medwireNews: A modeling study predicts a greater than 20% increased need for insulin to treat patients with type 2 diabetes over the next 22 years, with implications for medication access.
The findings reported in The Lancet Diabetes & Endocrinology also show the likely effects of adopting a more relaxed glycated hemoglobin (HbA1c) target for older patients.
The recent IDF estimates show a projected type 2 diabetes prevalence of 405.6 million people in 2018, rising to 510.8 million in 2030. Based on this and the proportion of people requiring insulin, the researchers calculate that its use would increase from 516.1 million 1000-unit vials per year in 2018 to 633.7 million per year in 2030.
However, the proportion of people actually using insulin represented only around half of those who required it. If global demographics changed as anticipated, but insulin access remained at current levels, Sanjay Basu (Stanford University, Palo Alto, California, USA) and team calculated that 7.4% of patients would use it in 2030.
But if all patients who needed insulin had access to it, this proportion would increase to 15.5%. The discrepancy between projected insulin use at current versus comprehensive access levels was largest in Africa, at 1.8% versus 12.5%, and smallest in the Americas, at a corresponding 13.6% and 19.2%.
“These estimates suggest that current levels of insulin access are highly inadequate compared to projected need, particularly in Africa and Asia, and more efforts should be devoted to overcoming this looming health challenge,” said Basu in a press statement.
He added: “Unless governments begin initiatives to make insulin available and affordable, then its use is always going to be far from optimal.”
In the scenario of comprehensive insulin access, treatment to an HbA1c target of 7% (53 mmol/mol) would avert a total of 331,101 disability-adjusted life–years (DALYs) in the year 2030, with 65% of these being in Asia, due to its current status of high diabetes prevalence but poor insulin access.
But the highest number of DALYs averted occurred when the researchers adopted a split target of 8% (64 mmol/mol) for people aged 75 years or older and 7% for younger patients. This strategy increased the number of DALYs averted by 44.2% relative to a universal 7% target, because it minimized hypoglycemic events among older patients.
This strategy is therefore “likely to improve overall health by balancing the risks of hypoglycaemia with longer-term microvascular disease benefit,” said Basu.
In an accompanying commentary, Hertzel Gerstein (McMaster University and Hamilton Health Sciences, Ontario, Canada) notes that, being a modeling study the results are based on a large number of assumptions, including that only eye, nerve, and renal disease respond to tight glycemic control, and that there will be no changes in the use of diabetes medications that are known to mitigate the risk for hypoglycemia.
“Such considerations suggest that predictions about the future need to be viewed cautiously,” he writes.
“Indeed, the rapid pace of diabetes-related research suggests that one or more of the foregoing assumptions will prove to be wrong. For example, any model in 1985 is unlikely to have accurately predicted the diabetes epidemic that was clearly apparent only 15 years later.”
Nevertheless, he echoes the researchers in saying that “insulin is likely to maintain its place as a crucial therapy for type 2 diabetes, and as such a sufficient global supply needs to be estimated and ensured.”
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