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annual worldwide sales).15 In addition, worldwide sales of insulin for Aventis exceeded $250 million during 2001, more than 10% of the total sales of the company.16 Thus, total worldwide insulin sales for the three largest manufacturers exceeded $3.3 billion in the last fiscal year.

Clinical and Economic Decisions About Insulin Therapy Business or economic considerations will not and should never be the sole or even the prime basis for decision-mak- ing in the selection of insulin therapy. On the other hand, cost should be one criterion in treatment design. Certainly, a theoretical relationship between cost and clinical efficacy constitutes one valid basis for the selection of treatment.

The current climate in the insulin market involves strong marketing and clinical advocacy in favor of newer prod- ucts. As discussed, there are possible specific advantages of these newer prod- ucts. However, clinicians should consid- er price differentials as well in their

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selection of insulin products with their patients. Novel pharmacokinetic proper- ties of insulin analogs and the ease of use of injection devices may enhance patient acceptance of insulin therapy and reduce hypoglycemia.

REFERENCES

1Dixon K, Exon PD, Malins JM: Insulin anti- bodies and the control of diabetes. Quart J Med 176:543–553, 1975

2Galloway JA, Bressler R: Insulin treatment in diabetes. Med Clin North Am 62:663–680, 1978

3Leichter SB: Human insulin: the index case. J Kentucky Med Assoc 82:367–369, 1984

4Novo Nordisk Corporation: Frequently asked questions. http://www.novonordisk- us.com/view.asp?ID=1264

5Gerich J: Novel insulins: expanding options in diabetes management. Am J Med 113:308–316, 2002

6Richter B, Neises G: “Human” insulin vs. animal insulin in people with diabetes mellitus. Cochrane Rev Issue 4, 2002 http://www.cochrane.org/cochrane/revabstr/ab003 816.htm

7Gualandi-Signorini AM, Giorgi G: Insulin formulations: a review. Eur Rev Med Pharmacol Sci 5:73–83, 2001

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8Trautmann ME: Effect of the insulin analog ([LYS(B28),PRO(B29)] on blood glucose con- trol. Horm Metab Res 26:588–590, 1994

9Chapman TM, Noble S, Goa KL: Insulin aspart: a review of its use in the management of type 1 and type 2 diabetes mellitus. Drugs 62:1945–1981, 2002

10Leichter SB: The business of insulin pumps in diabetes care: clinical and economic considera- tion. Clinical Diabetes 20:214–216, 2002

11Graff MR, McClanahan MA: Assessment by patients with diabetes mellitus of two insulin pen delivery systems versus a vial and syringe. Clin Ther 20:486–496, 1998

12http://www.imshealth.com/public/structure/ dispcontent/1,2779,1203-1203-143180,00.html

13http://www.imshealth.com/public/structure/ dispcontent/1,2779,1203-1203-144138,00.html

14http://newsroom.lilly.com/news/story.cfm?id =1045

15http://annualreview.novonordisk.com/view.a sp?ID=108

16Aventis: Annual Report, 2001. Frankfurt, Germany

Steven B. Leichte , MD, FACP, FACE, is codirector of the Institute for Healthcare Leadership in Columbus, Ga., and a pro- fessor of medicine at Mercer University School of Medicine in Macon, Ga.

Volume 21, Number 1, 2003 CLINICAL DIABETES

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