Journal of Diabetes Science and Technology
Volume 2, Issue 4, July 2008 Diabetes Technology Society Spending for Diabetes Drugs is Increasing in the United States
David C. Klonoff, M.D., FACP As of 2007, the treatment of diabetes has become the (6) viral infections, (7) Alzheimer's and Parkinson's Disease, leading source of increased spending on prescription (8) psychosis, (9) urologic diseases, (10) dermatologic diseases, drugs. This was reported by Medco Health Solutions Inc. (11) pain requiring non-narcotic relief, (12) depression, in its 2008 Drug Trend Report, a comprehensive analysis and (13) hyperlipidemia. The basis of this report is of prescription drug spending and utilization.1 In 2007, benefit data from Medco, the nation's leading pharmacy diabetes drugs accounted for 7% of prescription drug benefit manager. The data are from Medco's 2007 total spending in the United States (U.S.). See Table 1.
net revenues of more than $44 billion, which go toward prescription drug benefit programs for one-in-five Top Therapeutic Categories Contributing to Drug
The overall increase in spending on prescription drugs Spending by Medco in 20071
was low, at 2.0%, during the past year, which the report Contribution to overall defined as between 2006–2007. The increase in spending plan spending (%) on diabetes drugs increased because of a combination CNS, Neurology, Mental Health, and Pain of factors. The number of patients using diabetes drugs increased only slightly, by 2.3%; however, the sharp increase of 9.5% in the unit cost per drug per patient and the large number of patients with coverage for diabetes Respiratory and Allergy combined to generate a 12% increase in spending on diabetes drugs. The increased cost per patient can be attributed to a combination of an increased number of Musculoskeletal and Rheumatology patients, a rise in prices of brand-name drugs, and a migration of patients receiving treatment toward newer more expensive drugs.
Diabetes drugs had the distinction of contributing 20.6% to the overall 2.0% rise in prescription medication costs Increased use of various synthetic insulin products, such to Medco. Diabetes is now first on the list of the ten as rapid-acting analogs, including Apidra® (sanofi-aventis), greatest contributors to the upward trend in prescription Humalog® (Eli Lilly), and NovoLog® (Novo Nordisk), and costs. The top 13 diseases in descending order are long-acting analogs, such as Lantus® (sanofi-aventis), currently (1) diabetes, (2) respiratory diseases, (3) cancer and Levemir (Novo Nordisk), contributed to the trend and transplants, (4) rheumatologic diseases, (5) seizures, in increased spending. Total sales of Exubera® (Pfizer), Author Affiliation: Mills-Peninsula Health Services, San Mateo, California
Abbreviation: (U.S.) United States
Keywords: cost, diabetes, drugs, generic, medications, Medco, spending
Corresponding Author: David C. Klonoff, M.D., FACP, Mills-Peninsula Health Services, 100 South San Mateo Drive, Room 3124, San Mateo,
CA 94401; email address dklonoff@yahoo.com J Diabetes Sci Technol 2008;2(4):543-545 Spending for Diabetes Drugs is Increasing in the United States which was withdrawn from the market in late 2007, clinical recommendations will affect prescribing patterns contributed very little to overall spending on insulin and can increase or decrease the costs of prescriptions. products. The unit cost of insulin, which also reflects Recently reported evidence has demonstrated that some migration from insulin vials to insulin pens, colesevelam may improve glycemic control as well as increased by 14.5% last year. This rise outstripped the reduce LDL-cholesterol levels in patients with type 2 increase in the unit costs of oral agents.
diabetes receiving sulfonylurea-based therapy.4 Finally, the increasing prevalence of diabetes that is expected Among noninsulin hypoglycemic agents, utilization in the next few years will increase utilization of and growth was led by Januvia™ (Merck), which was launched spending on diabetes drugs.
in December 2006. Byetta (Amylin Pharmaceuticals), which was launched in April 2005, also contributed to The use of generic drugs can reduce the cost of increased spending in this category. Two recently medications while continuing to provide effective care. approved oral combination drugs also added to the growth Generics can provide the safety and efficacy of brand- of this category: ACTOplus met™ (Takeda), launched in name products at a lower cost.5 Before a patent on a drug August 2005, and Avandaryl® (GlaxoSmithKline), launched expires and it is produced generically, a pharmaceutical in June 2006. Increased spending for all of these drugs company may launch a newer brand name product offset the decline in sales of Avandia® (GlaxoSmithKline), containing the same basic ingredient. To extend the following release of evidence that use of this drug was patent life of an existing compound, a manufacturer linked to cardiovascular disease.2 Despite a decline in may choose to adopt one or more of the following six the unit cost for many generic diabetes drugs, overall spending on generic drugs increased by 8.7%.
1. Develop a once-daily, extended-release version of a product. This approach was used for Glucotrol® XL The Medco report went on to predict that over the next (Pfizer) and Glynase® PresTab® (Pfizer).
three years, from 2008 to 2010, spending on diabetes drugs would increase by 8%. Such an increase for 2. Introduce a new combination product. This approach diabetes would be second only to that for lipid-lowering was used for Glucovance® (Bristol-Myers Squibb), drugs. New drugs in the pipeline that are likely to be Avandamet® (GlaxoSmithKline), Metaglip™ (Bristol- submitted to the Food and Drug Administration for Myers Squibb), ACTOplus met (Takeda), Avandaryl approval include agents from the glucagon-like peptide-1 (GlaxoSmithKline), Janumet™ (Merck), and Prandimet™ and dipeptidyl peptidase-4 inhibitor families. Also a (Novo Nordisk).
combination drug containing nateglinide and valsartan 3. Obtain a new indication for a product and market is under development.
it under a different brand name. This approach was used for Revatio® (Pfizer) for pulmonary arterial Future spending trends for diabetes will likely be hypertension, which contains the same active affected by multiple factors. Newly approved drugs for ingredient as Viagra® (Pfizer), but was approved for a diabetes and obesity will probably be expensive. New different indication at a different dose and strength.
indications for selected existing diabetes drugs, such as the prevention of diabetes or obesity, will increase use 4. Add another molecule to the basic drug to extend its of these products. New dosage forms, such as alternate half-life. This approach was being considered by Nektar routes of insulin administration, will offer convenience for developing a long-acting form of Exubera (Pfizer). and possibly better predictability of absorption, but at 5. Develop a single-isomer version of a racemic a cost.3 New combination products might be released compound. This approach is being considered for and the costs of these products compared to those of thiazolidinedione products that are currently on their components might increase or decrease spending the market, such as Actos® (Takeda) and Avandia for these drugs. Patent expirations and first-time generic introductions will lower overall spending for diabetes drugs. The next diabetes drug whose patent is 6. Introduce an active metabolite of an existing product. scheduled to end will be Prandin® (Novo Nordisk) in This approach is being studied for Combrestatin-A4.7 2009. Drugs can become approved for over-the-counter This compound is a potential antihyperglycemic use and this tends to lower the necessary spending for agent, and it is the active metabolite of Zybrestat™ the drugs by prescription plans because the expense (OXiGENE), which is being developed as a is generally shifted to the patient. New research and J Diabetes Sci Technol Vol 2, Issue 4, July 2008 Spending for Diabetes Drugs is Increasing in the United States At this time, there is plenty of room for improvement in 9. Li G, Zhang P, Wang J, Gregg EW, Yang W, Gong Q, Li H, Li H, the control of diabetes in the U.S. The latest data from Jiang Y, An Y, Shuai Y, Zhang B, Zhang J, Thompson, TJ, Gerzoff MB, Roglic G, Hu Y, Bennett PH. The long-term effect of lifestyle the National Health and Nutrition Examination Survey, interventions to prevent diabetes in the China Da Qing Diabetes reported in April 2008, indicated that between 1999 Prevention Study: a 20-year follow-up study. Lancet 2008 May 24; and 2004, the age-adjusted percentage of people with diagnosed diabetes achieving a hemoglobin A1c target 10. American Diabetes Association. Total prevalence of diabetes & pre- level of <7.0% was 57.1%.8 In type 1 diabetes, additional (accessed May 25, 2008).
drug delivery methods are needed and in type 2 11. Mainous AG 3rd, Baker R, Koopman RJ, Saxena S, Diaz VA, diabetes additional drugs are needed for those patients Everett CJ, Majeed A. Impact of the population at risk of diabetes who cannot achieve adequate results from a healthy diet on projections of diabetes burden in the United States: an epidemic and regular exercise. Such new drug delivery systems on the way. Diabetologia. 2007 May;50(5):934-40. Epub 2006 Nov 21. and drugs are in the pipeline. In spite of strong evidence that a healthy diet and exercise program can decrease the incidence of diabetes,9 diabetes is likely to become more prevalent in the U.S. The number of affected adult patients is likely to climb from the current estimated number, 20.6 million, which is 9.6% of the adults in the U.S.,10 to as many as 37.7 million by 2031, which would be 14.5% of the projected adult population.11 It is very likely that spending on drugs for diabetes will continue to increase.
1. Medco Health Solutions, Inc. Drug Trend Report. Vol. 10, 2008. t rend s.jsp?BV_ S e s sion I D = @@@@ 0699039265.1211756818 hfdfhi.0&articleId=DT_Report_2008 (accessed May 25, 2008).
2. Sarafidis PA. Thiazolidinedione derivatives in diabetes and cardiovascular disease: an update. Fundam Clin Pharmacol. 2008 Jun;22(3):247-64. Epub 2008 Apr 15.
3. Khafagy el-S, Morishita M, Onuki Y, Takayama K. Current challenges in non-invasive insulin delivery systems: a comparative review. Adv Drug Deliv Rev. 2007 Dec 22;59(15):1521-46. Epub 2007 4. Fonseca VA, Rosenstock J, Wang AC, Truitt KE, Jones MR. Colesevelam HCl Improves Glycemic Control and Reduces LDL-Cholesterol in Patients with Type 2 Diabetes Inadequately Controlled on Sulfonylurea-Based Therapy. Diabetes Care. E pub 2008 May 5. Available from: http://care.diabetesjournals.org/cgi/ 5. Bagchi AD, Esposito D, Verdier JM. Prescription drug use and expenditures among dually eligible beneficiaries. Health Care Financ Rev. 2007 Summer;28(4):43-56.
6. Jamali B, Bjørnsdottir I, Nordfang O, Hansen SH. Investigation of racemisation of the enantiomers of glitazone drug compounds at different pH using chiral HPLC and chiral CE. J Pharm Biomed Anal. 2008 Jan 7;46(1):82-7. Epub 2007 Sep 8. 7. Zhang F, Sun C, Wu J, He C, Ge X, Huang W, Zou Y, Chen X, Qi W, Zhai Q. Combretastatin A-4 activates AMP-activated protein kinase and improves glucose metabolism in db/db mice. Pharmacol Res. 2008 Apr;57(4):318-23. Epub 2008 Mar 15.
8. Ong KL, Cheung BM, Wong LY, Wat NM, Tan KC, Lam KS. Prevalence, treatment, and control of diagnosed diabetes in the U.S. National Health and Nutrition Examination Survey 1999-2004. Ann Epidemiol. 2008 Mar;18(3):222-9. Epub 2008 Jan 16. J Diabetes Sci Technol Vol 2, Issue 4, July 2008

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Int. J. Biomedical Engineering and Technology, Vol. 1, No. 4, 2008 Dynamic generation of a Health Topics Overview from consumer health information documents Trudi Miller* and Gondy Leroy School of Information Systems and Technology, Claremont Graduate University, 130 E. Ninth Street, Claremont, CA 91711, USA E-mail: trudi.miller@cgu.edu E-mail: gondy.leroy@cgu.edu

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