In 1923, the Nobel Prize in Physiology or Medicine was awarded for the discovery of a drug which turned out to be one of the landmark discoveries in the history of medicine. Such a gift to humanity it was, the three scientists involved in the project sold the patent to manufacture the drug for a total of just three Canadian dollars, one dollar for each of them, to the University of Toronto.
They did so because they felt that it would be unethical for doctors to profit from a discovery that was meant to save lives, says historian Michel Bliss, in his book, Discovery of Insulin .
Is it not ironical that nearly 100 years after insulin was discovered, this life-saving drug has today become one of the most expensive and unaffordable drugs in many poor, low and middle income countries, driving the health-care costs up? Prices of insulin variants have tripled in the past one decade in many countries, including India.
Type 2 diabetes mellitus (T2DM) has indeed turned out to be a gold mine for pharma companies which aggressively market newer and more expensive versions of the drug and for some doctors, who enthusiastically shift their patients to the newer drugs.
An estimated 20% of the adult Kerala are afflicted by T2DM.
As more and more patients are put on newer insulins and the cost of diabetes care skyrockets, the question that should be naturally asked is, are things getting any better?
No significant benefits?
“Analog (synthetic) insulins might suit a certain profile of patients but for the majority, these do not offer significant advantages over the less expensive human insulin. Patients’ affordability is a key consideration as the treatment is long term,” says K.P. Paulose, a senior physician and former professor of Medicine.
Many international experts share the view.
A study, which followed T2DM patients for nearly two years, found that the use of the more expensive insulin analogs did not appear to result in better safety (JAMA June 23, 2018).
Yet another study of some 23,000 patients over a 11-year period (April 2016, JAMA)said that despite its incremental benefits, their premium price raised the question whether they are really necessary, and if so, for whom?
“Diabetes management is a flourishing industry and no doubt, there are rich dividends for pushing expensive drugs to patients. Cost effective options and adherence to diabetes drug protocols are only for the public sector, which caters to only a small section of the diabetic population in the State,” points out K. Thankappan, former head of Achutha Menon Centre for Health Science Studies and a public health professional.
Advantages
Those who prefer using newer versions of drugs counter it.
“Analog insulins have certain benefits such as prevention of nocturnal hypoglycemia episodes, cardiac protection or no weight gain. These might not be affordable to all. The aim of diabetes management is to prevent the patient from developing complications, as the disease progresses. Treatment is highly individualised, based on the clinical characteristics of each and hence cost of care would differ” says Mathew John, a consultant endocrinologist.
While there are patients whose diabetes medication costs have been steady at less than ₹500 a month for the past five years, there are also those whose monthly medication costs come in the range of ₹7,000-20,000.
The World Health Organisation (WHO), in calling for all physicians to strike a balance between implementing the best-established standard of care and what is feasible on a large scale in resource-limited settings, had rejected proposals in 2011 and 2017, to include insulin analogs on model drug list.
This was following the report of its Expert Committee on the Selection and Use of Essential Medicines that the relatively modest overall benefit from analogs was outweighed by the price difference between these and human insulin and that uncertainty remained regarding the association between analog insulins and increased cancer risk.
C. Maya
