Pharmacoeconomic challenges in the management of diabetic nephropathy

Diabetes is the most common cause of end-stage renal disease (ESRD)-kidney failure to the point of requiring dialysis or a kidney transplant. representing 45% of all new patients enrolling into ESRD programs. Approximately 400,000 patients in the United States have ESRD, and this number has doubled over the decade from 1991-2001. Dialysis is a very expensive modality costing more than 50,000 dollars per patient per year. Total medical spending for the 400,000 patients with ESRD cost 22.8 billion dollars in 2001, an almost 3-fold increase over the same 1991-2001 decade. ESRD spending represents 6.4% of the total Medicare budget, a 33% increase from 4.8% in 1991. This epidemic growth in ESRD has led to skyrocketing utilization of health care resources.

To summarize the (1) economic impact of the increased prevalence and costs associated with ESRD secondary to diabetes, (2) major evidence in diabetic nephropathy associated with the use of agents that block the renin-angiotensin-aldosterone system (RAAS) to delay the progression to ESRD, and (3) results of a recent pharmacoeconomic analysis on the economic impact of the use of the angiotensin receptor blocker (ARB) irbesartan to block the RAAS in diabetic nephropathy.

Application of pharmacoeconomic models demonstrate that use of irbesartan increases mean life expectancy from months to years, depending on when in the course of the disease irbesartan therapy is started. Further, use of this agent produces these results while lowering costs, with mean savings of 3,000 dollars to 12,000 dollars per patient.

Clinical trials show that blocking the RAAS with ARBs and angiotensin-converting enzyme inhibitors delays the progression of diabetic nephropathy to ESRD. Recent analyses using predictive models have concluded that the most effective strategy is to begin therapy early in disease progression.