Treatment for diabetes not so simple

lizard asleep on a branch, blue skyA once-weekly injection for type 2 diabetes could ‘transform the health of the nation’, says a newspaper headline today, but is there a bit more to it than that?

‘Simple way to treat diabetes’ is the splash on the front page of the Daily Express today.

It’s talking about a draft recommendation made by NICE (the National Institute of Health and Clinical Excellence) on a drug with the brand name Bydureon, which can be taken as a once-a-week injection to lower blood glucose in people with type 2 diabetes. If the recommendation goes ahead, this treatment could be available on prescription in England and Wales from next year. The Express says ‘this has huge implications for the health of the nation’.

Bydureon is a longer-acting version of Byetta, a twice-daily injectable drug for type 2 diabetes that has been available on the NHS since 2007. It is made by Eli Lilly and its generic name is exenatide.

Exenatide is a class of drug called a glucagon-like peptide-1 (GLP-1) receptor agonist. It was developed following the discovery of a compound in the saliva of the Gila monster lizard (pictured), which was found to have a glucose-regulating effect. In trials, exenatide has been shown to lower blood glucose but without the side-effects of hypoglycaemia (low blood sugar) and weight gain that come with other diabetes medications. In fact, it promotes weight loss.

So far, so good?

Sounds great, so far. But is it really going to transform your life if you have type 2 diabetes? Here is some background on the draft NICE guidance, which has yet to be confirmed:

• Bydureon will only be available to people with type 2 diabetes whose blood glucose is still above target levels despite using other medication (as well as diet and exercise).

• This means you would be most likely be injecting Bydureon as part of a ‘triple therapy’ regimen’ alongside two other medications, such as metformin in combination with a sulphonylurea or a thiazolidinedione.

• In addition, Bydureon is only recommended for people who are severely obese (BMI 35 or higher), or lower than 35 if insulin is not a suitable therapy.

• Some people might be able to take Bydureon if they are taking one other medication (dual therapy) but only if they cannot tolerate a combination of two other drugs.

• If you are already injecting insulin, exenatide is not a substitute for it and if you are also taking sulphonylureas, which can cause hyopglycaemia, you would still be vulnerable to this.

• Side effects of exenatide include ‘mild to moderate’ nausea, vomiting, diarrhoea and constipation, injection site reactions and headaches. At the recent meeting of the European Association for the Study of Diabetes, there was a debate on possible longer-term adverse effects of exenatide, including pancreatitis. Although it was stressed that reported incidences have been rare, more research was called for, as reported on MedPage Today.

• Availability of Bydureon may depend on your local prescribers’ view of costs. After liraglutide (Victoza), exenatide is the second most expensive drug for diabetes. Bydureon costs the NHS £73.36 plus VAT for a month’s supply.

• According to the NHS Information Centre, primary care trusts in England have varied widely in their approach to prescribing newer, more expensive diabetes drugs: in some PCTs these account for only 0.9% of diabetes drugs prescribed whereas in others it is 12.7%.

• As Diabetes UK told the Daily Express, Bydureon is initially most likely to benefit people with type 2 who are already having twice-daily injections of Byetta. This is a small number: in 2010/11, according to the NHS Information Centre, the twice-daily version of exenatide was prescribed around 250,000 times, out of 25.9 million items of diabetes drugs (excluding insulin). However, this compares with only 10,000 items prescribed in 2007/08, so growth has been rapid.

• The NICE Appraisal Committee is inviting comments on its draft guidance; the closing date is November 8. A final decision will be made in the New Year.

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  1. [...] The National Institute for Health and Clinical Excellence has given final approval for the use of Bydureon, a weekly injection treatment for people with type 2 diabetes who meet specific criteria. The treatment is a longer-acting version of the drug exenatide, which is already approved for use. For more on the guidance see the NICE website; for more on Bydureon on DiabetesChoices click here. [...]

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