Details

Autor(en) / Beteiligte

• Pawaskar, Manjiri

Titel

Cost-effectiveness of intensification with SGLT2 inhibitors for type 2 diabetes

Ist Teil von

• The American journal of managed care, 2021-08, Vol.27 (8), p.e269-e277

Ort / Verlag

Jamesburg: MultiMedia Healthcare Inc

Erscheinungsjahr

2021

Quelle

EZB Electronic Journals Library

Beschreibungen/Notizen

• Study Design: The cost-effectiveness analysis was performed with the validated IQVIA Core Diabetes Model. Am J Manag Care. 2021;27(8):e269-e277. https://doi.org/10.37765/ajmc.2021.88728 _____ Takeaway Points Treatment intensification with sodium-glucose co-transporter 2 (SGLT2) inhibitors demonstrated slightly better efficacy and cost savings compared with switching to glucagon-like peptide 1 receptor agonists (GLP-1 RAs): * The SGLT2 inhibitor + dipeptidyl peptidase-4 (DPP-4) inhibitor pathway showed slightly better quality-adjusted life-years; cost savings were driven by lower medication costs with SGLT2 inhibitor therapy compared with GLP-1 RAs. * Scenarios that tested differences in drug costs, clinical parameters, and cardiovascular effects confirmed the cost savings with the DPP-4 inhibitor + SGLT2 inhibitor pathway. * For patients who fail to achieve glycemic control on metformin plus a DPP-4 inhibitor, intensification by adding an SGLT2 inhibitor to the combination before moving to insulin could be a cost-saving strategy compared with switching from a DPP-4 inhibitor to a GLP-1 RA. _____ Type 2 diabetes (T2D) is a chronic condition in which the body becomes resistant to insulin, causing glucose to build up in the blood.1 High blood glucose results in complications in a variety of organs, including the eyes, kidneys, nerves, and heart.1 T2D is among the most prevalent chronic diseases in the world today and accounts for 90% to 95% of all diabetes cases.2 Twenty-one million Americans (8.6%) received a diagnosis of T2D in 2016.3 T2D is a multifactorial condition characterized by increasing chronic disability and higher risk of related conditions that contribute to increased patient morbidity and risk of mortality, such as cardiovascular disease (CVD) and obesity.1 It was the seventh leading cause of death in the United States in 2015, listed as the underlying cause for 79,535 deaths (2.9% of 2015 total mortality) and mentioned as a cause for 252,806 deaths (9.3%).2,4 Beyond exacting a large burden on individual patients, T2D imposes a substantial economic burden on health systems and the US population. In 2017, the total estimated cost of diagnosed diabetes was $327 billion, including $237 billion in direct medical costs and $90 billion in reduced productivity.5 The high cost of diabetes is driven by the substantial health care resource use in managing acute events and long-term complications.5 More than 21% of the 7.2 million hospital discharges with diabetes in 2014 were for major CVD, with another 4% associated with diabetic ketoacidosis and lower-extremity amputation.2 Emergency department visits totaled 14.2 million for hypo- and hyperglycemic events as well as other conditions for which diabetes was listed among the diagnoses.2 The goal of diabetes treatment is to manage blood glucose, which subsequently prevents or slows the progress of complications and their impact on quality of life.6 The 2018 guidelines from the American Diabetes Association (ADA) recommend a glycated hemoglobin A1c (HbA1c) target of 6.5% to 8%, depending on patient characteristics and history of hypoglycemia and adverse events.7 A threshold of 8% may be appropriate for patients with a history of severe hypoglycemia or advanced CVD complications who have not had success with previous glucose-lowering agents.7 Patients with T2D are first treated with metformin monotherapy.7 Although the ADA guidelines do not denote a specific preference for add-on therapies, sulfonylurea has been frequently prescribed after metformin because of its low cost and availability of long-term safety data.8 However, a 2010 meta-analysis revealed significant risk of hypoglycemia with sulfonylurea compared with placebo.9 Dipeptidyl peptidase-4 (DPP-4) inhibitors have been demonstrated to be at least as effective as sulfonylurea in glycemic control without increased risk of hypoglycemia and have become a commonly used add-on therapy among patients with T2D whose HbA1c is not at goal levels with metformin monotherapy.7,10 Evidence has also indicated lower all-cause mortality and fewer CVD events with DPP-4 inhibitors.11 For patients who fail to reach target HbA1c on metformin plus a DPP-4 inhibitor, there are many treatment options for intensification, which could include adding an oral therapy such as a sodium-glucose co-transporter 2 (SGLT2) inhibitor or switching to other products such as a glucagon-like peptide 1 receptor agonist (GLP-1 RA).7 Whereas GLP-1 RAs are not recommended for concurrent use with DPP-4 inhibitors,7 recent clinical trials of third-line therapy have demonstrated a clinical benefit of combinations with DPP-4 inhibitors and SGLT2 inhibitors that is significantly greater than the use of each individual component with metformin.12-18 With emerging evidence on the clinical benefits and cardioprotective effects of SGLT2 inhibitors, it is expected that treatment pathways for patients who fail on metformin with DPP-4 inhibitors may increasingly consider triple-therapy combinations.19-21 With the variety of treatment options that could be recommended by physicians along the treatment pathway in real-world practice, it may be difficult for clinical trials to capture the complete picture of every possible combination and sequence of treatments. [...]it is vital to understand the comparative performance and the associated economic outcomes for treatment options to ensure that key health care decision makers can support the use of products that bring the most value to patients and health care systems.