Recently, I had the opportunity to look at the data for a self-insured employer with a younger workforce and more women than men. Heart disease and related conditions like diabetes and hypertension should be reduced in this kind of employed population compared with other employers— 30% or less. Compare that with a population with an older, male blue-collar workforce where cardiovascular and related conditions lead to 60% of all healthcare spending based on real data from the last year. You cannot know this unless you have access to the all of the detailed data as required under the Consolidated Appropriations Act.
This younger workforce data listed the 100 drugs that led to the greatest healthcare spending for this employer. It was quite revealing. Six of the top twenty drugs in terms of employer spending were diabetes drugs. The drug that led the list was Trulicity ($1117/mo). The other five were Ozempic ($936/mo), Farxiga ($678/mo), Tresiba ($213/mo), Rybelsus ($1104/mo), and Novolog ($174/mo). Metformin was way down the list past the 80th drug generating high cost. There were almost half as many Trulicity prescriptions as metformin prescriptions. Metformin costs $4 a month.
The data is real, and it reflects a real problem. Diabetes guidelines say that every person who has been diagnosed with type 2 diabetes should be on metformin. That is because treating type 2 diabetes is not mainly about treating the sugar level. It is about reducing the risk of heart attack, death, and other diabetes complications. Patients on metformin have a 39% reduced risk of heart attack and a 32% reduced risk of other complications compared with other patients who have achieved the same blood sugar level— for $4 a month. By comparison, Trulicity reduced a combined outcome of non-fatal myocardial infarction, non-fatal stroke, or death from cardiovascular causes by 12%. It is easier to show benefit in a collection of outcomes as opposed to heart attack alone, and therefore metformin has more than three times the impact of Trulicity on reducing heart attacks. Ozempic reduced the risk of heart attack in patients with type 2 diabetes by 26%. That result is also inferior to metformin alone. With Rybelsus, the risk of heart attack was actually increased by 18%.
Farxiga reduced heart attack by 11%. There were 393 heart attacks in the Farxiga group vs 441 in the sugar pill (placebo) group. Tresiba and Novolog are insulins. Insulin treatment seems to increase the risk of death and heart attack. Metformin has the most powerful effect on heart attack reduction of any other single drug— for $4 a month.
But that is not even the real question in treating patients with type 2 diabetes. It is not a matter of what is the best drug to control weight or reduce the blood sugar. Here is the real question. What combination of diet, exercise, and medicines for diabetes (metformin), cholesterol (statins), high blood pressure (lisinopril or losartan and eplerenone or spironolactone) produce the best outcomes and here the example is clear. That combination is called optimal medical therapy. Farxiga reduces the relative risk of a heart attack by 11%. That is the difference of 393 heart attack vs 441 heart attacks. Optimal medical therapy reduces the risk of heart attack from 36 to 9. That is a four-fold difference vs a tiny fractional difference. The entire OMT protocol can be purchased for about $30 dollars. The benefit does not stop there. OMT results in a five-fold reduction in stroke, a six-fold reduction in dialysis, a threefold reduction in amputation and a threefold reduction in blindness. Patients on OMT live eight years longer than patients in usual care— the care most of us receive.
Even more sadly, the percentage of Americans who have their glucose numbers controlled to goal is completely stagnant despite the availability of these many new and expensive drugs. It has not improved over decades. As Atul Gawande said it best, “our system is designed for the great breakthrough, not the great follow through.” Advanced primary care teams focused on chronic conditions like diabetes do the best job of the “great follow through.” I have done this work before. Among my 242 patients with diabetes and hypertension, the mean HbA1c was 6.8%, with 64% (155/242) less than 7%. That was in 2004 and our only tools were metformin and insulin. The last national data shows that only about half of Americans with diabetes achieve a hemoglobin A1c of 7 or less despite the availability of these expensive new drugs.
There is a way to improve your health and delay the need for these expensive medications. Weight gain and diabetes are increasing because we are eating a lot more fast food, processed food, high fructose corn syrup, and sugar. A key part of slowing the progression to diabetes and expensive medications for diabetes and obesity is to eat real, whole food—lean meat, eggs, fruits, vegetables, beans, peas, and nuts. Prediabetes is defined as a fasting sugar of 100 or greater. Taking metformin and a whole food diet lead to weight loss and slows the progression to diabetes and expensive drugs. It is the same once a person with diabetes has a fasting sugar of 126 that establishes the diagnosis of diabetes. Metformin and a real food diet that cuts way back on carbs and sugar may be all that is needed. If treatment beyond metformin and diet is needed to achieve the glucose goal, the best next medication is a drug like Farxiga. It is the least expensive of the new medications for type 2 diabetes. It also has the dramatic benefit of reducing chronic kidney disease progression and heart failure hospitalization by 30%. An advanced primary care team focused on diabetes and related conditions like heart disease and high blood pressure can delay progression to expensive medications and serious complications like heart attack. We can do this now. Let’s get started!
Bill: I want to be a bit provocative here: primary care is not the answer. We have spent our whole careers promoting primary care and family medicine, and we are witnessing the death of both. It’s time to think about promoting optimal medical care for a range of chronic illnesses that most affect our public health, and to create this as a new speciality based on knowledge and science. Our greatest professional problems stem from overspecializing in areas of the body’s diseases. It is overly technologized and extractive, and serves the public poorly.
Thank you. The whole system needs a wake up call. But we also need to take ownership.