Following on from yesterday’s interview with AstraZeneca’s Director of Marketing Chris Boulton, PharmaTimes Digital puts the same questions on diabetes to Greg Jones, Diabetes Consultant, Honorary Associate Professor Diabetes Centre, Gartnavel General Hospital, Glasgow.
PT: Is diabetes enough of a national priority?
GJ: No. Things are improving but we spend less of our health budget on diabetes than it deserves by its prevelance. Also most of the resource committed is on the complications and consequences of diabetes. For instance only 6% of diabetes spending is on drug therapy to reduce glucose and 15% on non-diabetes drugs but 69% is spent on in-patient care of diabetes.
PT: What must be done nationally to improve the management of diabetes and therefore treatment outcomes?
GJ: In Scotland we are trying to be more joined-up in our thinking regarding diabetes. We have good IT resources now (SCI-DC) which shares information across all care providers which is a start. We also need to start focusing on health inequalities by co-ordinating medical and social care. The 'house of care' model for a proactive, patient centred, co-ordinated system of care and support for people with long-term conditions which was developed in England is a great way forward. We can then start looking at joint decisions with patients about what they want with regards to their diabetes and empower them to move towards those goals.
PT: Can pharma play a bigger role in improving diabetes management and outcomes?
GJ: We live in exciting times with regards to diabetes treatments that are fit for purpose. It is pharma’s role to continue to drive improvements in pharma therapy along with the healthcare providers and promote use of newer therapies to the right people at the right times.
PT: What are your thoughts on NICE’s type II diabetes guideline?
GJ: I would hope they are radically redrafted. It is methodologically poor in many ways. I note for instance that some drugs are presented as a class and others as an individual drug. This suggest a 'cherry picking' approach to methodology. The positioning of repaglinide is very puzzling. It is used very, very little at present in diabetes care. It has no sound CV outcome data and whilst causing less hypoglycaemia and weight gain than sulphonyurea treatments it still does cause these side effects. Pioglitazone is again oddly positioned compared to standard clinical care. Pioglitazone is a drug that's use is made less attractive by its linkage with heart failure, fractures and bladder cancer. My worry is that these medications are being overly thrust forward in NICE guideline only because they are off patent and cheap. Not because the evidence backs up their usage.
PT: Which new therapies do you expect to make the most impact in the treatment of diabetes?
GJ: The incetin (injectible GLP agonists and oral DPPv inhibitors) therapies are now well established. The SGLT2 inhibitors are a newer class which show great promise. We have been using the first to market in UK (dapagliflozin) in Scotland for a year longer than in England. SGLT2 inhibitors block the reuptake of glucose in the kidney tubules. This action is independent of insulin so the drug can be used in a wide range of patient types (i.e. add on metformin, with other oral agents or with insulin) Because you then lose glucose in the urine blood glucose levels and weight both decrease. As a bonus BP also goes down. This is a very good treatment profile for a glucose lowering drug.
PT: In clinical practice, do budget constraints interfere with managing the condition in the most effective way?
GJ: There are always pressures to reduce drug spend. It is my job as a clinician to stand up for patient choice and ensure pressure to prescribe in a cost effective manner doesn't impact the patient. There are times when a lower cost drug option may well have a greater overall cost. As an example, whilst a sulphonylurea might be a cheaper drug it may have hidden costs. The patient may need to be given a blood glucose meter and strips, they may have a hypoglycaemic episode with ambulance call out, they might put on weight with the health economic impact that has. I think the economic impact of these harms is often underplayed in order to drive down simple to measure prescribing indices which is short sighted.