Changes in Diabetes Management
Two of the most talked about changes in the management of diabetes in the past 5 years has been centered around new drug therapy and monitoring devices. We expect underwriters will encounter more of these examples in the coming years and when equipped with up-to-date knowledge, can be more effective in their decision making.
New Medications: GLP-1 agonists and SGLT-2 inhibitors
In recent years, we’ve seen an increase in prescriptions of GLP-1 agonists and SGLT-2 inhibitors in the treatment of diabetes. In underwriting we’ve started seeing these appear as an additional therapy for Type 2 diabetes after metformin. Previously, the ‘-gliptins’ (DPP-4 inhibitors) and the sulfonylureas were considered the popular choice.
Common SGLT-2 Inhibitors and GLP-1 agonists:
| Class of Medication | Generic Name | Brand Name |
| SGLT2 Inhibitor | Empagliflozin | Jardiance |
| Dapagliflozin | Farxiga | |
| Canagliflozin | Invokana | |
| Ertugliflozin | Steglatro | |
| GLP-1 Receptor Agonists | Exenatide | Exenatide |
| Liraglutide | Victoza | |
| Albiglutide | Tanzeum | |
| Dulaglutide | Trulicity |
As of 2019, the American Diabetes Association has changed its recommendations for patients with cardiovascular disease or chronic kidney disease to make GLP-1 agonists and SGLT-2 inhibitors the preferred medications after metformin. This is an important shift in diabetes management that acknowledges these new drugs not only for their beneficial effect on blood sugar control, but also on mortality.
A recent meta-analysis and review of current literature conducted by Zheng et al. found significant reductions in cardiovascular mortality by 21% with the use of SGLT-2 inhibitors and 15% with GLP-1 agonists. Notably, traditionally-prescribed DPP-4 inhibitors did not have any significant impact on mortality.
Also worth noting is that the SGLT-2 inhibitor empagliflozin, and the GLP-1 agonists liraglutide and exenatide were associated with reductions in all-cause mortality—32%, 15% and 14% respectively.
While the new guidelines indicate the ‘-gliptins’ are still recommended in cases without cardiovascular or kidney disease, the added all-cause mortality reduction will likely make select SGLT-2 inhibitors and GLP-1 receptor agonists a more popular choice for both patients and physicians in the years to come.
Unfortunately, these new ‘miracle’ drugs are not without consequence. Being newcomers to the pharmaceutical industry, almost all are brand name medications that come with a hefty price tag. For example, empagliflozin, brand name Jardiance, at the time of writing this article is priced at approximately $20 USD per pill. Compare that with the popular sulfonylurea, glipizide, which is priced at $0.67 USD per pill.
Bloodless Glucose Monitoring
Similar to the new medications, continuous glucose monitoring systems have been around for several years, although only recently reaching mainstream popularity and affordability. This increase in popularity is due in part to the decreased need for fingersticks and therefore, pain.
These systems aren’t perfect, however. As of this writing, no truly non-invasive solution to blood glucose monitoring exists, although many companies are competing to develop the first. Companies like Dexcom and Abbott Laboratories are leading the way with a method of monitoring involving sensor insertions that can last up to two weeks. These sensors sit just under the skin, and measure glucose in the interstitial fluid as opposed to blood. While still invasive, one ‘pin-prick’ every two weeks is a much more comfortable alternative to the traditional methods of checking glucose several times a day.
Other limitations to this technology often include a ‘warm up’ period of several hours, a lag on readings of several minutes, and of course, a hefty price tag. The Dexcom G6 system costs roughly $3,400 USD annually, and the Abbott Laboratories Freestyle Libre system $1,700 USD annually. On the bright side, more and more health insurance companies are now offering partial or complete coverage, making it more accessible to patients.
These systems were previously only recommended for Type 1 diabetics and children, but studies show better glycemic control with their use, regardless of the type of diabetes. As a result, the 2019 Standards from the American Diabetes Association now advises its usage for any condition that requires improving glycemic control in children to adults alike.
With better glucose monitoring available in the near future for all patients, the insurance industry will have access to more reliable readings and better data than that obtained from the typical A1c done every few months. Better data means better informed patients, better patients, and better informed underwriters.
