Diabetes Drugs Move from Injections to a Daily Pill, Raising Hopes of Cheaper Treatment in the Global South

Globally, one in nine people between the ages of 20 and 79 lives with diabetes, and one in eight people globally is obese. Against that background, medication that has been a lifeline for patients with uncontrollable diabetes is now slowly shifting from injections to pills, a move that could alter treatment for the disease and who can access it.

This shift could also affect the treatment of obesity, a condition once associated with overeating and laziness rather than the metabolic disorder it is now recognised as.

GLP-1 (glucagon-like peptide-1) receptor agonist therapy is not new. The first FDA-approved drug, Exenatide, hit the market in 2005 and was followed by Liraglutide in 2009, which was seen as a revolutionary alternative to insulin.

But the market has until recently been dominated by weekly injections like Ozempic and Wegovy (semaglutide), and Mounjaro (tirzepatide). These drugs have also proved successful for weight loss.

Now, once-daily oral GLP pills are emerging as an alternative, especially for the diabetes-stricken Global South.

Oral once-daily pills of the same drug could make access more affordable, and less reliant on the cold chain that GLP-1 injections and insulin depend on and that is harder to secure in emerging economies.

The GLP injections come with a high price tag and are often not covered by insurance companies, which treat them as an elective drug.

In the United States, Mounjaro costs about $500 for a month's worth of doses; in the UK, about 199 pounds ($264); and in Saudi Arabia, 1,261 riyals ($336). In India, the brand is locally manufactured and available at 14,766 rupees ($157). In Pakistan, the imported Mounjaro costs 220,000 rupees ($723), while the locally manufactured Tirzepatide from Getz Pharma costs 17,000 rupees ($61).

While pills are usually taken once a day, injections are once per week.

Pakistan has the highest diabetes prevalence in the world, with 31.4 percent of its population suffering from the disease, followed by the Marshall Islands (25.7 percent) and Kuwait (25.6 percent). Many other Middle Eastern countries rank among nations with the highest diabetes prevalence.

For many countries in the Global South, the relative affordability of oral GLP drugs, where the locally manufactured oral semaglutide is about $18 for a 30-day supply, could make them more accessible for diabetes and obesity patients, remove the need for refrigeration and make rural distribution easier.

Dr Zakir Alavi is an endocrinologist in Karachi, Pakistan and has been treating patients with diabetes and obesity for nearly 30 years. 'Pakistan is a country of contrast. We have, on one hand, childhood malnutrition, underweight, and stunted growth. On the other hand, we have childhood and adult obesity,' said Alavi.

According to doctors, malnutrition during pregnancy can lead to low birth weight, and babies born small who gain weight rapidly in infancy face a higher risk of childhood obesity. Alavi said there is at least some element in adult and childhood obesity which can be linked to a malnourished mother and an underweight, premature baby.

Alavi said GLP drugs, whether the injectables or pills, have revolutionised the management of type 2 diabetes and obesity. They not only help type 2 diabetes patients manage their weight, but can also help non-diabetics tackle obesity, improving cardiac and renal outcomes, liver disease, obstructive sleep apnea and osteoarthritis. 'They can be used for management of all these things when weight reduction is important, or sugar control is important, or both,' he said.

Rayaz Malik is a professor of medicine at Weill Cornell Medical College Qatar, and a senior consultant at Hamad Medical Corporation in Doha. Malik, who has been at the front line of helping patients with diabetes and obesity, echoed Alavi's views. Speaking of research on the subject, he said the magic number for how much weight you need to lose to cure diabetes seemed to come in at around 15kg, at least.

Jens Juul Holst is one of the central scientists behind the GLP revolution. A professor, physician and physiologist who lives in Copenhagen, he began his journey with gut hormones in the 1970s. 'When we discovered this, what we found was an insulin-releasing peptide from the gut,' Holst said. 'We were interested in what regulates insulin secretion.'