Ladies and gentlemen, we find ourselves in a dire situation. Our balloon is sinking and in order to save ourselves, one of us must be thrown out. Each of us will now present our case as to why we should not be the one to go.
Now that’s probably a strange opening for a blog you might think, but with recent statements from the MHRA, professional bodies, regulators, and health professional opinions on social media, this analogy sprang to my mind. Except in this example, there are only two types of people in the balloon, Type 2 Diabetics and people who are suffering from the equally impacting disease of obesity.
Also, it is not a sinking balloon, but the shrinking stock levels of the GLP-1 analogues used in the treatment of both conditions.
So, who do we throw out of the balloon?
Pharmacy isn’t naïve to stock shortages. It is a situation it has been handling for well over a year now, but of late the extent and the degree to which the shortages are impacting pharmacy (and of course their patients) is increasing. C&D were reporting about the pandemic shortages and HRT demands in August of last year, and a good proxy for the stock problems that pharmacy is currently facing are the concession prices granted by the Department of Health and Social Care (DHSC).
Community Pharmacy England (CPE) are reporting record numbers of concessions granted by the DHSC, with monthly concessions for over a 100 stock items or more, and in CPE’s own words, ‘show no signs of abating, and we know that many pharmacies now find themselves in a critical situation…’.
The issue with GLP1-RA is quite unique, in that as a class of medication, all the products in the category are effected by the shortages, so there’s no possibility of an “in class” switch for patients. The DHSC issued a recent Medicine Supply Notification outlining the issues to clinicians, and the harsh reality is that supplies won’t return to some form of normality until the middle of 2024.
There had been recent interest in the use of this class of drug for weight management, and the NICE Technology Appraisal was recommending the use of Semaglutide in the management of overweight and obese patients. When you consider that the 2019 Health Survey for England estimated 28% of adults in England were obese and government estimates place the costs of obesity at £6.1 billion to the NHS, this seems an appropriate intervention to develop.
But the shortages became newsworthy for the non-pharmacy outlets, and unsurprisingly the blame started to be lain at the feet of patients seeking the drugs for weight loss, and the private prescribing of the products. Online pharmacies providing prescribing services (often seen as the black sheep of the pharmacy family) offering these products were also criticised for their part in the shortages. Although I have seen comment that such supplies appear to be obtained outside of the UK supply chain, so shouldn’t be impacting on the stock issues. Guidance was provided to prescribers, along the lines that “off-label” prescribing should be prevented. I even saw guidance provided to pharmacy teams, suggesting that stocks should be reserved for NHS prescriptions for diabetes treatment rather than private prescriptions for any other indication.
I appreciate the consequences for the type 2 diabetics, whose condition was being successfully treated with these products, is significant. I read that Leeds Community Healthcare Trust was suggesting that around 600 patients would potentially require the complex switch to insulin treatment. But I did feel uncomfortable at the apparent dismissal of the disease of obesity. Then there’s also the implication of calling a prescriber’s judgement into question if they were treating such patients with these agents. Although you will note that the MSN is guidance or to ‘strongly discourage’ prescribers, as their right to prescribe is enshrined in the Human Medicines Regulations. Then we also put pharmacy teams in an ‘invidious position’ where they could be questioning the patients’ right to access the medication, legally prescribed for them.
But is it right to place the blame with those patients? It seems the global demand for these drugs, and especially the American market has led to the shortages. Novo Nordisk recently launched their product in Germany, and this has meant they never had sufficient stock to sell it in the UK. Is the UK market the best place for a return on investment for manufacturers – it is said our acquisition costs for medicines plays a part in this complex situation. So, do we really know what the true cause/s of the shortages are; And is it right to blame a cohort of patients?
So back to the balloon analogy, and the choice we have to make – who’s life is of greater value?
Don’t ask me, because I can’t (and won’t) make that call.