Introduction
The National List of Essential Medicines (NLEMs) is not only a guide for rational
prescription, but also a barometer of a country′s health priorities, whereas most
NLEMs are similar to the World Health Organization (WHO) list, each country′s list
has additions, deletions and modification, which reflect its unique health related
challenges.[1]
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The South East Asia region (SEARO) of the WHO, along with neighboring South Asian
world′s countries of Afghanistan and Pakistan, is home to some of the world′s, largest
populations. This region also plays unwilling host to the diabetes pandemic: Almost
all of its countries care for significant number of people living with diabetes.
In such a situation, it becomes necessary to study the NLEMs of these nations, to
assess if adequate provision has been made for essential antidiabetic drugs. An online
search was performed to identify the latest NLEMs of the 11 SEARO countries. These
are Bangladesh, Bhutan, Democratic People′s Republic of Korea (DPRK), India, Indonesia,
Maldives, Myanmar, Nepal, Sri Lanka, Thailand and Timor Leste. Two geographically
contiguous member countries of the South Asian Association for Regional Cooperation
(SAARC), viz. Afghanistan and Pakistan, were also included in the search.
National List of Essential Medicines were available for all states except DPRK, for
which the WHO has issued a list of life-saving drugs to guide potential donors.
The antidiabetic drugs listed each NLEM were analyzed according to class of drugs,
and strengths. Various NLEMs were compared with assess similarities and contrasts.
Secretagogues
All countries (with the exception of DPRK) mention glibenclamide as an essential drug,
specifying both 2.5 mg and 5 mg strengths. Some countries such as Afghanistan, Bhutan,
Myanmar, and Sri Lanka include only the 5 mg tablet in the NLEM.
Recently, the WHO restricted use of glibenclamide in persons aged >60 years, because
of the risk of hypoglycemia.[14] In view of this, most SEARO/SAARC countries have included newer generation sulfonylurea
in their NLEMs. Myanmar is the only country with three modern sulfonylureas, viz.
glipizide (5 mg), gliclazide (80 mg) and glimeperide (1, 2 mg) in its NLEM. Thailand
lists glimepiride (strength not specified), gliclazide (80 mg) and a meglitinide secretagogue
(repaglinide 0.5, 1, 2 mg) in the NLEM. Maldieves includes gliclazide 80 mg in its
NLEM. Nepal lists glipizide (2.5, 5 mg), while Indonesia includes its 5 mg strength
Afghanistan, Bhutan India, Nepal, and Pakistan do not list any sulfonylurea apart
from glibenclamide in their NLEMs.
Sensitizers
Metformin 500 mg is included in the NLEM of all countries. Pioglitazone is another
insulin sensitizer, which finds mention in the Bhutanese (15 mg) and Thai (15, 30
mg) NLEMs.
Alpha Glucosidase Inhibitors
Alpha Glucosidase Inhibitors
The class of Alpha-glucosidase inhibitors is represented in the NLEM of Thailand by
acarbose. However, the strength of the molecule is not mentioned. Other classes of
oral antidiabetic drugs are not included in any NLEM.
Insulin
Insulin is an essential, lifesaving drug, which deserves mention in NLEM. North Korea,
however, does not include insulin in its guidance for donors, which lists - life saving
drugs that can be provided to the country.
Regular insulin is included in all other NLEMs of the SEARO region and the SAARC countries.
Most countries also include intermediate - acting insulin. While some countries specify
only isophane (neutral protamine Hagedorn (NPH]) insulin, others continue to list
the now discontinued lente/insulin zinc suspension formulation.
An issue which needs to be addressed is that of correct terminology for insulin. Intermediate
insulin is described by various names, and this can lead to confusion among health
workers. Myanmar, for example, lists both types, while defining “insulin - long-acting
insulin zinc suspension (mixed, crystalline).” India, Nepal, and Pakistan include
both NPH and Lente, Thailand specifies NPH alone. Indonesia does not mention particular
type of intermediate insulin, while Bangladesh omits this category from its NLEM.
Premixed insulin is included by Bhutan, Sri Lanka, India, Indonesia and Nepal in their
essential lists.
Thailand includes selected insulin analogs: Aspart and biphasic lispro (ratio not
mentioned) as part of the NLEM. Again, the required strength, delivery devices and
needles are not specified
There is considerable variation regarding the concentration of insulin preparation
of insulin, Bhutan, India Nepal ask for 40 IU/ml; Bangladesh, Indonesia Myanmar and
Sri Lanka for 100 IU/ml, while Thailand does not specify any preference. Afghanistan
Maldives and Timor Leste accept both strengths as being essential.
Pakistan presents a unique scenario: Soluble insulin is listed as 100 U/ml strength,
while intermediate insulin is specified in both 40 and 100 U/ml concentrations.
None of the countries specify insulin syringes an irreplaceable component of the insulin
prescription, as being essential.
Hypoglycemia
The Indian NLEM devotes a separate section to the management of hypoglycemia, and
mentions injection glucagon and 25% dextrose as essential drugs.
Discussion
This analytical study of South East Asian and South Asian countries reveals significant
findings.
The SEARO region and neighboring SAARC countries are a diverse group of nations, united
by the diabetes epidemic. Their choice of antidiabetic drugs in NLEMs exhibits commonalities
(e.g., metformin, glibenclamide, regular insulin) as well as differences (other sulfonylureas,
pioglitazone acarbose, insulin strength, insulin analogues).
Some of these differences can be explained by local dietary habits (acarbose, repaglinide
and aspart for postprandial hyperglycemia in Thailand, for example), local availability
(40 IU vs. 100 IU strength of insulin) or prescription habits of physicians. Other
dissimilarities, however, cannot be explained so easily.
Metformin is considered an essential drug by all countries, while another sensitizer,
pioglitazone, is included in two lists. This assumes significance in view of the recent
controversy regarding this molecule in India.[15]
Some SEARO countries display a proactive, modern approach to sulfonylurea therapy
by including safer, newer generation molecules. This is a welcome trend, as it supports
the concepts of safety (minimizing hypoglycemia), addresses the challenge of geriatric
diabetes, and allows freedom of choice in prescription.
The Alpha-glucosidase inhibitor acarbose is listed by one SEARO country (Thailand),
this inclusion highlights the importance and efficacy of this molecule, especially
in this part of the world.
Insulin is included in every NLEM of SEARO/SAARC. However, there is marked heterogenecity
in choice of preparations, nomenclature, and insulin concentrations. Insulin analogues
are listed by one country (Thailand), but insulin syringes are not specified separately.
Five countries include premixed insulin as an essential drug. This fact underscores
the universal appeal and efficacy of this insulin preparation.
The issue of hypoglycemia is addressed by one nation (India). This is a welcome step,
as it highlights the importance of managing this preventable complication in people
with diabetes.
Conclusion
Not much attention has been paid by clinicians to NLEMs. In the past concerted action
is needed to tackle diabetes, however. This includes ensuring listing and availability
of all important antidiabetic drugs in NLEMs. While some authors have analyzed NLEMs
in the past,[14]
[15] these important documents need to be highlighted in mainstream literature.
Best practice sharing between various countries, interdisciplinary discussion between
pharmacologists, public health specialists and diabetes care professionals, and indigenous
health economics data are required to create robust NLEMs for diabetes.
Regular updation of the diabetes sections of NLEMs is also necessary to keep pace
with advances in pharmaceuticals. Newer oral antidiabetic drugs and insulin analogs,
with proven safety, should be included in NLEMs, even if for restricted use. This
will help these drugs benefit the people who people who need them most.
The NLEMs are an important tool in our crusade against diabetes: We must not under-estimate
their importance rather, we should work together to strengthen their utility in this
regard, and to promote rational drug use in diabetes care.
How to cite this article: Kalra S, Gupta Y, Saboo B. Essential drugs in diabetes: South and South East Asian
perspective. J Soc Health Diabetes 2015;3:4-6.
Source of Support: Nil.
