8 October 2019

We need a new strategy to take on the scourge of diabetes

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Medical experts have long recognised that the standard of care for diabetes is outdated and needs to change. Based primarily on studies of European and North American men, our current approach to treatment is failing to stop a disease that kills four million people a year, mostly in developing countries, and costs the global economy $825 billion each year.

It’s time for a new approach. With an early, more aggressive treatment strategy, we believe millions of people around the world could live longer, healthier, more productive lives while reducing stress on overburdened healthcare systems.

A new landmark study published in The Lancet medical journal supports this conclusion with welcome new data: treating patients with type 2 diabetes simultaneously with two medicines immediately after diagnosis dramatically delayed progress of the disease. The study is the first to investigate long-term clinical benefits of combining two medicines in type 2 diabetes, and the findings point to a potentially new strategic approach with an early combination and holistic care for diabetes.

Regardless of where you live, if you have diabetes, one thing is certain: the longer you delay treatment, the more likely you are to face devastating complications.

Even in the best of circumstances, where patients have access to quality medical care, complications from diabetes can include eye disease resulting in blindness; kidney disease requiring dialysis or transplants; nerve damage and peripheral vascular disease, eventually leading to amputation; and heart disease, stroke and brain damage. In low and middle-income countries, these outcomes are tragically common.

The current standard of care calls for sequential treatment with one medicine, metformin, followed by another oral medicine, and only after the first treatment fails. This standard was formulated with little data from low and middle-income countries, where type 2 diabetes today tends to present earlier and progress more quickly, and negative outcomes are far more common.

Recognising the inadequacy of this approach, a consortium of stakeholders in healthcare and government sought to close this gap in our understanding of the disease’s progression, as well as the effectiveness of different treatment approaches. The pioneering five-year study, sponsored by Novartis, included 2001 patients in Africa, Asia, and Latin America, as well as Europe.

The results are unambiguous: early treatment with both medicines, metformin and vildagliptin, reduced the likelihood of treatment failure for newly diagnosed patients by a staggering 49% compared to treatment with only metformin, the current standard of care. The complementary therapy also delayed progression toward other health complications, such as the secondary loss of glycemic control, the body’s ability to regulate blood sugar. Patients who are most vulnerable to the disease—such as individuals with low birth weights or presence of other non-modifiable risk factors for diabetes—also demonstrated a positive response to this new treatment approach.

If the standard of care for type 2 diabetes were to reflect this approach, while stressing the importance of early diagnosis and treatment, we could ease tremendous amounts of suffering and realise significant economic gains. After all, up to 85% of the cost of diabetes comes from managing its devastating complications.

Early diagnosis and treatment with two medicines in combination would cut medical costs by postponing complications and reducing hospital visits with a median cost of $290 per inpatient, while raising the quality of life and lengthening the productive lifespans of diabetes patients, boosting economic growth. This is especially important in high-incidence low- and middle-income countries such as Mexico (with an estimated prevalence of 12.6%) and Egypt (prevalence 16.8%), where type 2 diabetes is a tremendous and growing drag on economic growth and prosperity.

We also need to ensure that a combination treatment for management of diabetes—a single pill that contains both metformin and vildagliptin or any given combination with similar evidence in the future—is affordable, easy to take, and widely available.

It is now clear that “better late than never” does not apply to diabetes. According to the study results, the same combination treatment given later in the disease’s progression did not yield the same benefits. Early diagnosis and treatment are crucial to patient success, and stronger health care systems will realise greater gains.

These findings are encouraging us that this disease can be controlled—and someday cured. However, it will require a concerted scientific, technical and public health effort to deliver the benefits of these discoveries to the world, and a commitment to affordability and availability to ensure they are shared equally.

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Sir Michael Hirst is Co-chair of Parliamentary Diabetes Global Network (PDGN) and President of the International Diabetes Federation 2013-2015. Dr Päivi Maria Paldánius is Worldwide Medical Director Diabetes at Novartis, and the medical lead of the landmark study, VERIFY.