Microsoft word - diabetes-medicationanalysis.doc
Potential Effect of a Low-Fat, Vegan Diet on Medication Costs in
Type 2 Diabetes
Diabetes treatment typical y involves the use of several pharmaceutical agents.
Often, one, two, or more drugs are required for blood glucose control, along with
additional agents to reduce blood cholesterol and blood pressure. While drug
treatments are often necessary and can be lifesaving, their use entails significant
costs, as wel as adverse effects.
Recent studies suggest that diet changes al ow individuals with diabetes to
achieve benefits that are similar to those of medications and may al ow
reductions in medication use. In particular, low-fat vegetarian and vegan diets
reduce blood glucose, blood cholesterol, and blood pressure, and help control
body weight. The fol owing brief analysis examines the potential for cost savings
that may accrue from reductions in medication use that may be expected from
the use of a low-fat vegan diet for type 2 diabetes. An Example Regimen
An example of a common drug regimen in current use for individuals with
diabetes includes al of the fol owing:
1. Metformin, often along with a sulfonylurea or thiazolidinedione
2. A cholesterol-lowering drug, such as atorvastatin (Lipitor)
3. A blood-pressure-lowering medication, such as an angiotensin
converting enzyme (ACE) inhibitor (eg, lisinopril), or an angiotensin receptor blocker (ARB) (eg, losartan), often along with hydrochlorothiazide. The choice of a common regimen for analytical purposes is somewhat arbitrary. Many, although not most, individuals with type 2 diabetes use insulin, and some use newer medications, such as exenatide or sitagliptin. Each of these entails significant costs, but were not included in this analysis. The fol owing analysis assumes that diabetes medications are taken at or near maximal effective doses, lipid-lowering and blood pressure medications are taken at common, not necessarily maximal, doses, and that medications are used singly (not in combinations) and are purchased monthly from an online discount outlet.
The fol owing prices are from DrugStore.com (www.drugstore.com, accessed
January 8, 2007). Prices at retail pharmacies may be somewhat higher.
Metformin generic 1,000 mg, 1 pil twice daily: 60 pil s = $55.99
Metformin (Glucophage) 1,000 mg, 1 pil twice daily: 60 pil s = $109.91
Glipizide generic 10 mg, 1 pil twice daily: 60 pil s = $10.99 Glipizide XL (Glucotrol XL) 10 mg, 1 pil twice daily: 60 pil s = $58.25
Glimepiride (Amaryl) 4 mg, 1 pil twice daily: 60 pil s = $69.98
Glyburide (Micronase) 5 mg, 2 pil s twice daily: 120 pil s = $126.41
Rosiglitazone (Avandia) 8 mg, 1 pil daily: 30 pil s = $175.08 Pioglitazone (Actos) 45 mg, 1 pil daily: 30 pil s = $179.99
Atorvastatin (Lipitor) 40 mg, 1 pil daily: 30 pil s = $103.99
HCTZ generic 25 mg, 1 pil daily: 30 pil s ($8.99 per 100 pil s) = $2.70
Lisinopril generic 20 mg, 1 pil daily: 30 pil s = $10.99
Lisinopril (Prinivil) 20 mg, 1 pil daily: 30 pil s = 31.19
Losartan (Cozaar) 50 mg, 1 pil daily: 30 pil s = 57.99
Additional costs, such as glucose meters, test strips, lancets, blood tests
(including tests required to monitor potential adverse effects of medications), and
medical visits are not included in this analysis, because some monitoring wil be
required even for wel -control ed diabetes. These costs are significant. For
example, a 100-pack of One Touch Ultra strips (a commonly used product) costs
$97.99, and could easily be used in the course of a few weeks. Effect of a Low-Fat Vegan Diet
A low-fat vegetarian or vegan diet reduces A1c by roughly the same degree as a
single oral hypoglycemic agent. In a 22-week randomized clinical trial including
99 individuals with type 2 diabetes, the use of a low-fat vegan diet was
associated with an average drop in A1c of 1.0 percentage points (Barnard 2006).
Such a diet also reduces low-density lipoprotein cholesterol by 20-40%, which is
similar to the effect of common statins.1-3
The expected drop in blood pressure from such a diet is less clear. In absence of weight loss, vegetarian diets lead to smal but significant reductions in systolic and diastolic blood pressure.4 However, vegan diets also cause weight loss, leading to larger drops in blood pressure. We present below the costs of common medication regimens and show the savings that would be adduced if dietary effects obviate the need for one of two oral diabetes medications (a sulfonylurea or thiazolidinedione). We then present the savings that would accrue if diet changes also permitted the elimination of a statin drug, and one of two antihypertensives (hydrochlorothiazide). Greater savings would be realized if ACE inhibitors or ARBs were eliminated. For purposes of this analysis, we assume that a diet change obviates the need for a medication if its effect is similar in magnitude to that of a medication. However, we note that some clinicians may choose to prescribe statins in the absence of hypercholesterolemia. Our figures show that the elimination of a single diabetes medication would be expected to produce annual savings ranging from $131.88 (the cost of a generic sulfonylurea) to $2,159.88 (the cost of a thiazolidinedione). If diet changes also permitted the elimination of a statin and hydrochlorothiazide, annual savings would range from $1,412.16 to $3,440.16 for the scenario described above. The lower figure applies to an individual who discontinues a generic sulfonylurea, atorvastatin, and hydrochlorothizide. The higher figure differs only in that the discontinued diabetes drug would be a thiazolidinedione. We caution that this analysis is intended to provide a likely scenario for a common individual case, not comprehensive data for groups of individuals with varied regimens. It should be noted that individual results from any diet regimen vary, depending in part on adherence. Some individuals wil not be able to reduce medication use, despite dietary changes, and some may be able to reduce their dosages, but not eliminate their medications. Individuals who do not fol ow prescribed diets wil not achieve any corresponding benefits. However, this analysis suggests that programs that encourage dietary changes are likely to yield substantial benefits. This analysis disregards differential food costs, which are often lower on vegetarian diets, compared to omnivorous diets, but may be higher for individuals who are not yet accustomed to shopping for such diets. It also disregards intangible benefits of diet changes, such as weight loss, reduced cancer risk, reductions in neuropathy symptoms or joint pain, or the prevention of hypoglycemic episodes (a common result of sulfonylurea treatment).
Monthly Costs for Common Medication Regimens Used for Diabetes
SU, ACE High-
Blood pressure control
1Costs without 1 diabetes medication
1,2Costs without 1 diabetes medication, 1 statin, and 1 blood-pressure medication
1. Ornish D, Scherwitz LW, Bil ings JH, Brown SE, Gould KL, Merritt TA, Sparler S, Armstrong
WT, Ports TA, Kirkeeide RL, Hogeboom C, Brand RJ. Intensive lifestyle changes for reversal of
coronary heart disease. JAMA 1998;280:2001-7.
2. Jenkins DJA, Kendal CWC, Marchie A, et al. Effects of a dietary portfolio on cholesterol-
lowering foods vs lovastatin on serum lipids and C-reactive protein. JAMA 2003;290:502-510.
3. Barnard ND, Cohen J, Jenkins DJ, Turner-McGrievy G, Gloede L, Jaster B, Seidl K, Green AA,
Talpers S. A low-fat, vegan diet improves glycemic control and cardiovascular risk factors in a
randomized clinical trial in individuals with type 2 diabetes. Diab Care 2006;29:1777-1783.
4. Berkow S, Barnard ND. Blood pressure regulation and vegetarian diets. Nutr Rev 2005;63:1-8.
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Asthma – Minimum Requirements May 2009 version 1) The TUE application for the use of the inhaled beta-2 agonists (terbutaline, salbutamol, salmeterol and formoterol) needs to clearly establish whether the diagnosis is: • exercise-induced asthma (EIA; some patients require only pre-exercise treatment); • mild or more severe chronic, persistent asthma with an exercise-induced