Research Letter: Antihypertensive Drugs Market in India: An Insight on Size,Trends, and Prescribing Preferences in the Private Health Sector, 2016–2018

Background:India has a high burden of hypertension. While the private sector provides 70% of out-patient care in the country, a significant proportion of patients seeking care from the public sector buy drugs from private markets. This study aimed to describe India’s private sector antihypertensive drugs market at the national and state levels over 2016–2018.Methods:Antihypertensive drugs sales in India from 2016–2018 were analysed using a large nationally representative dataset for the private pharmaceuticals market. In addition, data for five states (Punjab, Madhya Pradesh, Kerala, Telangana, and Maharashtra) that were the foci of a large hypertension control program were studied.Results:The Indian hypertension drug market grew at a rate of 6.9% from 2016 to 2018 with a total of 21,066 million pills sales in 2018. Single-pill combinations (SPCs) contributed to 39.1% of total sale volumes. The market comprised of 182 different antihypertensive drugs including 134 SPCs. Total volume of sales covered a maximum of 26% of treatment need for the estimated population with hypertension. Two-drug SPCs had the highest market share (36%), followed by calcium channel blockers (18%), beta-blockers (16%) and angiotensin receptor blockers (14%). Among SPCs, amlodipine+atenolol had highest sales (9.8%). Twenty-five drugs, a mix of single drugs and SPCs, accounted for 80% of total sales. There were large state-to-state variations in sales per capita, preferred therapeutic classes and drugs.Conclusions:Despite the large antihypertensive drugs market, there exists a high unmet need for treatment in India. Inter-state differences in product sales indicate variable treatment practices, underscoring the need for private sector engagement to improve hypertension care practices aligned with national and international guidelines. SPCs contributed to a large share of the private market and inclusion of select antihypertensive SPCs in the national list of essential medications should be considered for the public health system.     

Sex differences in adherence to antihypertensive treatment in patients aged above 55: The French League Against Hypertension Survey (FLAHS)

Despite the availability of efficient therapies to reduce the risk of cardiovascular complications, poor adherence to antihypertensive (anti‐HTN) drugs is frequent, especially during the first year of treatment and among uncontrolled/resistant hypertensive patients. The aim of the study was to identify factors associated with adherence to anti‐HTN treatment and to examine whether they differ across sex. A total of 2743 treated hypertensive participants to the cross‐sectional Metascope survey (France, 2015) aged 55 years or more were included. The authors measured adherence to anti‐HTN treatment using the 6‐item Girerd compliance test. Variations in adherence were examined using the Rao‐Scott statistics and Poisson regression. Overall, 63.6% of participants were adherent to anti‐HTN treatment. Adherence was more frequent among women than men (69% vs 58%, P < 10⁻⁴). For both sexes, level of adherence was positively associated with age (P < 10⁻⁴), but inversely associated with number of anti‐HTN tablets, number of tablets taken for metabolic diseases, history of cardiovascular diseases, number of other chronic diseases (all P < 10⁻⁴). The inverse relationship between adherence and the number of anti‐HTN tablets significantly differed between sexes (P < 10⁻⁴): Adherence decreased sharply when taking two or more anti‐HTN tablets in men, whereas the decrease in women was only observed when taking three or more anti‐HTN tablets. This study suggests that adherence to anti‐HTN treatment is higher among women, decreases with the number of tablets prescribed, and differentially so across sex. Reducing the number of tablets for anti‐HTN treatment may improve adherence, especially among men and patients with multiple comorbidities.     

Angiotensin‐converting enzyme inhibitors increase anti‐fibrotic biomarkers in African Americans with left ventricular hypertrophy

Angiotensin‐converting enzyme inhibitors (ACEi) are part of the indicated treatment in hypertensive African Americans. ACEi have blood pressure‐independent effects that may make them preferred for certain patients. We aimed to evaluate the impact of ACEi on anti‐fibrotic biomarkers in African American hypertensive patients with left ventricular hypertrophy (LVH). We conducted a post hoc analysis of a randomized controlled trial in which hypertensive African American patients with LVH and vitamin D deficiency were randomized to receive intensive antihypertensive therapy plus vitamin D supplementation or placebo. We selected patients who had detectable lisinopril (lisinopril group) in plasma using liquid‐chromatography/mass spectrometry analysis and compared them to subjects who did not (comparison group) at the one‐year follow‐up. The pro‐fibrotic marker type 1 procollagen C‐terminal propeptide (PICP) and the anti‐fibrotic markers matrix metalloproteinase‐1 (MMP‐1), tissue inhibitor of metalloproteinases 1 (TIMP‐1), telopeptide of collagen type I (CITP), and N‐acetyl‐seryl‐aspartyl‐lysyl‐proline (Ac‐SDKP) peptide were measured. Sixty‐six patients were included, and the mean age was 46.2 ± 8 years. No difference was observed in the number and intensity of antihypertensive medications prescribed in each group. Patients with detectable lisinopril had lower blood pressure than those in the comparison group. The anti‐fibrotic markers Ac‐SDKP, MMP‐1, and MMP‐1/TIMP‐1 ratio were higher in patients with detectable ACEi (all p < .05). In a model adjusted for systolic blood pressure, MMP‐1/TIMP‐1 (p = .02) and Ac‐SDKP (p < .001) levels were associated with lisinopril. We conclude that ACEi increase anti‐fibrotic biomarkers in hypertensive African Americans with LVH, suggesting that they may offer added benefit over other agents in such patients.     

Introduction of standardised tobacco packaging and minimum excise tax on in the UK: a prospective study

BackgroundStandardised packaging for factory made and roll your own tobacco was implemented in the UK in May, 2017, alongside a minimum excise tax for factory made products. As other jurisdictions attempt to implement standardised packaging, the tobacco industry continues to suggest that it would be counterproductive, in part by leading to falls in price due to commoditisation. Here, we assess the impact of the introduction of these policies on the UK tobacco market.MethodsWe did a prospective study of UK commercial electronic point-of-sale data from 11 constituent geographic areas. The main outcomes were changes in sales volumes, volume-weighted real prices, and tobacco industry revenue. These were assessed using trend estimation from generalised additive mixed models. Products distributed to less than 10% of stores were excluded for sample design reasons; nevertheless, the analysis included an estimated 91% of the UK tobacco market products. The study did not require ethical approval.Findings107 572 monthly observations of products from May, 2015, to April,2018were included in the analysis. Introduction of standardised packaging and a minimum excise tax was associated with a doubling of the rate of sales decline. The most marked change in sales volumes was among the cheapest factory-made brands, where substantial sales growth stopped and prices rose markedly (prices increased by 0·035 p for the cheapest factory-made brands compared with 0·016 p across all factory-made brands and a 0·004 p increase across all products from May, 2015, to April, 2018). There was no evidence of commoditisation as market segmentation (price differentiation and different price trajectories for premium and lower priced products) continued. Company monthly net revenues declined from GBP £231 million (95% CI £222 million to £240 million) in May, 2015, to £192 million (£182 million to £201 million) in April, 2018.InterpretationThe concurrently introduced policies of standardised packaging and minimum excise tax were associated with declining tobacco sales and tobacco industry revenue, which might underpin the tobacco industry's opposition to the policies. Prices at the end of the period were higher than the at the start, implying no long-term price falls. A minimum excise tax might limit the tobacco industry's ability to keep low-priced tobacco, which is popular with young and disadvantaged smokers, available. The complementary introduction of standardised packaging and the minimum excise tax meant effects could not be distinguished statistically.FundingCancer Research UK and British Heart Foundation (grant number C27260/A23168).     

Clinical effectiveness and safety of amlodipine/losartan‐based single‐pill combination therapy in patients with hypertension: Findings from real‐world,multicenter observational databases

Various single‐pill combinations (SPCs) have been introduced to improve drug compliance and clinical efficacy. However, there is a lack of real‐world evidence regarding the effectiveness of these SPCs for hypertension. This study evaluated the real‐world clinical efficacy and safety of amlodipine/losartan‐based SPC therapies in patients with hypertension in a real‐world setting. A total of 15 538 patients treated with amlodipine/losartan‐based SPCs [amlodipine + losartan (AL), amlodipine + losartan + rosuvastatin (ALR), and amlodipine + losartan + chlorthalidone (ALC)] were selected from the database of three tertiary hospitals in Korea. The efficacy endpoints were target blood pressure (BP) and low‐density lipoprotein cholesterol (LDL‐C) achievement rates. Safety was evaluated based on laboratory parameters. Drug adherence was defined as the proportion of medication days covered (PDC). The target BP attainment rate was above 90% and was similar among the three groups. Although many patients in the AL and ALC groups took statins, the target LDL‐C attainment rate was significantly higher in the ALR group than in the AL and ALC groups. Safety endpoints were not significantly different among the groups, except serum uric acid level and incidence rate of new‐onset hyperuricemia, which were significantly lower in the AL and ALR groups than in the ALC group. The PDC was > 90% in all groups. In the real‐world hypertensive patients, amlodipine/losartan‐based SPC therapy demonstrated good target BP achievement rates. Especially, rosuvastatin‐combination SPC showed better target LDL‐C goal achievement rate compared to the other SPCs. All three amlodipine/losartan‐based SPC had excellent drug adherence.     

Phone calls for improving blood pressure control among hypertensive patients attending private medical practitioners in India: Findings from Mumbai hypertension project

Despite the availability of effective medication, blood pressure control rates are low, particularly in low‐ and middle‐income countries. Adherence to medication and follow‐up visits are important factors in blood pressure control. This study assessed the effectiveness of reminder telephone calls on follow‐up visits and blood pressure control among hypertensive patients as part of the Mumbai Hypertension Project. This project was initiated by PATH with the support from Resolve to Save Lives from January 2019 to February 2020. The study included hypertensive patients attending 164 private practices in Mumbai, India; practitioners screened all adults visiting their clinic during the project period. Among 13 184 hypertensive patients registered, the mean age was 53 years (SD = 12.38) and 52% were female. Among the 11 544 patients that provided phone numbers and gave consent for follow‐up calls, 9528 responded to phone calls at least once and 5250 patients followed up at least once. Of the 5250 patients, 82% visited the clinic for follow‐up visit within one month after receiving the phone call. The blood pressure control rate among those who answered phone calls and who did not answer phone calls increased from 23.6% to 48.8% (P <.001) and 21.0% to 44.3% (P <.001), respectively. The blood pressure control rate at follow‐up was significantly associated with phone calls (OR: 1.51, 95% CI: 1.34 ‐ 1.71). The study demonstrates that telephone call intervention and follow‐up visits can improve patient retention in care and, subsequently, blood pressure control among hypertensive patients attending urban private sector clinics in India.     

The pharmaceutical industry as a medicines provider

Rising prices of medicines are putting them beyond the reach of many people, even in rich countries. In less-developed countries, millions of individuals do not have access to essential drugs. Drug development is failing to address the major health needs of these countries. The prices of patented medicines usually far exceed the marginal costs of their production; the industry maintains that high prices and patent protection are necessary to compensate for high development costs of innovative products. There is controversy over these claims. Concerns about the harmful effects of the international system of intellectual property rights have led the World Trade Organization to relax the demands placed on least developed countries, and to advocate differential pricing of essential drugs. How these actions will help countries that lack domestic production capacity is unclear. Better access to essential drugs may be achieved through voluntary licensing arrangements between international pharmaceutical companies and manufacturers in developing countries.     

Prevalence,awareness, treatment,and control of hypertension in Bangladesh: Findings from National Demographic and Health Survey, 2017–2018

The purpose of this study was to estimate the age‐standardised prevalence, awareness, treatment, and control of hypertension and to identify their risk factors in Bangladeshi adults. Data from 12 904 adults aged 18–95 years, available from the most recent nationally representative 2017–2018 Bangladesh Demographic and Health Survey were used. Hypertension was defined as having systolic blood pressure ≥140 mmHg and/or a diastolic blood pressure ≥90 mmHg, and/or taking anti‐hypertensive drugs to control blood pressure. Age‐standardized prevalence of hypertension and management were estimated with direct standardisation. A multilevel mixed‐effects Poisson regression model with a robust variance was used to identify risk factors associated with hypertension and its awareness, treatment, and control. The overall age‐standardized prevalence of hypertension was 26.2% (95% CI, 25.5‐26.9); (men: 23.5%, women: 28.9%). Among those with hypertension (n = 3531), 36.7% were aware that they had the condition, and only 31.1% received anti‐hypertensive medication. The prevalence of controlled hypertension was 12.7% among those with hypertension and 43.6% among those treated for hypertension (n = 1306). Factors independently associated with hypertension were increasing age, higher body mass index, being women, having diabetes, and residing in selected administrative divisions. A declining trend of hypertension control was observed with increasing age and low education. Hypertension is highly prevalent (one in four) in Bangladeshi adults, while awareness, treatment, and control are low. Irrespective of the risks associated with hypertension and its management, programs to increase its awareness, treatment, and control should be given high priority in reducing hypertension prevalence and improving hypertension control in Bangladesh.     

Development of type 1 diabetes in a patient treated with anti‐interleukin‐6 receptor antibody for rheumatoid arthritis

Interleukin‐6 is a pleiotropic cytokine that plays a pathogenic role in type 1 diabetes. Therefore, anti‐interleukin‐6 receptor antibody, tocilizumab, used for the treatment of rheumatoid arthritis, is considered a candidate for immune intervention in type 1 diabetes. Here, we report the case of a 73‐year‐old woman (HLA‐DR9‐DQ3 homozygote) with well‐controlled rheumatoid arthritis who developed type 1 diabetes while receiving tocilizumab treatment. At 57 years‐of‐age, the patient was diagnosed with rheumatoid arthritis, for which she underwent tocilizumab therapy that enabled complete suppression of her joint inflammation. A total of 17 months after starting tocilizumab therapy, she noticed polydipsia, polyuria, general fatigue and weight reduction (−2 kg/month), and was diagnosed with type 1 diabetes with diabetic ketoacidosis based on an arterial pH of 7.26, serum ketone body of 7,437 μmol/L, blood glucose level of 925 mg/dL, glycated hemoglobin of 13.2% and the presence of anti‐islet autoantibodies. This case report shows valuable insight regarding the effect of anti‐interleukin‐6 receptor antibody therapy on type 1 diabetes prevention.     

Alcohol prices, beverage quality, and the demand for alcohol: quality substitutions and price elasticities

BACKGROUND: Although the published literature on alcohol beverage taxes, prices, sales, and related problems treats alcoholic beverages as a simple good, alcohol is a complex good composed of different beverage types (i.e., beer, wine, and spirits) and quality brands (e.g., high-, medium-, and low-quality beers). As a complex good, consumers may make substitutions between purchases of different beverage types and brands in response to price increases. For this reason, the availability of a broad range of beverage prices provides opportunities for consumers to mitigate the effects of average price increases through quality substitutions; a change in beverage choice in response to price increases to maintain consumption. METHODS: Using Swedish price and sales data provided by Systembolaget for the years 1984 through 1994, this study assessed the relationships between alcohol beverage prices, beverage quality, and alcohol sales. The study examined price effects on alcohol consumption using seemingly unrelated regression equations to model the impacts of price increases within 9 empirically defined quality classes across beverage types. The models enabled statistical assessments of both own-price and cross-price effects between types and classes. RESULTS: The results of these analyses showed that consumers respond to price increases by altering their total consumption and by varying their brand choices. Significant reductions in sales were observed in response to price increases, but these effects were mitigated by significant substitutions between quality classes. CONCLUSIONS: The findings suggest that the net impacts of purposeful price policy to reduce consumption will depend on how such policies affect the range of prices across beverage brands.     

Intranasal influenza vaccination using a new synthetic mucosal adjuvant SF‐10: induction of potent local and systemic immunity with balanced Th1 and Th2 responses

Background

We found previously that bovine pulmonary Surfacten^® used in newborns with acute respiratory distress syndrome is a safe and efficacious antigen vehicle for intranasal vaccination.

Objectives

The objective of this study was to industrially produce a synthetic adjuvant mimicking Surfacten^® for clinical use without risk of bovine spongiform encephalopathy.

Methods

We selected three Surfacten lipids and surfactant protein (SP)‐C as essential constituents for adjuvanticity. For replacement of the hydrophobic SP‐C, we synthesized SP‐related peptides and analyzed their adjuvanticity. We evaluated lyophilization to replace sonication for the binding of influenza virus hemagglutinin (HA) to the synthetic adjuvant. We also added a carboxy vinyl polymer (CVP) to the synthetic adjuvant and named the mixture as SF‐10 adjuvant. HA combined with SF‐10 was administered intranasally to mice, and induction of nasal‐wash HA‐specific secretory IgA (s‐IgA) and serum IgG with Th1‐/Th2‐type cytokine responses in nasal cavity and virus challenge test were assessed.

Results and Conclusions

Intranasal immunization with HA–SF–10 induced significantly higher levels of anti‐HA‐specific nasal‐wash s‐IgA and serum IgG than those induced by HA‐poly(I:C), a reported potent mucosal vaccine, and provided highly efficient protection against lethal doses of virus challenge in mice. Anti‐HA‐specific serum IgG levels induced by HA–SF–10 were almost equivalent to those induced by subcutaneous immunization of HA twice. Intranasal administration of HA–SF–10 induced balanced anti‐HA‐specific IgG1 and IgG2a in sera and IFN‐γ‐ and IL‐4‐producing lymphocytes in nasal cavity without any induction of anti‐HA IgE. The results suggest that HA–SF–10 is a promising nasal influenza vaccine and that SF‐10 can be supplied in large quantities commercially.     

Prices of antihypertensive medicines in sub‐Saharan Africa and alignment to WHO’s model list of essential medicines

Objective To investigate compliance of National Essential Medicines Lists (NEMLs) with the WHO Essential Medicines List (WHO/EML) in 2007 and to compare prices of antihypertensive drugs in and between 13 sub‐Saharan African countries. Methodology Data on NEMLs and drug prices were collected from 65 public and 65 private pharmacies (five of each per country). Prices were compared with the International Drug Price Indicator Guide (IDPIG). The cost of drug treatment within a country was calculated using defined daily doses (DDD) and between countries using DDD prices adjusted for purchasing power parity‐based gross domestic product per capita. Results All surveyed countries had a NEML. However, none of these lists were in complete alignment with the 2007 WHO/EML, and 38% had not been updated in the last 5 years. Surveyed medicines were cheaper when on the NEMLs; they were also cheaper in public than in private pharmacies. Prices varied greatly per medicine. A large majority of the public prices were higher than those indicated by the IDPIG. Overall, hydrochlorothiazide is the cheapest drug. Conclusion There are substantial differences in NEML composition between the 13 countries. The proportion of NEMLs not regularly updated was double the global United Nations estimates. Prices of WHO/EML‐advised drugs differ greatly between drugs and for each drug within and between countries. In general, the use of drugs on the NEML improves financial accessibility, and these drugs should be prescribed preferentially.     

Prevalence of counterfeit anthelminthic medicines: a cross‐sectional survey in Cambodia

Objectives To assess the prevalence of counterfeit anthelminthic medicines in Cambodia, and to determine influential factors. Methods Commonly used anthelminthic medicines were collected from private drug outlets. Medicines were carefully observed including their registration labelling, and their authenticity was investigated with the manufacturers and the Medicines Regulatory Authorities. Samples were analysed by High‐Performance Liquid Chromatography at the National Health Product Quality Control Centre, Cambodia. Results Two hundred and three samples of anthelminthics were collected from 137 drug stores. Domestic products constituted 36.9%. Of 196 samples which were verified for registration, 15.8% were not registered. Of 165 samples successfully investigated for their authenticity, 7 (4.2%) were identified as counterfeit. All of these medicines were purchased in open packs or containers, and most of them were foreign manufactured and/or without registration. Conclusion The results of our survey urge strict implementation of drug registration and vigilance on the availability of unregistered medicines to combat counterfeit medicines in Cambodia.     

Revisiting the strategies for the pharmacological management of type 2 diabetes – From glycemic control,organ protection,safety to weight reduction

With the development of several new classes of anti‐diabetic drugs in the past decade, the concept for the pharmacological management of type 2 diabetes is evolving from ‘glycemic control’ to ‘organ protection’. Besides, the increase in the prevalence of an aging population urges a strategy focusing on safety and de‐intensification. In the coming years, with the development of several novel and potent anti‐obesity drugs, the ‘weight‐centric’ strategy is expected to gain more and more attention in the treatment of diabetes, since it can both prevent diabetic complications and optimize the quality of life. With all these strategies, clinicians should consider the patient’s clinical characteristics and make an individualized goal through shared decision making with the patient.

The goals of diabetes care are to prevent complications and to optimize the quality of life. Based on these goals, several strategies have been developed and are still evolving for the pharmacological management of type 2 diabetes. In the past decade, various new anti‐diabetic drugs have been developed, including dipeptidyl peptidase‐4 (DPP‐4) inhibitors, sodium‐glucose cotransporter 2 (SGLT2) inhibitors, glucagon‐like peptide‐1 receptor agonists (GLP‐1 RAs), and several insulin analogs. The findings from cardiovascular and renal outcome trials of SGLT2 inhibitors and GLP‐1 RA have led to a paradigm shift in the treatment of type 2 diabetes. In addition to glycemic control, cardiovascular or renal protective effects beyond glycemic control, or the ‘organ protection’ effects, have been emphasized in several guidelines published by academic associations. On the other hand, with the global trend of an aging population, a different strategy should be considered to treat diabetic patients of advanced age, focusing primarily on safety issues. Recently, the development of novel anti‐obesity drugs with clinically significant weight reduction effects has shed some light on a new ‘weight‐centric’ strategy for the treatment of diabetes. Therefore, it is time to revisit different strategies in the pharmacological management of type 2 diabetes.Findings from several cardiovascular or renal outcome trials of SGLT2 inhibitors and GLP‐1 RAs have demonstrated their ‘organ protection’ effects in people with type 2 diabetes. As a result, the guidelines from academic associations recommend that physicians consider the baseline hemoglobin A1c (HbA1c) level independently and prescribe SGLT2 inhibitors or GLP‐1 RAs with proven cardiovascular or renal benefits to diabetic patients at risk of or with established atherosclerotic cardiovascular diseases, heart failure, or diabetic kidney diseases. However, the results from meta‐regression of the cardiovascular outcome trials have demonstrated that there is a significant association between HbA1c reduction and the risk of major adverse cardiovascular events, especially for the risk of stroke ¹ . These findings restate the importance of glycemic control in reducing cardiovascular events in diabetic patients. It is well known that the United Kingdom Prospective Diabetes Study (UKPDS) and the UKPDS follow‐up study showed the relationship between intensive glycemic control and a reduced risk of microvascular and macrovascular complications and all‐cause mortality ² . In a meta‐analysis of data in the UKPDS, the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial, the Action in Diabetes and Vascular Disease: Preterax and Diamicron MR Controlled Evaluation (ADVANCE) trial, and the Veterans Affairs Diabetes Trial (VADT), a 0.88% decrease in HbA1c was associated with a 15% reduction in the risk of fatal and non‐fatal myocardial infarction ³ , which is comparable to the ‘organ protection’ effects demonstrated in the cardiovascular outcome trials. Therefore, in diabetic patients with poor glycemic control or a high HbA1c, anti‐diabetic drugs with a potent glucose‐lowering effect, such as sulfonylurea, some GLP‐1 RAs, and insulin, should be considered preferentially.The ‘organ protection’ and the ‘glycemic control’ strategies emphasize more the prevention of complications. In contrast, in diabetic patients of old age, with fragility, terminal diseases, or disability, optimizing the quality of life should be the focus in the treatment of diabetes. Therefore, avoiding the side effects of anti‐diabetic medications is a major consideration in choosing appropriate drugs for these patients. These patients have some common clinical features, including decreased appetite, cognitive impairment, functional disability, being vulnerable to fall and fracture, and reduced renal function etc. As a result, they more easily develop hypoglycemia and are less likely to respond appropriately. Hypoglycemia is associated with an increased risk of arrhythmia, and diabetic microvascular and macrovascular complications. Besides, hypoglycemia may impair cognitive function and forms a vicious cycle together with fragility and dementia. Thus, de‐intensification or the withdrawal of medications with a risk of hypoglycemia should be considered, such as sulfonylurea and insulin. In addition, the incidence of side effects of certain anti‐diabetic medications in addition to hypoglycemia may have unfavorable effects on the quality of life, such as gastrointestinal side effects for GLP‐1 RAs, genital or urinary tract infection for SGLT2 inhibitors, and edema for thiozolidinediones. On the other hand, adverse events of DPP‐4 inhibitors are less frequent, which make DPP‐4 inhibitors the preferred choice in these patients. Taken together, in diabetic patients of old age, with fragility, terminal diseases, or disability, DPP‐4 inhibitors should be prioritized for their safety among the other anti‐diabetic medications, and de‐intensification should be considered.The ‘weight‐centric’ strategy has been proposed for a long time and is back in focus recently with the development of novel and potent drugs for weight reduction ⁴ . Obesity is an important pathophysiology of diabetes and its complications. Besides, obesity also leads to the development of various risk factors of atherosclerosis, such as hypertension and dyslipidemia. Therefore, focusing on weight reduction to improve glycemic control and to prevent complications is a reasonable approach for the management of diabetes. Indeed, weight reduction by more than 5% is beneficial for the management of diabetes, hypertension, and dyslipidemia, and medications for these diseases usually can be reduced. Weight reduction by more than 10% can have an additional benefit for obesity‐related diseases, such as non‐alcoholic fatty liver disease, sleep apnea, cardiovascular diseases, or even reducing cardiovascular mortality. In addition, weight reduction can also improve fitness and may have psychological and social benefits. However, there have only been limited therapeutic options in previous years. Lifestyle modification has been shown to be effective. Nonetheless, a team‐based approach and coaching are usually needed for its success, and it is often difficult to maintain sustained weight loss in the long term. On the other hand, bariatric surgery is another effective option, but it is limited because of its short‐term and long‐term adverse effects. There have been some drugs for weight reduction previously. Orlistat is associated with only a modest weight‐reducing effect, which limits its benefits in the management of diabetes and diabetic complications. Phentermine is another drug for weight reduction. However, it is only approved for short‐term use, mainly in the USA, and is associated with adverse events in the cardiovascular, gastrointestinal, and central nervous systems. Among anti‐diabetic drugs, SGLT2 inhibitors, GLP‐1 RAs, and metformin are associated with weight loss, but most of these drugs have only a modest effect in weight reduction. Therefore, the beneficial effects of weight reduction on metabolic control or on reducing cardiovascular risks by these drugs are usually not expected. Recently, the GLP‐1 RA semaglutide, at a dose of 1.0 mg every week, was shown to have a more pronounced effect on weight reduction (3.5–5%). In the STEP 2 study, semaglutide 2.4 mg weekly was associated with an even greater effect on weight loss (6.2%), which was accompanied by a HbA1c decrease of 1.6% and the proportion of subjects achieving a HbA1c of <6.5% was 68% ⁵ . Similarly, liraglutide 3 mg per day was shown to have a greater effect on weight loss, compared with liraglutide at 0.6–1.8 mg per day (the doses for anti‐diabetic effects). In the future, there are several novel weight reduction drugs in the pipeline, such as the GLP‐1 and gastric inhibitory polypeptide (GIP) dual agonist tirzepatide, the amylin agonist cagrilintide, or the combination of semaglutide and cagrilintide. Based on current reports, these drugs were associated with a mean weight loss of 10.8–17.1%, and the proportion of subjects reaching a HbA1c of <6.5% was more than 80%. With the development of these new drugs, the ‘weight‐centric’ strategy aiming at a weight loss of more than 5–10% is emerging, and the selection of an appropriate population for this strategy as well as the individualized target and rate for weight reduction should be issues to be explored in the near future.Figure 1 shows the proposed strategies for the pharmacological management of diabetes. To decide which strategy is to be used, clinicians should consider the patient’s clinical characteristics individually, such as age, comorbidities, general condition, body mass index, glycemic control, risk of hypoglycemia, and the risk of or the presence of diabetic complications. Then, clinicians should discuss with the patient and go through a shared‐decision‐making process. Once the strategy has been chosen, the indicated drugs shown in Figure 1 should be considered preferentially.Open in a separate windowFigure 1Proposed strategies for the pharmacological management of diabetes. DPP‐4i, dipeptidyl peptidase‐4 inhibitor; GLP‐1 RA, glucagon‐like peptide‐1 receptor agonist; SGLT2i, sodium‐glucose cotransporter 2 inhibitor; SU, sulfonylurea.In conclusion, with the development of several new classes of anti‐diabetic drugs in the past decade, the concept for the pharmacological management of type 2 diabetes evolves from ‘glycemic control’ to ‘organ protection’. Besides, the increase in the prevalence of an aging population warrants a strategy focusing on safety and de‐intensification. In the coming years, with the development of several novel and potent anti‐obesity drugs, the ‘weight‐centric’ strategy is expected to gain more and more attention in the treatment of diabetes, since it can both prevent diabetic complications and optimize the quality of life. With all these strategies, clinicians should consider a patient’s clinical characteristics and make an individualized goal through shared decision making with the patient.