PETALING JAYA, Jan 12 — More people are using insulin to treat diabetes despite current management guidelines recommending the use of newer glucose-lowering therapies, said Dr Zanariah Hussein, an endocrinologist at Putrajaya Hospital.
Dr Zanariah, who heads the endocrine unit at the government hospital, said there was a 7.2 per cent increase in the prescription of insulin at Ministry of Health (MOH) primary health clinics in the past seven years, with 30.3 per cent of MOH clinics prescribing insulin in 2019.
Despite the high use of insulin and the substantial amount of money spent in procuring insulin, Dr Zanariah said there has not been a reduction or improvement in the rates of glucose control or complications of diabetes.
“Insulin use is high. The MOH spends about RM400 million in its human insulin tender. That’s how high it is. But with an increment in use of insulin, we haven’t seen a result in reduction in or improvement in the rates of glucose control or complications.
“High insulin use is our problem in MOH primary care and hospital care, and lack of use of nephroprotective and cardioprotective medications, which we really need to solve,” said Dr Zanariah at the 6th Health Economics Forum 2022 here last November 23 organised by the Health Economics Outcomes Research (hEOR), a unit of the Galen Centre for Health and Social Policy.
Malaysia is estimated to have spent RM4.38 billion in direct health care expenditure on diabetes in the year 2017, which amounted to over 45 per cent of total costs of three non-communicable diseases (NCDs) – cardiovascular disease, diabetes and cancer – according to the Direct Health-Care Cost Of Noncommunicable Diseases in Malaysia report by MOH and the World Health Organization.
The report held that 70.56 per cent of the estimated cost for diabetes in 2017 was attributed to primary care and outpatient attendances.
Separately, the International Diabetes Federation (IDF) Diabetes Atlas 2021 showed that Malaysia’s total diabetes-related health expenditure in 2021 amounted to US$4.83 billion (RM20.5 billion), averaging at about US$1,090 (RM4,626) per person.
The IDF projects that Malaysia will spend US$5.65 billion, an increase of about 17 per cent, on diabetes-related health expenses by 2030. This translates to an average diabetes-related health spending of US$1,275 per person.
In addition to the prohibitive amount of money spent on tackling diabetes, Malaysia has to also contend with the comorbidities that are likely to accompany diabetes, Dr Zanariah said.
Dr Zanariah said patients facing type 2 diabetes (T2D) are at a greater risk of developing cardiorenal risks and nephropathy, or deterioration of kidney function.
Dr Zanariah cited data from the National Diabetes Registry Report 2013-2019 where nearly 70 per cent of T2D patients in primary care have developed nephropathy.
About 80.4 per cent have hypertension, which is one of the predominant risk factors for the development of several cardiovascular diseases, while 74.3 per cent have dyslipidemia or unhealthy levels of one or more kinds of lipid (fat) in a person’s blood, which can lead to cardiovascular disease with severe complications.
Despite the worrying figures, Dr Zanariah said there is a lack of prioritisation of lifestyle interventions and nutritional and weight management in treating diabetes.
“Diabetes is not just about drugs. I think a lot of focus has been about drugs, and not enough has been done to prioritise lifestyle interventions and nutritional management and weight management.
“This year, the American Diabetes Association and EASD (European Association for the Study of Diabetes) have actually prioritised weight management as probably the first target for managing diabetes. So, we really do have to focus on that,” Dr Zanariah said.
When it comes to choice of drugs, Dr Zanariah said although glucose drugs have undergone vigorous long-term testing to ensure efficacy and safety, especially in ensuring cardio and renal safety, Malaysians are unable to benefit from these drugs as it is not used “in a big way” in Malaysia.
Dr Zanariah highlighted the SGLT2-i (sodium/ glucose cotransporter-2 inhibitors) drug for treatment of T2D.
The SGLT2-i are a new type of glucose-lowering drug that can reduce blood glucose by inhibiting its reabsorption in proximal tubules and by promoting urinary glucose excretion. SGLT2-i are widely used in the clinical treatment of type 2 diabetes mellitus (T2DM).
In recent studies, SGLT2-i were found to not only reduce blood glucose but also protect the heart and kidney, which can significantly reduce cardiovascular events, delay the progression of renal failure, greatly improve the quality of life of patients, and reduce medical expenses for families and society.
“Now, I boxed up in [green], where the SGLT2-i [are], which is a not-so-new class of glucose-lowering drug, oral drug, but it has really made a huge impact in terms of lowering cardiac complications.
“And I think that it has been around Malaysia for some time, as I’ll show you, but we are unfortunate [not] to be able to use it in a big way, and therefore our patients, at large, are not able to get the benefit of preventing cardiorenal disease. Even mortality, in fact, because these drugs have been shown to reduce cardiovascular and renal death,” said Dr Zanariah.
Data presented by Dr Zanariah showed that the use of insulin to treat T2D by MOH has increased over the years. In 2013, the rate of use for insulin for T2D was 23.1 per cent, and in 2022, the figure is expected to hit 61.1 per cent – a 38 per cent increase in the span of nine years.
It was also noted that although the SGLT2-i was registered in Malaysia in 2014, it has only seen a 40.8 per cent usage in 2022. The reason for this minimal use of newer drugs by the MOH is budget, Dr Zanariah said.
“Unfortunately, when drugs come into the MOH, they don’t come with a budget or a special allocation. They come in and you just have to use the same amount of funds that you have already used and try to fit it in — which is really tough. And that’s why the newer drugs are being used really minimally.”
During the forum’s question and answer session, Dr Zanariah expressed her support for the use of co-payments to pay for drugs.
“In general, I would say I like the idea, and I have thought of that for years actually, but I’m not sure why it’s not possible in MOH. I know that in the universities sometimes they just have to pay a small amount of money for whatever prescription they have, if there are certain drugs on that prescription list.
“But generally, I have always agreed to it. I’ve mentioned it to some of the pharma who’ve approached me, especially for certain drugs that are very difficult to afford for the long term.
“And for diabetes it would be the GLP1 receptor. And they’re really beneficial and patients would benefit if they see the difference. I’m sure they (patients) would actually, some at least, would want to actually contribute to the payment of the drug.
“Right now for the SGLT2 inhibitors, we have a fair number in Putrajaya that actually pay out-of-pocket when we already tell them that this drug really, really does impact on their cardiorenal risk and improve it,” said Dr Zanariah.