The Big Business of Diabetes Drugs
There’s been a small run of Diabetes-related items in the New York Times recently and not-so-recently. The one that caught my eye is the one in the New York Times by Jerry Avorn about clinical guidelines and how they can be influenced http://www.nytimes.com/2013/06/12/opinion/healing-the-overwhelmed-physician.html?hpw. That one made me think about some of the new diabetes drugs that have been getting press. Glaxo-Smith Kline, which makes Avandia, was very happy the other day when the FDA said it will re-open the question about whether it’s drug is responsible for increased risk of heart attack http://www.nytimes.com/2013/06/03/business/second-thoughts-on-safety-of-avandia-stir-a-dispute.html?pagewanted=all. I also noticed that a new injectable one-a-week drug called Bydureon from Amylin just got approved even though there are concerns about thyroid cancer, pancreatitis, and cardiovascular problems http://www.nytimes.com/2012/01/28/health/bydureon-a-diabetes-drug-from-amylin-wins-fda-approval.html. Victoza, by Novo Nordisk, is a similar drug. That got me thinking: “are the new drugs better? Which led me to Walecia Konrad’s article in 2011 about how the older drugs are better, safer, and cheaper http://www.nytimes.com/2011/05/28/health/28consumer.html.
Hmmm… Why all these recent new treatments for diabetes? Boys and girls, big big money. We spent 22 Billion dollars on diabetes drugs last year. Merck made 5.7 billion on the sale of Januvia and Janumet, it’s newest agents. Bydureon is estimated by the company to cost $4200 per person per year and make the company 1 billion dollars. By contrast Metformin and Glipizide, which have been around for a long time, will run you about $120/year. Avandia will run you $1,500/year.
Let’s look at effectiveness. Maybe the cost is justified by the awesomeness of the newer drugs. Your blood sugar is determined by four factors: the amount of insulin you make (insulin lowers blood sugar), how sensitive your insulin receptors are, how much glucagon you have (glucagon increases insulin production) and how much sugar your liver makes and your digestive system absorbs. You can see that there are many points at which you can interfere with blood sugar levels with various drugs. Metformin doesn’t increase insulin production. It works by decreasing the amount of sugar your liver makes, making your insulin receptors more sensitive, and decreases intestinal absorption of sugars. Avandia increases insulin sensitivity, and also doesn’t increase insulin production. Bydureon is what we call a GLP-1 receptor agonist. This means that it mimics the effects of the naturally-occurring hormone glucagon. Glucagon increases insulin production. So if your sugar is too high Bydureon will get you to release more insulin. Glyburide does essentially the same thing, but Glyburide also decreases the amount of sugar the liver produces and increases the sensitivity of the insulin receptors. Comparative effectiveness data tends to be surprisingly hard to find. Metformin and Avandia are roughly equally effective. Bydureon interacts at fewer regulation points than Glybyride, and comparison studies haven’t really been done.
OK, so the newer drugs are not more awesome. Are they safer? The Mayo Clinic does a really great job with this question on their website http://www.mayoclinic.com/health/diabetes-treatment. All have side effects. The older ones have sort of test-of-time safety profiles. The newer ones, as I’ve said above, have some problems that may or may not be significant. Why have companies spent so much money coming up with new versions of the same thing? It’s all about the money.
So, take home message: start with the cheap, move to the expensive. Unless you’re talking about shoes or husbands, you don’t get what you pay for. What bothers me about the new diabetes drugs is not their mechanisms or side effects or even cost. It’s that pharmaceutical companies are investing millions of dollars to come up with new drugs that do the same thing as old drugs, in order to get in on the market. AND that they spend millions more defending their products and promoting their products disingenuously. I would love to see those companies invest their R&D money on things that are really new and really helpful, regardless of market value. I would love to see them use all that lovely money to make more than shareholder returns.