Faculty of Medicine and Health, University of Sydney, The George Institute for Global Health and Westmead Hospital, Sydney, NSW, Australia; Population Health Research Institute, Hamilton, ON, Canada.
Population Health Research Institute, Hamilton, ON, Canada.
Lancet Diabetes Endocrinol. 2018 Oct;6(10):798-808. doi: 10.1016/S2213-8587(18)30233-X. Epub 2018 Aug 28.
Data are scarce on the availability and affordability of essential medicines for diabetes. Our aim was to examine the availability and affordability of metformin, sulfonylureas, and insulin across multiple regions of the world and explore the effect of these on medicine use.
In the Prospective Urban Rural Epidemiology (PURE) study, participants aged 35-70 years (n=156 625) were recruited from 110 803 households, in 604 communities and 22 countries; availability (presence of any dose of medication in the pharmacy on the day of audit) and medicine cost data were collected from pharmacies with the Environmental Profile of a Community's Health audit tool. Our primary analysis was to describe the availability and affordability of metformin and insulin and also commonly used and prescribed combinations of two medicines for diabetes management (two oral drugs, metformin plus a sulphonylurea [either glibenclamide (also known as glyburide) or gliclazide] and one oral drug plus insulin [metformin plus insulin]). Medicines were defined as affordable if the cost of medicines was less than 20% of capacity-to-pay (the household income minus food expenditure). Our analyses included data collected in pharmacies and data from representative samples of households. Data on availability were ascertained during the pharmacy audit, as were data on cost of medications. These cost data were used to estimate the cost of a month's supply of essential medicines for diabetes. We estimated affordability of medicines using income data from household surveys.
Metformin was available in 113 (100%) of 113 pharmacies from high-income countries, 112 (88·2%) of 127 pharmacies in upper-middle-income countries, 179 (86·1%) of 208 pharmacies in lower-middle-income countries, 44 (64·7%) of 68 pharmacies in low-income countries (excluding India), and 88 (100%) of 88 pharmacies in India. Insulin was available in 106 (93·8%) pharmacies in high-income countries, 51 (40·2%) pharmacies in upper-middle-income countries, 61 (29·3%) pharmacies in lower-middle-income countries, seven (10·3%) pharmacies in lower-income countries, and 67 (76·1%) of 88 pharmacies in India. We estimated 0·7% of households in high-income countries and 26·9% of households in low-income countries could not afford metformin and 2·8% of households in high-income countries and 63·0% of households in low-income countries could not afford insulin. Among the 13 569 (8·6% of PURE participants) that reported a diagnosis of diabetes, 1222 (74·0%) participants reported diabetes medicine use in high-income countries compared with 143 (29·6%) participants in low-income countries. In multilevel models, availability and affordability were significantly associated with use of diabetes medicines.
Availability and affordability of essential diabetes medicines are poor in low-income and middle-income countries. Awareness of these global differences might importantly drive change in access for patients with diabetes.
Full funding sources listed at the end of the paper (see Acknowledgments).
关于糖尿病基本药物的可及性和可负担性的数据十分有限。我们旨在研究世界多个地区二甲双胍、磺酰脲类药物和胰岛素的可及性和可负担性，并探讨这些因素对药物使用的影响。
在前瞻性城乡流行病学（PURE）研究中，从 110803 户家庭的 604 个社区和 22 个国家招募了 35-70 岁的参与者（n=156625）；使用环境社区健康审计工具（Environmental Profile of a Community's Health audit tool）从药店收集了药物可及性（审计日药房是否有任何剂量的药物）和药物成本数据。我们的主要分析是描述二甲双胍和胰岛素的可及性和可负担性，以及两种常用于治疗糖尿病的药物组合（两种口服药物，二甲双胍加磺酰脲类药物[格列本脲（也称为格列吡嗪）或格列齐特]和一种口服药物加胰岛素[二甲双胍加胰岛素]）的可负担性。如果药物的费用低于支付能力的 20%（家庭收入减去食品支出），则认为药物是负担得起的。我们的分析包括从药店收集的数据和来自家庭代表性样本的数据。在药店审计期间确定药物可及性数据，同时确定药物成本数据。这些成本数据用于估算一个月糖尿病基本药物的供应费用。我们使用家庭调查的收入数据来估计药物的可负担性。
在高收入国家的 113 家（100%）药店中可以获得二甲双胍，在中上收入国家的 127 家（88.2%）药店中可以获得，在中下收入国家的 208 家（86.1%）药店中可以获得，在低收入国家（不包括印度）的 68 家（64.7%）药店中可以获得，在印度的 88 家（100%）药店中可以获得。在高收入国家的 106 家（93.8%）药店中可以获得胰岛素，在上中收入国家的 51 家（40.2%）药店中可以获得，在下中收入国家的 61 家（29.3%）药店中可以获得，在下低收入国家的 7 家（10.3%）药店中可以获得，在印度的 67 家（76.1%）药店中可以获得。我们估计高收入国家的 0.7%的家庭和低收入国家的 26.9%的家庭无法负担二甲双胍，高收入国家的 2.8%的家庭和低收入国家的 63.0%的家庭无法负担胰岛素。在报告患有糖尿病的 13569 名（PURE 参与者的 8.6%）参与者中，1222 名（74.0%）参与者在高收入国家报告使用糖尿病药物，而在低收入国家只有 143 名（29.6%）参与者报告使用。在多水平模型中，药物的可及性和可负担性与糖尿病药物的使用显著相关。
在中低收入国家，基本糖尿病药物的可及性和可负担性较差。了解这些全球差异可能会极大地推动患者获得药物的机会。
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