Diabetes physicians based in the UK are renowned for their encyclopaedic knowledge of drug acquisition costs. This is attributed to the dominance of NICE (the National Institute for Health and Care Excellence) which has a major focus on ‘cost-effectiveness’, widely and perhaps cynically equated to ‘cost per tablet’. Several recent developments, however, suggest that Germany aims to challenge this UK dominance.
In December 2013 AstraZeneca and Bristol-Myers Squibb ‘pulled’ their diabetes drug ‘Forxiga’ (dapagliflozin) from pharmacies in Germany. The move came after the companies were unable to reach an agreement on reimbursement from the country’s National Association of Statutory Health Insurance Funds (GKV-SV). This closely followed a decision from Boehringer Ingelheim (a German company) and its partner Eli Lilly not to launch the DPP-4 inhibitor ‘Trajenta’ (linagliptin) in 2012. Essentially the German Institute for Quality and Efficiency in Health Care (IQWiG) ruled that the comparator agent for linagliptin should be a sulphonylurea (SU) (low cost) agent rather than sitagliptin, the first to market within the DPP-4 class. The companies felt that the decision was “incomprehensible”. The scene had been set a few years earlier when ‘Lantus’ (the long-acting insulin analogue, glargine) was about to lose reimbursement in Germany, only to be saved by a renegotiation on price.
The impact of these decisions is seen clearly in practice. Whereas a country like France, with little financial restriction, sees DPP-4 inhibitors as the preferred second-line after metformin, the UK still has a major predominance of SU use. The financial restrictions imposed in Germany leads to parity in prescribing between the two classes. Interestingly, this is not dissimilar to the prescribing in Portugal, Spain and Greece, Eurozone member-states which the German economy is currently subsidizing. It would be interesting to know how German voters would view this situation.
Professor Steve Bain