Hypoglycemia frequency and treatment satisfaction in patients receiving insulin analogues for treatment of type 1 diabetes mellitus

ABSTRACT Objective: The aim of this study was to evaluate the frequency of hypoglycemia and the treatment satisfaction in patients with type 1 diabetes (T1D) using insulin analogues. Subjects and methods: This observational retrospective study included 516 adult patients with T1D from 38 cities in Southern Brazil. Demographics and clinical data were collected using a self-report questionnaire. Hypoglycemia was defined as an event based on either symptoms or self-monitored blood glucose < 70 mg/dL. Treatment satisfaction was evaluated using the Diabetes Treatment Satisfaction Questionnaire status version (DTSQs) and with a specific question with scores ranging from 0-10. Common mental disorders were assessed using the General Health Questionnaire (GHQ-12). Results: Overall, the mean age was 38 ± 14 years and 52% of the participants were women. The median diabetes duration was 18 years. The scores for insulin analogue treatment satisfaction were higher than those for previous treatments. DTSQ scores had a median value of 32 (interquartile range 29-35) and remained unchanged over time. The percentage of patients with hypoglycemia (including severe and nocturnal) was comparable across groups divided according to duration of use of insulin analogues. Most patients (n=395, 77%) screened positive for common mental disorders. Conclusions: Patient satisfaction with insulin analogue treatment was high and remained unchanged with time. Episodes of hypoglycemia also remained unchanged over time among patients using insulin analogues.

Evaluation of severe hypoglycemia and common mental disorders in patients receiving insulin analogues for treatment of type 1 diabetes

ABSTRACT This is a retrospective report of the frequency of severe hypoglycemia and the association between common mental disorders and type 1 diabetes mellitus treated with insulin analogues. Patients with severe hypoglycemia compared with those without this complication had a higher prevalence of positive screening for common mental disorders (88% vs.77%, respectively, p = 0.03).

Access to treatment for phenylketonuria by judicial means in Rio Grande do Sul, Brazil / Acesso ao tratamento para fenilcetonúria por via judicial no Rio Grande do Sul, Brasil

Treatment of phenylketonuria (PKU) includes the use of a metabolic formula which should be provided free of charge by the Unified Health System (SUS). This retrospective, observational study sought to characterize judicial channels to obtain PKU treatment in Rio Grande do Sul (RS), Brazil. Lawsuits filed between 2001- 2010 and having as beneficiaries PKU patients requesting treatment for the disease were included. Of 20 lawsuits filed, corresponding to 16.8% of RS patients with PKU, 19 were retrieved for analysis. Of these, only two sought to obtain therapies other than metabolic formula. In all the other 17 cases, prior treatment requests had been granted by the State Department of Health. Defendants included the State (n = 19), the Union (n = 1), and municipalities (n = 4). In 18/19 cases, the courts ruled in favor of the plaintiffs. Violation of the right to health and discontinuation of State-provided treatment were the main reasons for judicial recourse. Unlike other genetic diseases, patients with PKU seek legal remedy to obtain a product already covered by the national pharmaceutical assistance policy, suggesting that management failures are a driving factor for judicialization in Brazil.

O tratamento da fenilcetonúria (PKU) inclui o uso de uma fórmula metabólica (FM) fornecida sem custos pelo Sistema Único de Saúde (SUS). O objetivo do estudo foi caracterizar o uso da via judicial para obter tratamento para PKU no estado do Rio Grande do Sul (RS), Brasil, através de um estudo retrospectivo e observacional, analisando ações judiciais. Foram incluídas ações judiciais arquivadas entre 2001-2010 que possuíam como beneficiários indivíduos com PKU solicitando alguma forma de tratamento para PKU. Foram localizados 20 casos, correspondendo a 16,8% dos pacientes com PKU no RS, sendo 19 obtidos para análise. Somente dois procuravam obter outras terapias que a FM. Nos outros 17 casos, uma solicitação de tratamento anterior fora concedida pela Secretaria Estadual de Saúde. Os réus incluem o Estado (n = 19), União (n = 1) e municípios (n = 4). Em 18/19 casos, os tribunais decidiram a favor dos demandantes. Violação do direito à saúde e interrupção do tratamento prestado pelo Estado foram os principais motivos para recorrer aos tribunais. Diferente de outras doenças genéticas, os pacientes com PKU buscam o meio jurídico para obter um produto já incluso na política de assistência farmacêutica nacional, sugerindo que falhas de gestão são um dos fatores desencadeantes da judicialização no país.

Adherence to Treatment of Phenylketonuria: A Study in Southern Brazilian Patients

Abstract Introduction: Phenylketonuria (PKU) is caused by the deficient activity of phenylalanine hydroxylase. Aim: To identify the factors associated with treatment adherence among patients with PKU seen at a southern Brazil reference center. Methodology: A cross-sectional, outpatient-based study including 56 patients with PKU (median age, 12 years) for whom a Phe-restrict diet plus specific metabolic formula have been prescribed. Patients were considered adherent or nonadherent depending on the median phenylalanine concentration for the 12 months prior to study and target levels of phenylalanine for each age range (<13 years = ≤360 µmol/L; ≥13 years = ≤900 µmol/L). Data were collected through a review of patient's medical records and a set of interviews with patients and their relatives. Results: Eighteen patients (32.1%; ≥13 years, 11) were classified as treatment adherent. Among all factors analyzed, only mental retardation, living with parents, and level of maternal education were associated with adherence to treatment. Conclusion: Our findings reinforce the importance of the family as promoting factor for treatment adherence.

Judicialização do acesso ao tratamento de doenças genéticas raras: a doença de Fabry no Rio Grande do Sul / Court-ordered access to treatment of rare genetic diseases: Fabry Disease in the state of Rio Grande do Sul, Brazil

A judicialização do acesso a medicamentos de alto custo para doenças genéticas raras, como a doença de Fabry (deficiência de alfa-galactosidase A), é um fenômeno crescente e pouco estudado de forma sistemática. Realizou-se um estudo observacional, transversal e retrospectivo para caracterizar as ações judiciais relativas ao acesso ao tratamento da doença de Fabry por terapia de reposição enzimática no estado do Rio Grande do Sul até 2007. Foram identificadas 13 ações e 17 demandantes. Onze solicitaram alfa e 6 betagalsidase. Figuraram como réus o estado do RS, a União e 5 municípios, em litisconsórcio ou não. Houve 13 pedidos de antecipação da tutela, 12 concedidos, e 2 sentenças, ambas procedentes. "Risco de morte" foi alegado, por médicos, em 4 prescrições e, por advogados, nas 13 ações. Os dados sugerem a ausência de discussões que envolvam conjuntamente aspectos de eficácia e segurança médicas, custo-efetividade, impacto econômico e argumentos jurídico-constitucionais, sendo necessária uma política específica para doenças genéticas raras que padronize o acesso aos tratamentos.

Court-ordered access to high-cost drugs for rare genetic diseases, such as Fabry Disease (alpha-galactosidase-A deficiency), is a growing phenomenon as yet lacking systematic study. An observational, cross-sectional and retrospective study was conducted to characterize the lawsuits related to access to treatment for Fabry Disease by Enzyme Replacement Therapy in the State of Rio Grande do Sul prior to 2007. The study identified 13 lawsuits and 17 plaintiffs, 11 requesting alfa and 6 betagalsidase. The State of RS, the Federal Government, and 5 municipalities figured as defendants, in the form of joinder of parties or otherwise. There were 13 requests for interlocutory relief of which 12 were granted, and 2 sentences were handed down, both favorable. "Risk of death" was alleged by doctors in 4 prescriptions and by lawyers in the 13 lawsuits. The data suggest the lack of discussions combining aspects of medical efficacy and safety, cost-effectiveness, economic impact, and legal and constitutional arguments, which requires a specific policy for rare genetic diseases to standardize access to treatment.

A Secretaria Estadual da Saúde do Rio Grande do Sul e a distribuição dos medicamentos especiais para fibrose cística / The State Health Board of Rio Grande do Sul and the special drugs dispensation program for cystic fibrosis

O tratamento medicamentoso da fibrose cística (alfa dornase, suplementos pancreáticos, antibióticos orais e inalatórios) são fornecidos pela Secretaria da Saúde do Estado do Rio Grande do Sul como parte de sua responsabilidade na Política Nacional Assistência Farmacêutica do governo central para acesso a medicamentos especiais dirigido a indivíduos que tenham um diagnóstico confirmado. Para ter acesso ao tratamento os pacientes devem seguir os passos descritos no texto.

The pharmacological treatment of Cystic Fibrosis (alpha-dornase, pancreatic enzymes, oral and inhaled antibiotics) has been delivered by the State Health Board of Rio Grande do Sul as part of its responsibility on the National Drugs Policy from the central government to permit access to special treatments for those who have a confirmed diagnosis. In order to access the treatment patients must follow the steps described in the text.

Medicamentos de alto custo para doenças raras no Brasil: o exemplo das doenças lisossômicas / High cost drugs for rare diseases in Brazil: the case of lysosomal storage disorders

Este artigo aborda, de forma crítica, aspectos das políticas públicas brasileiras para medicamentos, com ênfase nos de alto custo dirigidos às doenças raras. As doenças lisossômicas foram utilizadas como exemplo pela sua raridade e pela tendência mundial para o desenvolvimento de novos fármacos para seu tratamento. Três doenças foram abordadas: doença de Gaucher, doença de Fabry e mucopolissacaridose tipo I. Embora todas tenham medicamentos registrados no Brasil, a doença de Gaucher é a única com protocolo clínico e diretrizes de tratamento balizadas pelo Ministério da Saúde. Os autores almejam, com este artigo, fomentar a discussão sobre o papel da avaliação de tecnologias em saúde para o tratamento das doenças raras no Brasil, enfatizando a necessidade de políticas legitimadas dirigidas especialmente a elas. A despeito das dificuldades de se estabelecer uma política de saúde específica para cada doença rara, é possível o estabelecimento de modelos racionais para lidar com esse crescente desafio.

This paper approaches in a critical way aspects of Brazilian public policies for drugs, emphasizing those classified as high cost and for rare diseases. The lysosomal storage diseases was taken as an example because of their rarity and the international trend for the development of new drugs for their treatment, all at high costs. Three lysosomal storage diseases were approached: Gaucher disease, Fabry disease and mucopolysaccharidosis type I. Gaucher disease has its treatment drug licensed in Brazil and guidelines for its use are established through a clinical protocol by the Ministry of Health. The others have their drug treatments registered in Brazil; however, no treatment guidelines for them have been developed by the government. The objective of the paper was to foster the discussion on the role of health technology assessment for high-cost drugs for rare diseases in Brazil, emphasizing the need for establishing health policies with legitimacy towards these diseases. Despite the difficulties in establishing a health policy for each rare disease, it is possible to create rational models to deal with this growing challenge.