Drug therapy for type 2 diabetes mellitus is primarily carried out with oral antidiabetics, and in advanced stages also with insulin. Last year, spending on oral antidiabetics rose by almost twelve percent, twice as much as the entire pharmaceutical market and now represents a spending level of over half a billion euros within the statutory health insurance system. There are sometimes large differences between the 17 KV regions in Germany in terms of per capita expenditure on oral antidiabetics, which are not least related to the different proportions of obese people - measured by the body mass index (BMI).

> Diabetes is considered a social challenge. The 2008 Drug Atlas makes a conservative estimate of currently around 3.3 million type 2 diabetics in statutory health insurance in Germany. Due to the growing proportion of older people in the population, the number of people with type 2 diabetes has increased significantly in recent decades and will probably continue to rise in the coming years. In many cases, diabetes can be prevented or at least delayed through appropriate prevention - ie a healthy diet, physical activity and a normal weight. Because: A healthy lifestyle reduces the risk of developing diabetes.
It is assumed that around 81 percent of type 2 diabetics take a daily therapy dose of an oral antidiabetic drug (OAD) every day (see Häussler, Bertram et al.: Medicinal Atlas 2008, p. 91). The GKV market for this OAD will be examined in more detail below.
12 % increase in spending
for oral antidiabetics
According to INSIGHT Health, the statutory health insurance market for oral antidiabetics had a spending volume of 520 million euros in 2008 - valued at current pharmacy sales prices. This corresponds to an increase of 11.7 percent compared to 2007 (for comparison: insulins: + 4.9 percent; entire pharmaceutical market + 5.3 percent).
The number of statutory health insurance prescriptions for OAD increased by only 6.1 percent in the same period - to 17.6 million prescriptions billed in 2008. This means that the expenditure on oral drug therapy for diabetes has increased significantly more than the corresponding prescription numbers. This is primarily due to the six new active ingredients introduced since October 2006. Active ingredient combinations that alone resulted in almost 50 million euros in additional expenditure in 2008 compared to 2007. In addition, the growth rates have increased noticeably compared to the changes from 2006 to 2007 (Fig. 1).
Almost every third euro is
spent on metformin
Different classes of active ingredients are used for the drug therapy of type 2 diabetes. The biguanide antidiabetic drugs with metformin are the most relevant in this regard, accounting for 31.0 percent of expenditure. The sales share of glitazones of 26.2 percent (of which 11.7 percentage points for glitazone combination preparations) is also considerable. The alternative sulfonylurea antidiabetic drugs account for 19.1 percent of sales. The expenditure share of DPP-4 inhibitors of 9.4 percent is remarkable, as this class of active ingredients has only been established on the market since 2007. A corresponding combination preparation with metformin has also been available since August 2008 (Fig. 2).
The reason for the high status of metformin in oral diabetes therapy - which, by the way, is even more pronounced in the number of prescriptions with a share of 56.9 percent - can be stated that metformin is particularly recommended for obese diabetics due to the lack of weight gain (as long as there are no contraindications present) is currently the “gold standard” of pharmacotherapy. Likewise, during insulin therapy, i.e. in patients with advanced diabetes, the treatment of insulin resistance with an oral antidiabetic drug - and this is usually metformin - must be continued (see Matthaei, Stephan / Häring, Hans Ulrich: Treatment of diabetes mellitus type 2, in : Diabetology 2008 (3) 2, p.161). Some antidiabetics are also only approved in combination with metformin or sulfonylureas (see, for example, KV Berlin: Information on the prescription of oral antidiabetics, May 2008).

High correlation between BMI and antidiabetic drug spending across regions
A comparison of the 17 KV regions reveals major differences: While in Schleswig-Holstein in 2008 only 4.93 euros were spent per GKV insured person on oral antidiabetics, in Saxony it was 11.73 euros. In 2008, the national average expenditure per insured person for oral antidiabetic drugs was 7.40 euros (for comparison: insulin: 16.60 euros).
It is exciting to compare the differences in spending on oral antidiabetics in the KV regions and the corresponding proportion of obese people (BMI > 30). Ultimately, the selection of the antidiabetic drug is based on the severity of the diabetes, among other things, on the BMI. As shown in Figure 3, parallels exist between obesity and OAD drug spending in many KV regions.
Ultimately, however, BMI is not the only weight indicator to be taken into account. For example, it is considered useful to measure abdominal circumference in addition to the overweight indicator BMI. The fat deposits in the abdominal area increasingly release substances into the blood that can, among other things, promote type 2 diabetes (see Pischon, Tobias et al.: General and Abdominal Obesity and Risk of Death in Europe, in: N Engl J Med 2008;359:2105-2120)."

The mega topic of obesity calls for prevention
In addition to BMI, other factors such as lifestyle, age and comorbidities must of course also be taken into account when choosing medication, so that such a comparison of two parameters (such as BMI and OAD expenditure here) can ultimately only show a trend. There are also regional differences in terms of care structures, such as structural contracts and disease management programs.
The goal of most therapy and training programs for type 2 diabetics is to influence the disease behavior of those already affected as favorably as possible. With the help of well-founded information and advice, those affected should be able to do their own part to ensure that the disease progresses as complication-free as possible. When developing new care concepts, however, consideration should not only be given to the optimal treatment of diabetics, but also to the prevention of new diabetes diseases. The mega issue of overweight seems to be of considerable importance here. This brings the question of suitable and sustainable prevention options to the fore. <<

by: Christian Bensing /
Dr. André Kleinfeld*