Introduction:
Treatment for type 2 diabetes centers on effective control
of blood glucose to avoid serious and systemic long-term consequences such as microvascular
complications (e.g., retinopathy, nephropathy, and neuropathy) and
macrovascular complications (e.g., coronary heart disease, stroke). The
American Diabetes Association (ADA) issues annual treatment guidelines; since
2008, these guidelines have recommended lifestyle changes such as diet and
exercise and the use of metformin at diagnosis. Our analysis of newly diagnosed
type 2 diabetes patients in the United States shows that branded agents then
compete for share as add-on or stand-alone therapy after metformin. In
particular, Takeda’s Actos (pioglitazone) and Merck’s Januvia (sitagliptin) are
vying for positioning as the leading second-line branded agent following
metformin. When patients require even stronger glycemic control, physicians
turn to insulins and insulin analogues such as Sanofi-Aventis’s Lantus (insulin
glargine) and Novo Nordisk’s Levemir (insulin detemir). In choosing
pharmacotherapy, prescribing physicians seek a balance between efficacy in
lowering HbA1c, potential side effects, and cost, as most patients
eventually require combination therapy for glycemic control. Our analysis integrates
patient-level claims data and insight from 152 U.S. endocrinologists and PCPs whom
we surveyed to determine how concerns over side effects associated with the
PPAR-gamma agonist drugs and the availability of Januvia have changed
prescription patterns since our last report (in 2008). This report determines
the share of each currently marketed drug by line of therapy, analyzes why key
drugs are chosen over others, and anticipates how physicians’ prescribing
habits will change over the next two years with the launch of Bristol-Myers
Squibb/AstraZeneca’s Onglyza (saxagliptin), the expected launch of Novo
Nordisk’s GLP-1 analogue Victoza (liraglutide), and the impending launches of
Alkermes/Amylin/Eli Lilly’s Byetta LAR, a once-weekly formulation of the first-in-class
GLP-1 analogue Byetta (exenatide), from Amylin and Eli Lilly.
Questions Answered in This Report:
*
Metformin is the leading agent in first- and second-line therapy
for type 2 diabetes.
What is the treatment initiation rate for newly
diagnosed patients, and what are the major barriers to initiating treatment?
What are the retention rates for other early-line treatments, including
differences between Januvia and Actos? Which drugs are used most often with
metformin? How closely do prescribing physicians adhere to the ADA guidelines through all three lines of therapy?
*
Pathways to key therapies: Longitudinal claims data reveal which
agents in a given class are placed ahead of other agents in lines of
therapy.
How are Actos and Januvia positioned relative to each other in
each line of therapy? When do physicians turn to Byetta, and what could limit
Victoza’s uptake in the type 2 diabetes market? What drugs precede the use of
Lantus and Levemir, and what does this pattern say about how physicians use
each agent?
*
Physician behavior: Type 2 diabetes patients are treated by both
endocrinologists and PCPs; the reasons physicians give for changing treatment
from a given agent differ between the two types of treating physicians.
What
factors most influence each physician type when making drug choices? What drug
attributes are most critical in differentiating between Actos and Januvia,
between Byetta and Lantus, and between Lantus and Levemir? What do surveyed
endocrinologists and PCPs view as the differential advantages of Actos,
Januvia, Byetta, and Lantus? What are physicians most likely to do upon failure
of metformin therapy?
*
Forecast: Many surveyed physicians say they will increasingly
consider weight loss in their prescribing habits and reduce their early-line
use of metformin and sulfonylureas.
For which drug classes do
physicians anticipate writing more prescriptions over the next two years? How
do endocrinologists and PCPs differ in their anticipated prescribing? To which
drugs will physicians turn more often than metformin and the sulfonylureas?
Will Januvia’s increased use in type 2 diabetes treatment continue over the
next two years? How will Onglyza’s greater specificity for DPP-IV help it
challenge Januvia’s position? Will Victoza be able to compete against Byetta
LAR? Scope:
Primary research: Quantitative results from our
survey of 152 physicians (77 endocrinologists and 75 PCPs):
- Physician opinion on how drug use differs by patient severity.
- Most influential drug attributes when physicians choose between agents.
- Anticipated changes in the line of therapy in which physicians use key
agents.
Primary patient-level data: Quantitative findings
from our analysis of data covering 61 million lives from 98 geographically
diverse U.S. health plans:
- Quantified lines of therapy analysis showing exact share of each agent
in each line of therapy, including rate of progression between lines and length
of time patients are on each line.
- Progression flowcharts through one year of treatment for newly diagnosed
patients receiving each of the following first-line agents: Takeda’s
Actos, GlaxoSmithKline’s Avandia, Merck’s Januvia, Lilly/Amylin’s Byetta,
Takeda’s Actoplus Met, GlaxoSmithKline’s Avandamet and Avandaryl, glyburide-metformin,
Merck’s Janumet, Takeda’s Duetact, Sanofi-Aventis’s Lantus, Novo Nordisk’s
Levemir, Novo Nordisk’s Prandin, and Novartis’s Starlix.
- Flowcharts tracking the preceding therapy patterns for patients taking
each of the following key therapies: metformin, sulfonylureas,
metformin ER, Actos, Lantus, Januvia, short-acting insulin analogues,
glyburide-metformin, Janumet, Actoplus Met, mixed insulins, Byetta, Daiichi
Sankyo’s Welchol, Avandia, long-acting regular insulins, short-acting regular
insulins, Levemir, Prandin, Avandamet, Starlix, Amylin’s Symlin, Avandaryl,
Precose, Metaglip, and Duetact.