes concluded that the diabetes drug associated with the most physician payments was Invokana® (canagliflozin).

So let's talk about that drug. Invokana, which is also marketed as a combination drug with metformin (Invokamet®), reduces glycated hemoglobin very effectively. It causes patients to lose weight, which is often helpful for patients with diabetes. It also lowers blood pressure, and many patients with type 2 diabetes have high blood pressure. And more recently it has been shown to have cardiovascular benefit. Metformin, despite numerous studies, has never really been shown to decrease heart attacks or strokes.

So we have these great new drugs that are not only working better with fewer side effects, but they also might be saving lives... I think that's a good thing. Does it cost money? Yes. Are we overpaying for this benefit? That's a tough question. Undoubtedly some of the costs related to these admittedly expensive drugs are due to the marketing. If you educate doctors about newer, more effective agents, and they start using them, I don't think that's a bad thing. There's a balance. Yes, if you're going to use better drugs that are more effective and/or have fewer side effects, it's going to cost more money. If you want to save money, you can use the cheaper drugs, but cheaper drugs don't necessarily work as well and have more side effects. So what do you want to do? If you're the doctor, you want to do the best thing for your patient. If you're a patient, you want to get the best medication.

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