A Focus on Prescribing Trends and Payer Strategy for Diabetic Macular Edema and Diabetic Nephropathy

Patients with type 2 diabetes (T2D) often present with multiple comorbidities, which boosts overall medical care costs. As the number of patients with T2D increases with population aging, so will the prevalence of diabetic comorbidities, including diabetic macular edema (DME) and diabetic nephropathy (DN). Such comorbidities are frequently an outcome of uncontrolled T2D, which results from a multitude of factors including poor access to more-effective, but yet premium-priced therapies, and poor compliance with treatment (usually metformin, followed by other less-expensive options such as sulfonylureas). Indeed, the use of novel therapies, such as DPP-IV inhibitors, GLP-1 analogues, and SGLT-2 inhibitors, which could provide greater disease control and thus lower the incidence of diabetes-related comorbidities, is hampered by limited healthcare budgets. Moreover, the detection and management of DME and DN is also far from ideal in these cost-constrained markets, which drives faster disease progression and significantly increases the financial and societal impact of these comorbidities and, consequently, the budgetary burden of T2D.

Questions Answered in This Report:

  • Poor diabetes control can result in several concomitant complications, such as DME and DN. What percentage of respondents’ diabetes patients are affected by comorbidities? How does the presence of diabetic comorbidities affect patients’ compliance with treatment? Do payers perceive current T2D agents as beneficial or detrimental toward the prevention of comorbidities? What are the greatest obstacles and unmet needs in the management of T2D and its related comorbidities, specifically DN and DME? How do physicians and payers perceive current DN and DME agents regarding their efficacy for managing these comorbidities?

  • Patients’ lack of access to more-effective therapies for T2D, DME, and DN is contributing to the failure of early treatment approaches. Which diabetic comorbidities concern physicians and payers the most, in terms of disease progression and currently available/covered treatments? How does access to treatment for T2D, DME, and DN vary between Brazil and Mexico, and how does it shape physicians’ current prescribing practices? How do prescribing practices differ between physicians directly managing the diabetic patient (primary care physicians [PCPs]/endocrinologists) and specialists managing the comorbidity (ophthalmologists or nephrologists)?

  • Emerging therapies for DN and DME will strengthen the treatment armamentarium for these comorbidities. How do physicians and payers perceive the need for new therapies for DN and DME? Do payers expect access to therapies for these comorbidities to evolve in the next 2-3 years? What obstacles will novel therapies face? How do physicians and payers perceive emerging therapies for these diabetic comorbidities? What role would clinical and pharmacoeconomic outcomes related to comorbidities play in the coverage of novel antidiabetic agents versus current standards of care?

  • Progression to late disease stages drives significant financial and societal losses. What clinical and financial challenges do physicians face when treating diabetic patients with multiple associated conditions? Which diabetic comorbidities are perceived by payers as having the greatest financial impact on their healthcare systems? Are payers measuring this impact and relating it to direct or indirect diabetes treatment costs? Within DN, how many patients evolve to renal replacement therapy?


This Emerging Physician & Payer Forum surveys 100 endocrinologists and PCPs, 101 nephrologists, and 104 ophthalmologists, and interviews 16 payers in Brazil and Mexico to assess the budgetary impact of treating diabetic comorbidities, particularly DME and DN, to these countries’ healthcare systems. It also seeks to explore the extent to which the financial burden of diabetic comorbidities is taken into account by healthcare organizations when determining the treatment algorithm for T2D, budget allocation, and coverage decisions, and how this panorama is expected to evolve in these countries in the next 2-3 years. Interviewees were required to be influential in determining patient access to therapies for T2D, DME, and/or DN at the institutional or regional/national level, and came from the following backgrounds:

- Brazil: Head of pharmaceutical assistance programs at São Paulo State; head of the pharmaceutical division of a major public hospital in São Paulo, consultant for the São Paulo State Department of Health and the Ministry of Health, specialist in pharmacoeconomics; director of the drug standardization committee and audit department at a major HMO; medical auditor responsible for the disease and portfolio management at a major insurance company, member of the drug standardization committee of the institution; nephrologist KOL, professor at a university hospital, member of the drug standardization committee of the institution; ophthalmologist KOL, member of the drug standardization committee at a major private HMO; ophthalmologist/retina specialist, member of the drug standardization committee at a university hospital, private practice owner.

- Mexico: Coordinator of the National Staged Diabetes Medical Management Program at ISSSTE; endocrinologist responsible for the diabetes and obesity program at a family medicine unit from IMSS; endocrinologist KOL, director of the endocrinology department at a major private hospital in Mexico, member of the Board of Governors of Mexico State at the Mexico chapter of the American College of Physicians; chief of the ophthalmology department at a hospital from ISSSTE; ophthalmologist responsible for the retina service at a hospital from IMSS; chief of ophthalmology at a hospital from the Secretaria de Salud; nephrologist KOL, active member of the Mexican Institute of Nephrology Research; chief of Nephrology at an IMSS hospital, director of a hemodialysis unit, member of the Board of Nephrologists of Mexico.

Author(s): Susana Silva, B.S., M.S.
Andreia Ribeiro, Ph.D.