Correspondence
The Lancet Diabetes & Endocrinology needs a more rigorous conflict of interest policy A conflict of interest correction1 has been added to the paper by Wenying Yang and Jianping Weng.2 This correction was necessary because the authors initially and incorrectly declared no competing interests. In their Series paper about treatment of type 2 diabetes in China, Yang and Weng2 seemed to dismiss the use of metformin, saying that the efficacy of the drug had been confirmed only “in overweight white patients”. They instead proposed a series of strategies based entirely on surrogate markers, with a treatment recommendation mostly consisting of repaglinide, liraglutide, and shortterm intensive insulin therapy at diagnosis. It is concerning that this unusual strategy does not consider cost, for neither the individual nor the health-care system, generally a major area of concern for The Lancet journals. Despite China now being classified as a middle-income country, catastrophic health expenditure is common, particularly in elderly people and in those with chronic disease.3 It was also curious that the authors’ recommendations largely seemed to represent the products of just one company, Novo Nordisk. This is a company to whom, in a paper published at the same time as their article in The Lancet Diabetes & Endocrinology, the authors expressed thanks for having “as a courtesy, funded the writing support, provided by Watermeadow Medical, …required to produce consensus manuscript in English” following an expert workshop on the use of intensive insulin strategies at diagnosis of type 2 diabetes.4 It seems that no writing support was necessary for writing the article published in The Lancet Diabetes & Endocrinology. 168
With declining profit margins in high-income countries, many large pharmaceutical companies such as Novo Nordisk5 are looking to emerging markets, in which they might have a virtual monopoly on continuing medical education. The Chinese market for diabetes treatments had an estimated worth of US$1·5 billion in 2011, and might contribute 29% of its global growth in the next decade.6 One of us has previously expressed concern about the editorial laxity that permitted two statistically substandard reports about Novo Nordisk products to be published in The Lancet, commenting that “the Lancet’s reprints are a major source of revenue for the journal, and a major part of drug company marketing.”7 We recognise the commercial necessity for The Lancet journals to use strategies, such as fast-track publication of landmark studies and of breakthrough therapies, which encourage the sale of such reprints. We contend, however, that it is of paramount importance for The Lancet journals to maintain rigorous scientific integrity when doing so to avoid inadvertently playing a part in promoting company-related products in Chinese (and other) markets—a particular risk with reviews of treatment strategies such as that by Yang and Weng.2 We would commend to The Lancet journals the policy recently announced by the BMJ8 whereby clinical education articles will be authored by experts without financial ties to industry, with the intention of extending this policy to all reviews by the end of 2016. TAS holds Novo Nordisk stock. JSY declares no competing interests.
*Thomas A Schmidt, John S Yudkin [email protected] The Emergency Department, Holbaek University Hospital 60, Holbaek 4300, Denmark (TAS); and Div of Medicine, Faculty of Medical Sciences, University College London, London (JYS) 1
Correction to Lancet Diabetes Endocrinol 2014; 2: 992–1002. Lancet Diabetes Endocrinol 2014; 2: e17.
2
3
4
5
6
7 8
Yang W, Weng J. Early therapy for type 2 diabetes in China. Lancet Diabetes Endocrinol 2014; 2: 992–1102. Li Y1, Wu Q, Xu L, et al. Factors affecting catastrophic health expenditure and impoverishment from medical expenses in China: policy implications of universal health insurance. Bull World Health Organ 2012; 90: 664–71. Weng J, Retnakaran R, Ammini AC, et al. Short-term intensive insulin therapy at diagnosis in type 2 diabetes: plan for filling the gaps. Diabetes Metab Res Reb 2014; published online Nov 18. DOI:10.1002/dmrr.2603. Novo Nordisk. The Blueprint for Change Programme. Changing diabetes in China. Feb 2011. http://www.novonordisk.com/ images/Sustainability/PDFs/Blueprint%20 for%20change%20-%20China.pdf (accessed Feb 6, 2015). Alcorn T, Ouyang Y. Diabetes saps health and wealth from China’s rise. Lancet 2012; 379: 2227–28. Burch D, Mafham M and Yudkin JS. What are editors for? Lancet 2012; 379: 2240. Chew M, Brizzell C, Abbasi K, Godlee F. Medical journals and industry ties. BMJ 2014; 349: g7197.
Editors’ reply We thank Thomas Schmidt and John Yudkin for their letter in which they express concerns of bias in a recent publication about early treatment of type 2 diabetes in China by Wenying Yang and Jianping Weng1 and offer advice to ensure that articles, especially review articles, published by The Lancet family of journals are unbiased in their presentation of the evidence. Concerning specific allegations of bias in the article, Schmidt and Yudkin suggest that Yang and Weng dismiss metformin. We do not share their view. Yang and Weng discuss metformin’s place in the Chinese Diabetes Society (CDS) guidelines and state simply that, by contrast with American and European guidelines, the CDS guidelines list metformin along with other first-line drugs. They also state that there is no equivalent of the UK Prospective Diabetes Study—ie, long-term outcomes of metformin in Chinese patients with type 2 diabetes are unknown. Schmidt and Yudkin also suggest that Yang and Weng propose that other newer and more costly drugs, especially those produced by Novo Nordisk, should be used earlier in the course of type 2
www.thelancet.com/diabetes-endocrinology Vol 3 March 2015
Correspondence
diabetes. Although Yang and Weng discuss the CDS guidelines, which do recommend the use of newer drugs or insulin earlier in the disease than do American and European guidelines, we disagree that there is a bias towards Novo Nordisk’s products. In their Series paper, the authors list more than 20 treatments available to Chinese patients; of these, only four are produced by Novo Nordisk. They discuss seven treatments in detail, of which only two are produced solely by Novo Nordisk. The editors of The Lancet Diabetes & Endocrinology take the need for scientific integrity very seriously. To this end, we ask all authors of Reviews and Personal Views to disclose any potential conflicts of interest before commissioning them to write. In particular, we do not commission an article from any author who, “within the past 3 years, and with a relevant company or competitor, has any stocks or shares, equity, a contract of employment, or a named position on a company board”. We also mandate that all authors of any Review or Personal View submit an ICMJE Conflicts of Interest form at the time of submission, before peer review. This policy has been in place across The Lancet family of journals for more than a decade2—much longer
than such policies have been in place at the BMJ, to which Schmidt and Yudkin refer in their letter. Schmidt and Yudkin also imply that revenue is a potential driver behind our choice of commissioned articles, but nothing could be further from the truth! We do not commission or accept any article based on consideration of reprint revenue, and the sales team operates entirely separately from editorial teams of The Lancet family journals. Yang and Weng were commissioned by The Lancet Diabetes & Endocrinology to write an article that compared and contrasted CDS guidelines with those of the USA and Europe, and to discuss these differences based on physiology and supporting trial evidence in Chinese patients with type 2 diabetes. The article was extensively peer reviewed by three external reviewers from both within and outside China. The revision was reviewed by a single reviewer who had access to all previous reviewers’ comments. The editors were satisfied before accepting the article that the authors had fulfilled their remit and reviewed the evidence in an unbiased manner. Schmidt and Yudkin imply that writing support supplied to these authors for an article published elsewhere suggests that they had writing support for the article written
www.thelancet.com/diabetes-endocrinology Vol 3 March 2015
for The Lancet Diabetes & Endocrinology. We were puzzled by this insinuation, but asked the authors to specifically respond to it. They confirmed that they received no writing support or other financial support for writing their review for us. As for all Reviews and Personal Views commissioned by the journal, the authors received support and guidance from the editorial team throughout the editorial process. We agree with Schmidt and Yudkin that cost is important when considering treatment options; however, given the limitations of space and the broad remit of the article that was commissioned, we did not ask the authors to cover this aspect; indeed, cost-effective treatment for type 2 diabetes in China could the basis for an entire separate review article. We are employees of Elsevier and each receive a fixed salary. We declare no other competing interests.
For more about declaration of interests in The Lancet Diabetes & Endocrinology see http://www. thelancet.com/landia/ information-for-authors/ statements-permissionssignatures#conflicts-of-interest
*Justine Davies, Sarah Linklater, Fiona Mitchell [email protected] The Lancet Diabetes & Endocrinology, 125 London Wall, London EC2Y 5AS 1
2
Yang W, Weng J. Early therapy for type 2 diabetes in China. Lancet Diabetes Endocrinol 2014; 2: 992–1102. James A, Horton R. The Lancet’s policy on conflicts of interest. The Lancet 2003; 361: 8–9.
For more about The Lancet’s policy on ICMJE forms see http:// www.thelancet.com/pb/assets/ raw/Lancet/authors/icmje-coiform.pdf
169
The Lancet Diabetes & Endocrinology needs a more rigorous conflict of interest policy A conflict of interest correction1 has been added to the paper by Wenying Yang and Jianping Weng.2 This correction was necessary because the authors initially and incorrectly declared no competing interests. In their Series paper about treatment of type 2 diabetes in China, Yang and Weng2 seemed to dismiss the use of metformin, saying that the efficacy of the drug had been confirmed only “in overweight white patients”. They instead proposed a series of strategies based entirely on surrogate markers, with a treatment recommendation mostly consisting of repaglinide, liraglutide, and shortterm intensive insulin therapy at diagnosis. It is concerning that this unusual strategy does not consider cost, for neither the individual nor the health-care system, generally a major area of concern for The Lancet journals. Despite China now being classified as a middle-income country, catastrophic health expenditure is common, particularly in elderly people and in those with chronic disease.3 It was also curious that the authors’ recommendations largely seemed to represent the products of just one company, Novo Nordisk. This is a company to whom, in a paper published at the same time as their article in The Lancet Diabetes & Endocrinology, the authors expressed thanks for having “as a courtesy, funded the writing support, provided by Watermeadow Medical, …required to produce consensus manuscript in English” following an expert workshop on the use of intensive insulin strategies at diagnosis of type 2 diabetes.4 It seems that no writing support was necessary for writing the article published in The Lancet Diabetes & Endocrinology. 168
With declining profit margins in high-income countries, many large pharmaceutical companies such as Novo Nordisk5 are looking to emerging markets, in which they might have a virtual monopoly on continuing medical education. The Chinese market for diabetes treatments had an estimated worth of US$1·5 billion in 2011, and might contribute 29% of its global growth in the next decade.6 One of us has previously expressed concern about the editorial laxity that permitted two statistically substandard reports about Novo Nordisk products to be published in The Lancet, commenting that “the Lancet’s reprints are a major source of revenue for the journal, and a major part of drug company marketing.”7 We recognise the commercial necessity for The Lancet journals to use strategies, such as fast-track publication of landmark studies and of breakthrough therapies, which encourage the sale of such reprints. We contend, however, that it is of paramount importance for The Lancet journals to maintain rigorous scientific integrity when doing so to avoid inadvertently playing a part in promoting company-related products in Chinese (and other) markets—a particular risk with reviews of treatment strategies such as that by Yang and Weng.2 We would commend to The Lancet journals the policy recently announced by the BMJ8 whereby clinical education articles will be authored by experts without financial ties to industry, with the intention of extending this policy to all reviews by the end of 2016. TAS holds Novo Nordisk stock. JSY declares no competing interests.
*Thomas A Schmidt, John S Yudkin [email protected] The Emergency Department, Holbaek University Hospital 60, Holbaek 4300, Denmark (TAS); and Div of Medicine, Faculty of Medical Sciences, University College London, London (JYS) 1
Correction to Lancet Diabetes Endocrinol 2014; 2: 992–1002. Lancet Diabetes Endocrinol 2014; 2: e17.
2
3
4
5
6
7 8
Yang W, Weng J. Early therapy for type 2 diabetes in China. Lancet Diabetes Endocrinol 2014; 2: 992–1102. Li Y1, Wu Q, Xu L, et al. Factors affecting catastrophic health expenditure and impoverishment from medical expenses in China: policy implications of universal health insurance. Bull World Health Organ 2012; 90: 664–71. Weng J, Retnakaran R, Ammini AC, et al. Short-term intensive insulin therapy at diagnosis in type 2 diabetes: plan for filling the gaps. Diabetes Metab Res Reb 2014; published online Nov 18. DOI:10.1002/dmrr.2603. Novo Nordisk. The Blueprint for Change Programme. Changing diabetes in China. Feb 2011. http://www.novonordisk.com/ images/Sustainability/PDFs/Blueprint%20 for%20change%20-%20China.pdf (accessed Feb 6, 2015). Alcorn T, Ouyang Y. Diabetes saps health and wealth from China’s rise. Lancet 2012; 379: 2227–28. Burch D, Mafham M and Yudkin JS. What are editors for? Lancet 2012; 379: 2240. Chew M, Brizzell C, Abbasi K, Godlee F. Medical journals and industry ties. BMJ 2014; 349: g7197.
Editors’ reply We thank Thomas Schmidt and John Yudkin for their letter in which they express concerns of bias in a recent publication about early treatment of type 2 diabetes in China by Wenying Yang and Jianping Weng1 and offer advice to ensure that articles, especially review articles, published by The Lancet family of journals are unbiased in their presentation of the evidence. Concerning specific allegations of bias in the article, Schmidt and Yudkin suggest that Yang and Weng dismiss metformin. We do not share their view. Yang and Weng discuss metformin’s place in the Chinese Diabetes Society (CDS) guidelines and state simply that, by contrast with American and European guidelines, the CDS guidelines list metformin along with other first-line drugs. They also state that there is no equivalent of the UK Prospective Diabetes Study—ie, long-term outcomes of metformin in Chinese patients with type 2 diabetes are unknown. Schmidt and Yudkin also suggest that Yang and Weng propose that other newer and more costly drugs, especially those produced by Novo Nordisk, should be used earlier in the course of type 2
www.thelancet.com/diabetes-endocrinology Vol 3 March 2015
Correspondence
diabetes. Although Yang and Weng discuss the CDS guidelines, which do recommend the use of newer drugs or insulin earlier in the disease than do American and European guidelines, we disagree that there is a bias towards Novo Nordisk’s products. In their Series paper, the authors list more than 20 treatments available to Chinese patients; of these, only four are produced by Novo Nordisk. They discuss seven treatments in detail, of which only two are produced solely by Novo Nordisk. The editors of The Lancet Diabetes & Endocrinology take the need for scientific integrity very seriously. To this end, we ask all authors of Reviews and Personal Views to disclose any potential conflicts of interest before commissioning them to write. In particular, we do not commission an article from any author who, “within the past 3 years, and with a relevant company or competitor, has any stocks or shares, equity, a contract of employment, or a named position on a company board”. We also mandate that all authors of any Review or Personal View submit an ICMJE Conflicts of Interest form at the time of submission, before peer review. This policy has been in place across The Lancet family of journals for more than a decade2—much longer
than such policies have been in place at the BMJ, to which Schmidt and Yudkin refer in their letter. Schmidt and Yudkin also imply that revenue is a potential driver behind our choice of commissioned articles, but nothing could be further from the truth! We do not commission or accept any article based on consideration of reprint revenue, and the sales team operates entirely separately from editorial teams of The Lancet family journals. Yang and Weng were commissioned by The Lancet Diabetes & Endocrinology to write an article that compared and contrasted CDS guidelines with those of the USA and Europe, and to discuss these differences based on physiology and supporting trial evidence in Chinese patients with type 2 diabetes. The article was extensively peer reviewed by three external reviewers from both within and outside China. The revision was reviewed by a single reviewer who had access to all previous reviewers’ comments. The editors were satisfied before accepting the article that the authors had fulfilled their remit and reviewed the evidence in an unbiased manner. Schmidt and Yudkin imply that writing support supplied to these authors for an article published elsewhere suggests that they had writing support for the article written
www.thelancet.com/diabetes-endocrinology Vol 3 March 2015
for The Lancet Diabetes & Endocrinology. We were puzzled by this insinuation, but asked the authors to specifically respond to it. They confirmed that they received no writing support or other financial support for writing their review for us. As for all Reviews and Personal Views commissioned by the journal, the authors received support and guidance from the editorial team throughout the editorial process. We agree with Schmidt and Yudkin that cost is important when considering treatment options; however, given the limitations of space and the broad remit of the article that was commissioned, we did not ask the authors to cover this aspect; indeed, cost-effective treatment for type 2 diabetes in China could the basis for an entire separate review article. We are employees of Elsevier and each receive a fixed salary. We declare no other competing interests.
For more about declaration of interests in The Lancet Diabetes & Endocrinology see http://www. thelancet.com/landia/ information-for-authors/ statements-permissionssignatures#conflicts-of-interest
*Justine Davies, Sarah Linklater, Fiona Mitchell [email protected] The Lancet Diabetes & Endocrinology, 125 London Wall, London EC2Y 5AS 1
2
Yang W, Weng J. Early therapy for type 2 diabetes in China. Lancet Diabetes Endocrinol 2014; 2: 992–1102. James A, Horton R. The Lancet’s policy on conflicts of interest. The Lancet 2003; 361: 8–9.
For more about The Lancet’s policy on ICMJE forms see http:// www.thelancet.com/pb/assets/ raw/Lancet/authors/icmje-coiform.pdf
169
