Drugs to lower blood sugars don’t do much for your health
• In the last five years in British Columbia, taxpayers – that would be you and I – spent over $100 million on drugs and insulins for type-2 diabetes through our Pharmacare program. In addition, people in BC probably spent another $200 million out of their own pockets and the pockets of our employer-sponsored drug plans on diabetes treatments. Add to that the costs of all the doctor’s visits and the diabetes paraphernalia – including glucose test strips, lab tests and so on to keep blood sugars monitored – and two things are clear: this is one expensive disease and it creates a huge amount of medical busywork.
Maybe the hundreds of millions of dollars we’re spending on diabetes measurements and treatments is well spent. Surely, it would be if we could be sure people are getting the drugs they need so they don’t suffer heart attacks and strokes and the more serious complications of diabetes. But can we be sure of that? Hmm, probably not.
There is one particularly strong theme you’ll hear when doctors discuss diabetes: that if you have it, you are increasing your cardiovascular risk, for example, your risk of a heart attack and stroke, both which could be fatal. People with type-2 diabetes have difficulty processing sugar, a condition that is described in guidelines as a “complex chronic disease characterized by hyperglycemia due to defective insulin secretion, defective insulin action or both.” Insulin is produced by the pancreas and regulates both the breakdown and movement of glucose, which is critical to maintaining blood sugar levels within normal ranges. The good thing is if you’ve got too much sugar floating around in your bloodstream, there are many drugs to lower those sugars.
But if you read no further in this column, here’s the punch line: Most of the money we spend in this province on drugs to reduce blood sugars in type-2 diabetics achieves almost nothing. While the drugs can be extremely effective at lowering blood sugars – and so it appears they are doing something useful – they will do almost nothing at lowering serious health risks, such your chances of a cardiovascular event like a heart attack or stroke.
Don’t believe me? The latest newsletter put out by the Therapeutics Initiative at UBC, which assesses clinical studies of drugs, concluded, “Glucose lowering medications for people with type 2-diabetes are widely prescribed in Canada despite having been approved by Health Canada without credible evidence that they reduce mortality or major morbidity.”
The newsletter says a little bit more, but let’s consider the implications of this statement for the average person. A man named John is in his mid 70s and has lived all his life without any consideration that he may be ill. He has no symptoms, but after being sent for a routine blood test he is told he is now a diabetic and needs to take drugs and maybe insulins to control his disease. More specifically, he is told he has a “high” reading on his hemoglobin A1c test, (HbA1c), also known as a glycosylated hemoglobin test. This is a marker of how well one’s blood sugar has been controlled during the previous two to three months. If it is much higher than ‘normal’ the doctor will look for any signs of kidney or eye damage or damage to blood vessels in the legs, all of which are considered “microvascular complications” that are linked to diabetes. The next step is he’s put on a drug called metformin. This is how things usually roll.
In BC, the government sponsored diabetes care guidelines say that any hemoglobin A1c greater than 6.5% constitutes a diagnosis of type-2 diabetes. Most experts say that 7 percent is the magic threshold and keeping the HbA1c level below 7 percent will lead to fewer diabetes complications (eye or kidney disease). But again, this is controversial. Even Consumer Reports on Health in the US says there is no definitive proof that keeping HbA1c under 7 percent prevents heart disease or premature death and they remind us that most of the studies of HbA1c are short, a year or less. The upshot? Who knows what the long-term effects of driving blood sugars down below this level are?
But we push on. Why? Because John’s HbA1c is closer to 8.5 and the guidelines say it should be 6.5. The standard advice for anyone identified as having a “high” HbA1c level is to lose weight and control one’s blood sugars through diet and exercise. Controlling one’s diet – especially cutting back on carbohydrates – and getting more exercise can be the closest thing to a cure and the good news is you don’t have to be a marathon runner to get adequate exercise. In fact, daily walking is enough for many people to stave off diabetes, push their HbA1c down and avoid the worst complications of the disease.
Have you ever noticed how much activity there is around a disease if the drug industry can produce profitable products that appear to do something for it and can be sold for daily use over the long term? Well, type-2 diabetes is the poster-child for a drug-friendly disease, and you can imagine the absolute cornucopia of drug treatments for type-2 diabetics that are out there.
Diabetes is the marketer’s ideal condition as it allows a lot of profitable busywork around measuring blood sugar levels, altering those levels with drugs, and measuring again. Trying to get your blood sugars down to 7 or 6.5 percent makes for very good activity to distract people from the fact the drugs are doing almost nothing to alter the underlying course of the person’s diabetes.
Like most newly diagnosed type-2 diabetics, John first gets prescribed two of the oldest and cheapest drugs, metformin and glyburide. The real big money for the drug companies, however, comes from the newer treatments, including more than a dozen on-patent and much more expensive drugs that lower blood glucose. These include the Gliptins: sitagliptin (Januvia), saxagliptin (Onglyza), linagliptin (Trajenta), alogliptin (Nesina); the Tides: exenatide (Byetta), liraglutide (Victoza), albiglutide (Eperzan) and dulaglutide (Trulicity); and the Flozins: canagliflozin (Invokana), dapagliflozin (Forxiga) and empagliflozin (Jardiance).
Collectively, Canadians spend nearly $750 million per year on prescription drugs that lower glucose, an amount that works out to about 628 prescriptions per 1,000 people, about the same volume we consume in antibiotics. But how many drugs does one need to get those numbers down? In BC, about 100,000 people take a single drug (mostly metformin) every day to lower their blood glucose. But it doesn’t stop there. Nearly 65,000 BC residents take two or more diabetes drugs and nearly 30,000 take three or more.
A 2013 review from the Cochrane Collaboration found that ‘intensive glycemic control’ – trying to keep the HbA1c at or below the 7 percent mark – did not reduce rates of cardiovascular death, non-fatal stroke and end-stage kidney disease. What was cruelly ironic in that study – a meta-analysis of nearly 30 studies on the same question – is that patients who were subjected to intensive glycemic control had more serious adverse events, including severe hypoglycemia (which often ended in hospitalization). In other words, the taking of multiple drugs to drive one’s blood sugars lower and lower seems to be a fool’s game.
Who stands to benefit from the war on glucose? Just follow the money, I say. Driving for lower and lower blood sugars is big money in Canada. In BC alone we spend hundreds of millions of dollars chasing blood sugars into absurd territory. We allow the pharmaceutical companies to write the guidelines and our own doctors to be ‘educated’ about those pharma-funded guidelines.
Hoodwinked by the diabetes industry, we spend, as a society, tons of money treating this so-called risk factor called hemoglobin A1c, yet all that money does almost nothing to save lives or help people live longer. We should be spending healthcare dollars that purchase health. This diabetes scam just gives more profits to the drug companies while giving us nothing in return.
Alan Cassels lives in Victoria where he studies and writes about the pharmaceutical industry, disease mongering and overdiagnosis. His latest book is The Cochrane Collaboration: Medicine’s Best Kept Secret.