Diabetes exacts a high cost in human suffering, including increased burdens of cardiovascular disease, blindness, endstage kidney disease, and amputations. Landmark clinical trials have demonstrated the value of intensive pharmacotherapy to delay or prevent chronic complications of diabetes (1–6). Over the past decade, clinical trials demonstrated that several sodium–glucose cotransporter 2 (SGLT2) inhibitors and glucagon-like peptide 1 (GLP-1) receptor agonists decrease the risks of major adverse cardiovascular events, hospitalization for heart failure, and progression of diabetic kidney disease (7–12). In this issue of Diabetes Care, Zhou et al.(13) estimate the economic cost of glucose-lowering drugs at $57.6 billion per year in the US in 2015–2017 (; 15–20% of the estimated annual cost for all prescription drugs in the US). At a human level, the financial burden has a devastating impact on people without health insurance and people whose insurance imposes high deductiblesdthe people least able to afford the high cost of diabetes drugs. Thus, the high cost of diabetes drugs has important implications for both public policy and social justice.

Zhou et al.(13) obtained data from the Medical Expenditure Panel Survey, a nationally representative survey for the civilian noninstitutionalized population in the US National spending on glucoselowering drugs was estimated by extrapolating to the entire US population. The authors estimated that total national spending on glucose-lowering medications increased by 240%(from $16.9 to $57.6 billion per year expressed in 2017 dollars) in 2015–2017 compared with 2005–2007. Over the same time period, the authors estimateda38% increaseinthenumberof people using glucose-lowering drugs (from 15.3 to 21.1 million) and a 147% increase in the average annual cost per user (from $1,106 to $2,727). Further analysis revealed thought-provoking differences among different classes of diabetes drugs, with the largest increases in spending on insulins (+ 610%) and “newer”(currently proprietary) drugs (+ 1,730%). In contrast, spending on “older”(currently generic) drugs actually decreased (J80%), while spending on metformin changed relatively little (+ 11%) over the course of the decade. Despite the attention-grabbing nature of these estimates, the simplified analysis (13) does not do justice to this extremely complicated topic. Several critical factors were not adequately taken into account: