Ongoing efforts to improve the management of patients with diabetes in Bangladesh and the implications

Abstract

Background: Prevalence rates of patients with diabetes are growing across countries, and Bangladesh is no exception. Associated costs are also increasing, driven by costs associated with the complications of diabetes including hypoglycemia. Long-acting insulin analogues were developed to reduce hypoglycemia as well as improve patient comfort and adherence. However, they have been appreciably more expensive, reducing their affordability and use. Biosimilars offer a way forward. Consequently, there is a need to document current prescribing and dispensing rates for long-acting insulin analogues across Bangladesh, including current prices and differences, as a result of affordability and other issues. Methods: Mixed method approach including surveying prescribing practices in hospitals coupled with dispensing practices and prices among community pharmacies and drug stores across Bangladesh. This method was adopted since public hospitals only dispense insulins such as soluble insulins free-ofcharge until funds run out and all long-acting insulin analogues have to be purchased from community stores. Results: There has been growing prescribing and dispensing of long-acting insulins in Bangladesh in recent years, now accounting for over 80% of all insulins dispensed in a minority of stores. This increase has been helped by growing prescribing and dispensing of biosimilar insulin glargine at lower costs than the originator, with this trend likely to continue with envisaged growth in the number of patients. Consequently, Bangladesh can serve as an exemplar to other low-and middle-income countries struggling to fund long-acting insulin analogues for their patients. Conclusions: It was encouraging to see continued growth in the prescribing and dispensing of longacting insulin analogues in Bangladesh via the increasing availability of biosimilars. This is likely to continue benefitting all key stakeholder groups.

The Current Situation Regarding Long-Acting Insulin Analogues Including Biosimilars Among African, Asian, European, and South American Countries; Findings and Implications for the Future

“…Similar to previous projects, impressions were provided from physicians and pharmacists when no Ministry of Health or other robust data sets were available to document changes in utilisation and prices of insulin glargine as well as other insulin preparations in recent years. That is, if other information sources were unavailable due to issues of confidentiality and local culture since we were not paying physicians or pharmacy personnel for their time ( 35 , 97 – 99 ). The data from community pharmacies and drug stores have been supplemented with utilisation and expenditure data from hospitals where available.…”

“…Among the five surveyed public and private hospitals and institutions in Bangladesh, there was considerable variability in the prescribing of long-acting insulin analogues as a percentage of total insulins ( Table 3 ). These prescribing patterns reflect the fact that among public hospitals in Bangladesh standard insulins such as regular, intermediate and premix insulins are typically provided free-of-charge until monies and supplies run out; however, this is not universal ( 35 ). Following this, insulins are generally purchased from pharmacies and drug stores with 100% co-payment.…”

“…Following this, insulins are generally purchased from pharmacies and drug stores with 100% co-payment. Having said this, there are hardship funds available among some hospitals in Bangladesh to help cover the costs of insulin for the very poor given concerns with the potential catastrophic impact on the family if members have diabetes ( 35 , 127 , 128 ).…”

“…Alongside this, there have been calls for disinvestment in insulin glargine ( 29 ); however, this is changing ( 34 ). The same situation persists in Bangladesh where the Government only funds NPH and other insulins in public hospitals until funds run out, and in parts of India ( 18 , 35 ).…”

“…This matches limited price reductions for biosimilar insulin glargine seen in other markets, which are easily matched by the originator company reducing their attractiveness ( 53 ). Besides, there can be concerns with switching patients between originators and biosimilars due to different devices and the potential for hypoglycaemia in some countries ( 53 – 56 ); however, this is not universal ( 35 ). Concerns regarding the different devices resulted in, for instance, low use of insulin glargine biosimilars (9%) among diabetologists in the UK in 2017 ( 57 ).…”