India is referred to as the "Diabetes Capital of the World" because 17% of all global diabetic population reside in India. Nearly 80 million people in India have diabetes now, and by 2045, that number is expected to increase to 135 million [1] thus has also been given the status of "public health priority".  In developing country like India, diabetes treatment cost alone constitutes 5 to 25% of the average Indian households income.²

In India, diabetes is rapidly becoming a significant and expensive healthcare issue. As a result, controlling diabetes and related comorbidities is a significant challenge due to several problems and roadblocks, including a lack of knowledge about diabetes, its risk factors, cost of treatment and affordability, non-adherence to medication, etc. All these challenges and issues together, significantly exacerbate Indias economic diabetes crisis.[2],[3]

Another biggest problem and a major strain in our present healthcare system is medication adherence. The prevalence of economic instability, low literacy, and limited access to healthcare services in a resource-constrained nation like India may have contributed to a rise in the incidence of medication non-adherence. Cost of diabetes treatment is major factor of medication non-adherence, resulting reduced treatment effectiveness. For every 10% increase in treatment adherence there is decrease in HbA1c by 0.16%.⁸

In a cross-sectional observation study on medication adherence and determinants of non-adherence among Indian diabetes patients.[4]  The study showed an overall anti-diabetic medications adherence rate is 48% among patients. The main factors for non-adherence were lack of finance in 56% and poor accessibility in 20% of patients respectively. The study highlighted that the overall medication adherence rate as unsatisfactory.  Lack of finance and medicines inaccessibility as the major barrier to anti-diabetic medication adherence.[5]

To understand medication cost as the one of the major factor for non-adherence to antidiabetic therapy, let us discuss a case study from the real world. A 50-year-old vegetable vendor with T2DM, who was prescribed Sitagliptin and Metformin now presents at the clinic with HbA1c of 8.2% and BMI of 24kg/m².  “Inadequate HbA1c control and cost of therapy” are his prior concerns. The high cost of the therapy is the main concern and thus he failed to adhere to the prescribed therapy, which in turn resulted in uncontrolled HbA1c. In such a scenario, it is required to prescribe not only a cost-effective medication but with a similar efficacy that will help him to achieve his HbA1c goal. He was prescribed a combination of Metformin and Glipizide, an equally effective as well as pocket-friendly drug. Due to the equivalent efficacy and affordable regimen, he adhered to his prescribed regimen thus achieving his HbA1c goal of Ë‚ 7% HbA1c after 3 months of initiation of therapy.

From this, we can perceive that the need of the hour is affordable, accessible, and appropriate oral anti-diabetes agents (OADs) which help to maximize the treatment benefits in diabetes care. The selection of the OADs to be the responsible patient-centered approach. Metformin and modern SUs combination is the most used combination in India and is time tested affordable, available, accessible drug combinations in offering optimal glycemic control in a cost-effective manner.[6]

A multinational randomized parallel-group, the non-inferiority study reported that Glipizide or Sitagliptin added to the Metformin therapy resulted in similar HbA1c control (1.11 vs. 1.13, respectively). However, the adverse events with the use of the Glipizide + Metformin group were lower compared to Sitagliptin + Metformin (Nasopharyngitis, 75 vs. 10%; Urinary tract infections, 2% vs. 5%; osteoarthritis, 0.7% vs. 2%, respectively). These results proved that Glipizide reported equivalent HbA1c lowering efficacy as observed with sitagliptin when added to Metformin monotherapy; however, Glipizide use has been associated with lesser adverse effects than Sitagliptin.[7]

Choosing the right therapy for the right patient is important for enabling them to improve their glycemic control while reducing the burden on their pocket.

References:

[1] Why India is diabetes capital of the world. Available online at: http://timesofindia.indiatimes.com/articleshow/95509990.cms?utm_source=contentofinterest&utm_medium=text&utm_campaign=cppst

[2] Oberoi S et al. Int J Diabetes Dev Ctries. 2020 Oct; 40(4): 464–475.

[3] Bansode B et al. Diabetes & Metabolic Syndrome: Clinical Research & Reviews. 2019;13(4): 2469-2472.

[4] Medi RV et al. Journal of Social Health and Diabetes. 2015;3(1):48-51.

[5] Medi RV et al. Journal of Social Health and Diabetes. 2015;3(1):48-51.

[6] Das AK et al. Int J Adv Med. 2021 Oct;8(10):1618-1626.

[7] Nauck MA et al. Diabetes, obesity & metabolism. 2007;9(2):194-205.

8 Wabe NT, N Am J Med Sci. 2011 Sep; 3(9): 418–423.