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Cost of diabetes treatment spiralling says study

India November 14(IM): Swelling costs of diabetes treatment is pushing the poor towards out-of-pocket expenditure. A recent analysis of the expenditure pattern on diabetes, by centre-run Lady Hardinge Medical College (LHMC) has revealed that an underprivileged spends Rs8,958 on average annually even in a government healthcare facility.

The analysis was done on over 153 patients from a resettlement colony in Kalayanpauri who attended the Diabetic Clinic of Lal Bahadur Shastri Hospital in 2016. The two major heads of expenditure were in-patient treatment and medicines.

“Though basic drugs like anti-diabetics, anti-hypertensive, anti-lipid etc. are claimed to be available free of cost in Government settings, lack of supply of medicines becomes a prime reason for purchasing from outside time to time. A small proportion of patients also preferred buying medicines from outside to avoid delay while standing in long queues in a diabetic clinic of a government hospital,” said Archana Thakur from LHMC.

“33% of the diabetics were found to spend more than 5% and around 10% patients spent more than 20% of their family income on diabetes care only, which may be a matter of great challenge for policy makers,” she said.

Overall, the cost of diabetes treatment in India has witnessed a substantial escalation in past nine years, with a distinct rise in the use of newer oral antidiabetic drugs (OADs) and insulin analogues over traditional drugs. This is when affordability and availability of anti-diabetic therapy to low socioeconomic stratum remains markedly inadequate.

A recent paper published in Diabetes, Technology and Therapeutics Journal revealed that between December 2008 and December 2012, the cost of insulins sold increased from Rs151.2 crore to Rs218.7 crore, recording a 44% growth. Researchers claimed that this could be largely due to reduced “inertia” of patients and physicians to use insulin, more patients with diabetes-related complications where insulin needs to be used, and aggressive marketing of insulin by pharmaceutical companies.

Even in the period between December 2012 and December 2014, the cost of insulins sold more than doubled from Rs218.7 crore to Rs467.8 crore, recording 114% growth, possibly due to increasing availability and aggressive marketing of newer insulin analogues.

Similarly, between December 2014 and December 2016, the cost of insulins sold grew exponentially from Rs467.8 crore to Rs842 crore with a growth of 80%, probably due to availability of new basal insulin (degludec) and newer premix insulin (degludec plus aspart) to the armamentarium, the research paper said.

“It is important to note that chronic kidney disease due to diabetes is more prevalent in Asian Indians, and is increasingly being diagnosed, necessitating insulin therapy in a greater number of patients,” said Anoop Misra, author of the study.

The researchers studied nationwide trends in sales of all top selling drugs (20 brands) between December 2008 and December 2016, with emphasis on antidiabetic drugs. Sales data was obtained for 20 top selling drugs for insulin and OADs.

Insulins include a combination of regular and NPH insulin and glargine insulin, while OADs include a combination of glimepiride and metformin, and a combination of vildagliptin and metformin. Antibiotics included amoxycilinclavulanic acid combination, ceftriaxone (injections), cefuroxime (tablets and injections), cefixime and cefpodoxime.

Similarly, top selling diabetes drugs were divided into four categories i.e. older insulins, newer insulins, older OADs and newer OADs.

At present, a wide portfolio of oral drugs and insulins is available for the treatment of diabetes. Although older drugs such as sulfonylureas and metformin are mostly used, newer agents such as dipeptidyl peptidase-4 inhibitors (DPP-IVi) and sodium glucose cotransporter-2 inhibitors (SGLT-2i) are becoming attractive therapeutic options because of additional action that may be important in many patients who have diabetes with cardiovascular risk factors and other co-morbidities.

Specifically, the annual growth recorded for older insulins was 5.5%, whereas that for newer insulins was 10.9 %. For OADs, sale figures appeared in top 20 best-selling drugs for the first time in December 2013. Between December 2013 and December 2015, rapid increase in sales was recorded, from Rs278.5 crore to Rs570.9 crore (105% growth).

Between December 2015 and December 2016, the sale of OADs rose from Rs570.9 crore to Rs700 crore (23% growth). Specifically, the annual growth recorded for older OADs was 6.3%, whereas that of newer OADs was 29.8%, the study said.

“The substantial spurt in expensive treatment in diabetes, for both OADs and insulins is primarily because of huge increase in sale of newer and more expensive drugs and insulins, and is incongruous with poorly available and accessible basic healthcare, particularly in the population belonging to low socioeconomic stratum when one third of the world’s poor live in India,” said Misra.

The paper has highlighted that increasing the sales of high-cost medication is particularly worrisome since most Indians pay out of their pocket and nearly 7% experience catastrophic expenditure for diabetes.

“The drug industry in India, despite government’s efforts, suffers from inadequate regulations and their implementation, one of the perceived aspects being unethical promotional strategies,” said Misra.

“Given the huge commercial potential of drug sales in diabetes, new and expensive insulins. For instance, degludec that is sold at Rs1,800 ($30) per vial in India, is more expensive than in Europe, and costs 50% more than human insulins versus NPH, which costs Rs133 ($2.2) in India are promoted aggressively in private and government sectors,” he said.

The World Health Organisation (WHO) has already raised concerns on the financial burden that diabetes poses as it indicated that in low-income Indian families, if an adult has diabetes, as much as 25% of the family income was spent on diabetic care.

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