Majority of Patients in Poorer Nations Not Taking Diabetes Meds

Pam Harrison

September 10, 2018

Essential diabetes medications are inconsistently available in low- and middle-income countries and are frequently unaffordable, according to a new analysis from a prospective global epidemiological study.

Indeed, the results reveal that only around 30% of people with diabetes in low- and middle-income countries are actually taking medications to treat their condition.

"Access to medicines is recognized by the World Health Organization [WHO] as part of the right to health," Clara Chow, PhD, University of Sydney, Australia, and colleagues observe in their article published online August 28 in The Lancet Diabetes & Endocrinology.

"The data presented here show universal access is still a distant prospect and that government and industry really are not doing enough to ensure the availability and affordability of these essential medicines to people that need them," they state.

They single out insulin in particular as the medicine that requires the most effort to ensure availability and affordability for the majority of people with diabetes who require it.

Availability and Affordability

The new analysis was performed using data from the Prospective Urban Rural Epidemiology (PURE) study involving 156,625 adults from 110,803 households in 22 countries.

It is estimated that 61% of people with diabetes around the world (around 261 million) live in these 22 countries, the authors point out.

A total of 604 community pharmacies were audited for the availability of essential diabetes medications across different income strata: four high-income countries; eight upper middle-income countries; five lower middle-income countries, and five low-income countries. Pharmacies in India, although still considered a low-income country, were audited separately.

Availability was defined as the presence of medicines for diabetes in the pharmacy on the day the pharmacy was audited.

The investigators looked for metformin and other oral hypoglycemic agents, as well as insulin and commonly prescribed combinations, including metformin plus a sulfonylurea (glibenclamide or gliclazide) or metformin plus insulin.

"Metformin was the most widely available diabetes medicine...and insulin was the least available," Chow and colleagues report.

The researchers also estimated the cost of a month's supply of essential medicines for diabetes based on the pharmacy audits and assessed the affordability for varying levels of income.

Medicines were deemed affordable if the total monthly cost of taking the drugs was less than 20% of a household's capacity to pay (household income after food expenses).

Many Forms of Data Collection Needed to Adequately Monitor Situation

Countries Pharmacies, n Metformin, % Glibenclamide, % Gliclazide, % Insulin, %
High income 113 100 84.1 75.2 93.8
Upper-middle income 127 88.2 70.9 71.7 40.2
Lower-middle income 208 86.1 62.5 31.7 29.3
Low-income, excluding India 68 64.7 57.4 52.9 10.3
India 88 100 72.7 81.8 76.1

Most Patients in Low-Income Countries Not Taking Diabetes Medication

Metformin was the most affordable of all available diabetes medications, yet over a quarter of households in the poorest countries could not afford it.

The numbers were much worse for insulin.

Researchers estimated 26.9% of households in low-income countries and 0.7% of households in high-income countries could not afford metformin, while 63.0% of households in low-income countries and 2.8% of households in high-income countries could not afford insulin.

Among the 13,569 people (8.6% of PURE participants) who reported a diagnosis of diabetes, 1222 (74.0%) participants reported diabetes medicine use in high-income countries compared with 143 (29.6%) participants in low-income countries.

Or to state it another way, over 70% of those with diabetes in low-income countries, including India, were taking no medication for their diabetes.

And even in high-income countries — where diabetes medications are relatively widely available and affordable — slightly over one-quarter of people with diabetes, at 26%, reported taking no medication for their diabetes.

In multilevel-adjusted statistical models, availability and affordability were significantly associated with use of diabetes medicines.

"The poor availability and affordability of essential diabetes medicines in many communities, especially those from low- and middle-income countries, is a substantial driver of lower use of these medicines," Chow and colleagues observe.

Insulin Cost Must Be Addressed

The researchers also note that although they have focused on antidiabetic medicines, "they represent only part of the problem. Most patients with diabetes will need additional medicines, including those that lower blood pressure and statins to manage the patients' overall cardiovascular risk."

Their previous work from PURE has shown poor availability and affordability of cardiovascular medicines for hypertension and the secondary prevention of cardiovascular disease.

Access to essential medicines globally still "has a long way to go," they conclude.

"This situation requires a multifaceted response addressing the entire range of health systems building blocks, which create numerous barriers to effective care."

"For medicines the cost of insulin needs to be addressed, the manufacture of which is dominated by three large multinational companies with intellectual property issues surrounding the newer delivery devices acting as a barrier to lower cost supplies."

They also point to another issue that is "often overlooked," and that is the cost of glucose testing strips, "reflecting a business model in which manufacturers make profits from sales of strips typically designed for use with only one type of glucometer, and the high rates of hyperglycemia that this business model is likely to be contributing to."

Many Forms of Data Collection Needed to Adequately Monitor Situation

In an accompanying editorial, Alessandra Ferrario, PhD, Harvard Medical School, Boston, Massachusetts, points out that out-of-pocket costs for medication tend to be one of the largest health expenditures for people in low- and middle-income countries.

"Survey data, such as those from the PURE study, have a very important role particularly in obtaining information on the most vulnerable individuals who are usually not covered by health insurance and [who] pay for medicines out-of-pocket," she writes.

Ferrario also notes that other key sources through which the availability and affordability of medicines might be monitored include claims data, procurement data, wholesaler data, and import and local production data in regions of the world where quantities are reliably reported.

"As countries move towards universal health coverage, reducing out-of-pocket payments for essential medicines and securing affordable prices are essential to protect individuals from excessive spending and to ensure the long-term sustainability of healthcare systems," she observes.

"While additional data collection is needed in various settings, greater use of existing routinely collected data is an opportunity that should not be missed," she concludes.

WHO has recently released new diabetes treatment intensification guidelines aimed at low-income countries, as well as poorer populations in higher-income countries; in these, WHO takes into account the cost of diabetes medications when making recommendations regarding the most appropriate therapies.

The authors and editorialists have reported no relevant financial relationships.

Lancet Diabetes Endocrinol. Published online August 28, 2018. Abstract, Editorial

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