John A. Johnson, MD, MBA: If you check the current standards or guidelines, which would be [those from] the American Diabetes Association and the American Association of Clinical Endocrinologists, both advocate, initially, for starting with a single agent—whether it’s metformin, which is a biguanide—and then, subsequently, adding on other agents.
What we know in the United States is that diabetes is a progressive disease. So the longer you live with the condition, the more likely you will require more than one medication—unless you significantly change your diet and activity level.
Patients, or the public, tend to associate the number of medications (particularly the number of pills) with worsening of their disease or condition. So, what a lot of pharmaceutical companies have done, and WellCare supports this, is combine medications such that it’s 2 medications in 1 pill.
With combination therapy, to the patient it’s 1 pill; but it’s actually 2 medications. In the last 25 years, we’ve seen an expansion in the number of oral antidiabetic agents. Insulin, as you know, was developed in 1921. About 35 years later, sulfonylureas came on the market. But then, if you fast-forward to 1994 or 1995, the biguanides—[including] metformin, which I referenced—became available. Then, within the last 25 years, you see this expansion of another 10 agents in [various] classes. So, as our knowledge about diabetes, and how to treat and manage diabetes becomes more refined, more agents have become available. These are basically tools in the provider’s belt that help him manage a diabetic.
At WellCare, we try to ensure that all of these tools (medications)—the low-cost affordable options—are available on our preferred drug list. We work with the provider community to make the oral antidiabetic medications and insulin available on our preferred drug list so that providers and our members have access to those medications.
But, again, there is a myth that the number of medications you have, or that you’re on, portends worsening of your disease. And so, it’s about education and awareness and reassuring our members and patients that the number of medications is not meant to be punitive, but rather supportive— to help. Again, not all medications work for every patient. The drug cocktail is very patient-centered—very individualized such that it has to take into account other comorbidities and conditions you may have that may not allow you to take one agent over another.