NHS spends tens of millions on expensive diabetes drugs

For many of the 2.8 million diabetes sufferers in the UK synthetic insulin, to moderate their blood sugar level, is a crucial drug. But with the numbers of diabetics set to rise it’s a growing area of research, investment and profit for the pharmaceutical industry.

Now a joint investigation by Channel 4 News and BMJ (British Medical Journal) estimates that the more expensive type of insulins for people with Type 2 diabetes has cost the NHS tens of millions extra over the past five years. Our estimate reveals that if half of diabetics used a cheaper version then it could have saved the health service as much as £250 million during that period. Yet for most patients the extra cost does not correspond to equivalent extra health benefits.

If I spend twice the price for something, I sort of more or less expect to get twice the benefit – Dr Adler, NICE

Central to the Channel 4 News/BMJ investigation is the role of so-called modern insulins known as analogue insulins. They are molecularly tweaked to change the rate of absorption in the body. So the ones designed to give quick hit of insulin – say around a meal time – are swifter acting than the older versions, and those that are designed to give a low background level are a little longer lasting.

These tweaks undoubtedly give them some advantages over older insulins. Their makers claim that, amongst other benefits, they have smoother, more predictable action, the risk of low blood sugar levels (hypoglycaemia) is reduced and the convenience and ease of these insulins help patients to gain good control over their diabetes.

They now account for about 80 per cent of all insulin usage in the UK. Since 2004/5 that represents a 116 per cent increase in analogue insulin prescriptions. The trouble is that these benefits come at quite a cost – the newer drugs are expensive, typically two or three times as much as the equivalent older versions of insulin. But the question of whether they provide equivalent benefits is at the centre of the raging debate on the treatment of diabetes in the UK.

The National Institute for Clinical Excellence (NICE) which advises the NHS on which drugs are the most effective, has looked at the evidence for long acting analogues for Type 2 diabetics – the majority of insulin taking patients.

It concluded that for most of Type 2 patients beginning insulin therapy, the benefits of modern insulins do not justify their cost and they recommend that patients should be started on human insulin – an older, cheaper version of synthetic insulin which contains the human genetic code.

The cost difference can be striking. The starting insulin that NICE recommends for most Type 2 patients is a formulation called NPH. It costs £7.48 for a 10ml vial. The nearest analogue equivalent costs some £26 for a 10ml vial.

Dr Amanda Adler from NICE who was chair of the team that drew up their guidance thinks that up to 90 per cent of patients ought to be able to start on the cheaper NPH version and says patients “would probably do quite well on these human insulins compared with the long acting insulin analogues”.

“If I spend twice the price for something, I sort of more or less expect to get twice the benefit,” Dr Adler added. And while she recognises that over time some patients will need to switch to analogues she estimates that approximately 70 per cent ought to be successfully treated on the cheaper NPH insulin.

But it is the scale of the cost implications for the National Health Service as a result of this shift towards analogue insulin that is concerning practitioners. Figures collated for Channel 4 News suggest that if half of ALL those taking analogue insulins had been put on the equivalent human insulin instead the NHS would have saved at least £250m over the past five years.

Channel 4 News reports on diabetes investigation:

NHS wastes tens of millions on expensive diabetes drugs
A joint investigation by Channel 4 News and the BMJ reveals the NHS spends tens of millions more than necessary on modern insulins to treat diabetes despite guidance from NICE to use cheaper products.

Diabetes and insulin: your questions answered
Tom Clarke explains what the illness is and what you should do if you're affected.

Why diabetes is big business for drug companies
The numbers of those diagnosed with diabetes will continue to rise but, as Deborah Cohen, Investigations Editor of the BMJ explains, the cost to the NHS does not need to spiral out of control.

Diabetes is a huge and growing public health problem for the NHS and the bill is rising much faster than the average for the health service. While insulin is just one part of the overall burden of diabetes latest figures suggest the net bill for diabetes has grown by some 42 per cent compared with a 6 per cent general increase in net ingredient costs across the NHS over the same period.

The rise in the use of analogues in the UK and overseas has taken place despite a large body of evidence from systematic reviews and meta-analyses that have found that in almost all classes of insulin – short-acting, mixed insulins and long-acting versions – the clinical benefits for most patients is modest at best.

Nevertheless globally, analogues now account for approximately 60 per cent of the insulin market and the manufacturers are keen to develop this market further. This is a concern for the World Health Organisation. In an unpublished document seen by this investigation, Dr Hans Hogerzeil, the chief of the WHO’s essential medicine division, writes with concern about global insulin market being dominated by giant companies “who are pushing a new type of insulin analogue at 3-5 times the cost of human insulin, while its marginal cost-effectiveness is not fully established.”

The makers of analogue insulins say that looking at the direct costs of the insulins misses the wider value these drugs bring. They say that the overall advantages of the analogue insulins outweigh the extra upfront cost of the insulins itself.

Dr Andrew Hockey, Director of Medical Operations for Sanofi Aventis UK, makers of the largest selling analogue insulin globally, told Channel 4 News that “the value to patients is that the modern insulins offer a much better experience…compared to human insulin they’re less likely to have an attack of a dangerously low blood sugar…It’s allowed treatment to move out of hospitals back into GP’s surgeries and we know that is a cheaper place to treat diabetes. Using modern insulins you have to look beyond the cost of the insulins in itself.”

Withdrawing Mixtard 30

Mirroring the rise of analogues is the reduced role of human insulins. At the end of the year, one popular older insulin formulation called Mixtard 30 is being withdrawn by manufacturer Novo Nordisk. It’s estimated that some 90,000 people use this insulin and, as a result of the withdrawal, they are changing onto other insulins before the end of the year.

One person who has been using Mixtard 30 successfully for many years is Christine Crump. She is in an especially difficult position because she has experienced allergic reactions to all of the insulin alternatives she has tried. “Mixtard 30 has been my lifeline,” she told Channel 4 News. “Without an alternative insulin that doesn’t cause reactions, I am really worried about whether I’ll even be here this time next year.”

Novo Nordisk say that whenever new products that provide benefits in efficacy or safety become widely used manufacturers must consider ceasing production of older versions.

The debate on the relative merits of human and analogue insulins is unlikely to go away. The best way to settle the argument, according to Professor Edwin Gale from Bristol University, would be to have a double-blind clinical trial of insulin treatment for type 2 diabetes, which would assess analogue and human insulins head-to-head.

Remarkably, given the money at stake, such a trial has yet to happen.

Phil Carter is an independent film maker and journalist