Cost-Effectiveness of Canagliflozin versus Sitagliptin as Add-on to Metformin in Patients with Type 2 Diabetes Mellitus in Mexico

Economic Evaluation of Type 2 Diabetes Mellitus Interventions in Low- and Middle-Income Countries: A Systematic Review of the Literature

The primary aim of this study is to assess the evidence on the cost-effectiveness of type 2 diabetes mellitus (T2DM) interventions with a focus on diabetes education, lifestyle modifications, surgical intervention, and pharmacological therapy in low- and middle-income countries (LMICs). A systematic review was conducted to identify economic evaluations of T2DM interventions published in LMICs for the period 2009-2019. A total of 25 studies were identified, with more than half of the studies being decision analytic models. Critical appraisal of the identified studies showed they were of good quality. Overall, the reported interventions in this review were very heterogeneous, which made them difficult to compare. However, there was strong evidence suggesting that diabetes education was a very cost-effective strategy in LMICs. Further evidence on affordability and budget impact of bariatric surgery is required before adopting the intervention. Metformin-based therapy showed promising evidence on cost-effectiveness and thus should be offered to T2DM patients in LMICs. On the contrary, the cost-effectiveness of lifestyle modifications remains understudied in LMICs. The findings in this review can inform policy guidance toward the inclusion of T2DM interventions in the benefit packages for Universal Health Coverage in LMICs.

Cost-effectiveness of sodium-glucose cotransporter-2 inhibitors versus dipeptidyl peptidase-4 inhibitors among patients with type 2 diabetes with and without established cardiovascular diseases: A model-based simulation analysis using 10-year real-world data and targeted literature review

AIM

We conducted a model-based economic analysis of sodium-glucose cotransporter-2 inhibitors (SGLT2is) versus dipeptidyl peptidase-4 inhibitors (DPP4is) in patients with type 2 diabetes (T2D), with and without established cardiovascular diseases (CVDs), using 10-year real-world data.

MATERIALS AND METHODS

A Markov model was utilized to estimate healthcare costs and quality-adjusted life-years (QALYs) over a 10-year simulation time horizon from a healthcare sector perspective, with both costs and QALYs discounted at 3% annually. Model inputs were derived from analyses of Taiwan's National Health Insurance Research Database or published studies of Taiwanese populations. The primary outcome measure was the incremental cost-effectiveness ratios (ICERs). Incorporated with our study findings, a targeted literature review was conducted to synthesize updated evidence on the cost-effectiveness of SGLT2is versus DPP4is.

RESULTS

Over 10 years, use of SGLT2is versus DPP4is yielded ICERs of $3244 and $4186 per QALY gained for patients with T2D, with and without established CVDs, respectively. Results were robust across a series of sensitivity and scenario analyses, showing ICERs between $-1074 (cost-saving) and $8467 per QALY gained for patients with T2D with established CVDs and between $369 and $37 122 per QALY gained for patients with T2D without established CVDs.

CONCLUSIONS

Use of SGLT2is versus DPP4is was highly cost-effective for patients with T2D regardless of their CVD history in real-world clinical practice. Our results extend current evidence by showing SGLT2is as an economically rational alternative over DPP4is for T2D treatment in routine care. Future research is warranted to explore the heterogeneous economic benefits of SGLT2is given diverse patient characteristics in clinical settings.

Pharmacoeconomic evaluation of dipeptidyl peptidase-4 inhibitors for the treatment of type 2 diabetes mellitus: a systematic literature review

INTRODUCTION

Dipeptidyl peptidase-4 inhibitors (DPP-4i) are widely used oral antidiabetic agents that exert antihyperglycemic effects in type 2 diabetes mellitus (T2DM) without increased risk of weight gain or hypoglycemic events. The objective of this paper was to systematically review the latest evidence that was associated with the pharmacoeconomic evaluation of DPP-4i for the treatment of patients with T2DM.

AREAS COVERED

We conducted a systematic literature search of eligible articles published since inception up to March 2021 in Web of Science, MEDLINE (via PubMed), and ECONLIT. Fifty-four eligible articles were included in our review, in which DPP-4i were compared to metformin (4 studies), sulphonylurea (SU) (16 studies), alpha-glucosidase inhibitors (AGI) (3 studies), thiazolidinediones (TZD) (4 studies), other DPP-4i (3 studies), sodium-glucose co-transporter-2 inhibitors (SGLT-2i) (10 studies), glucagon-like peptide 1 receptor agonist (GLP-1RA) (18 studies), insulin (5 studies), and other antidiabetic therapies (5 studies).

EXPERT OPINION

This study provided the updated evidence of systematic pharmacoeconomic evaluation associated with DPP-4i for the treatment of patients with T2DM. The evidence from the literature suggested that DPP-4i may be more cost-effective compared to SU and insulin as second-line therapy after metformin but not a cost-effective alternative compared to SGLPT-2i and GLP-1RA.

Risk of Cardiovascular Events and Medical Cost of Dapagliflozin and Dipeptidyl Peptidase-4 Inhibitors

This study compared dapagliflozin, a sodium-glucose co-transporter 2 inhibitor, and dipeptidyl peptidase-4 inhibitors (DPP-4i) with regard to cardiovascular (CV) event incidence and direct medical costs during type 2 diabetes treatment. A retrospective cohort study was conducted using national health insurance claims data from September 1, 2014, to June 30, 2018, of patients in Korea. Patients who were prescribed dapagliflozin and DPP-4i for the first time were included. The primary outcome was the incidence of a composite of major adverse CV events (MACEs)—nonfatal myocardial infarction, nonfatal stroke, or in-hospital CV death. Proportional hazard models after propensity score weighting were used to determine hazard ratios (HRs) and 95% confidence intervals (CIs) for MACE in the dapagliflozin and DPP-4i groups. A decision analytic model was used to compare direct medical costs between the two treatment groups from a healthcare provider’s perspective. Of the 260,336 patients in the cohort, 23,147 and 237,189 received dapagliflozin and DPP-4i, respectively. During the follow-up, 184 patients receiving dapagliflozin and 3,674 receiving DPP-4i (incidence, 6.47 and 11.33 events/1,000 person-years, respectively) had MACE. The adjusted HR of MACE for dapagliflozin compared with that for DPP-4i was 0.69 (95% CI 0.57–0.83). The corresponding HRs were consistent among patients with and without underlying CV disease. The estimated direct medical cost appeared to be lower by $68,452 in the dapagliflozin group than that in the DPP-4i group for 3 years, in 1,000 hypothetical patients. In this population-based cohort study, the use of dapagliflozin instead of DPP-4i was associated with a reduced risk of MACE, which subsequently reduced direct medical costs. These data provide valuable information to patients, practitioners, and authorities regarding the risk of CV events associated with dapagliflozin versus DPP-4i use in clinical practice.

Cost-utility analysis of second-line anti-diabetic therapy in patients with type 2 diabetes mellitus inadequately controlled on metformin

BACKGROUND

There are significant differences in costs and effectiveness among the second-line treatment options for type 2 diabetes (T2DM). We aimed to evaluate the cost-effectiveness of the second-line anti-diabetic therapy in T2DM patients inadequately controlled on metformin (MET) in Taiwan from the perspective of the National Health Insurance (NHI).

METHODS

The Cardiff T2DM model was used to predict the occurrence of mortality, diabetes-related complications, and drug adverse events. Five second-line treatments were selected for the analysis: sodium-glucose cotransporter 2 inhibitors (SGLT-2-i), glucagon-like peptide-1 receptor agonists (GLP-1-RA), dipeptidyl peptidase-4 inhibitor (DPP-4-i), sulfonylurea (SU), and insulin (INS). Treatment efficacy data were obtained from meta-analyses and randomized clinical trials, whereas cost data were derived from the NHI databases.

RESULTS

The analysis found that SU + MET (DPP-4-i as triple therapy) had the lowest cost, and SU + MET (SGLT-2-i as triple therapy) was associated with a mean incremental benefit of 0.47 quality-adjusted life years (QALYs) at an incremental cost of NT$2769, resulting in an incremental cost-effectiveness ratio (ICER) of NT$5840/QALY. Compared to their next less costly strategies, SGLT-2-i + MET (SU as triple therapy) and SGLT-2-i + MET (DPP-4-i as triple therapy) had ICER values of NT$63,170/QALY and NT$64,090/QALY, respectively. These results were fairly robust to extensive sensitivity analyses, but were relatively sensitive to baseline HbA1c, HbA1c threshold, and utilities.

CONCLUSION

The addition of either SU or SGLT-2-i to MET was found to be cost-effective, using the 2019 forecast for GDP per capita of Taiwan (NT$770,770) as the willingness to pay (WTP) threshold.

A Systematic Review of Cost-Effectiveness of Sodium-Glucose Cotransporter Inhibitors for Type 2 Diabetes

PURPOSE OF REVIEW

Sodium-glucose cotransporter 2 inhibitors (SGLT2i) are the most recently approved class of drugs (since 2012) for type 2 diabetes mellitus (T2DM), but their economic merits have yet been fully confirmed. The objective of this review was to evaluate the most updated evidence that examined the cost-effectiveness of SGLT2i for T2DM.

RECENT FINDINGS

We systematically searched Medline (PubMed), EMBASE, and Web of Science for eligible articles from January 1, 2011, to October 31, 2019, using combinations of search words. A supplementary search using reference lists of eligible articles and other review articles was also performed. A multistage screening process was carried out with duplicates removal, abstract screening, and full-text reading to confirm eligibility. Two reviewers independently screened the eligible articles and assessed reporting quality using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist. A total of 24 studies were included in the final review. All studies showed good quality according to the CHEERS checklist (scored 21-24). Seven studies compared SGLT2i vs. dipeptidyl peptidase-4 inhibitors (DPP-4i), 3 studies compared SGLT2i vs. sulfonylureas (SU), 3 compared SGLT2i vs. glucagon-like peptide-1 receptor agonist (GLP-1 RA), 2 compared SGLT2i vs. SGLT2i, 3 compared SGLT2i vs. other antidiabetic therapies including thiazolidinediones (TZD), alpha-glucosidase inhibitors (AGI) or insulin, and 5 compared SGLT2i vs. standard care/metformin. Most studies concluded SGLT2i was cost-effective relative to its comparator except GLP-1 RA, where two studies suggested GLP-1 RA was the favorable treatment option relative to SGLT2i. The literature demonstrated that SGLT2i may be cost-effective compared to many antidiabetic therapies including DPP-4i, SU, TZD, AGI, insulin, and standard care .

Cost Utility of Sodium-Glucose Cotransporter 2 Inhibitors in the Treatment of Metformin Monotherapy Failed Type 2 Diabetes Patients: A Systematic Review and Meta-Analysis

OBJECTIVES

Type 2 diabetes mellitus (T2DM) and associated ailments are leading economic burdens to society. Sodium glucose cotransporter-2 (SGLT2) inhibitors are recent antidiabetic medications with beneficial clinical efficacy. This meta-analysis was conducted to quantitatively pool the incremental net benefit of SGLT2 inhibitors in T2DM patients who failed metformin monotherapy.

METHODS

Relevant economic evaluation studies of T2DM patients were identified from PubMed, Scopus, ProQuest, the Cochrane Library, and the Tufts Cost-Effective Analysis Registry until June 2018. Studies were eligible if they studied T2DM patients who failed metformin monotherapy and assessed the cost-effectiveness/utility between SGLT2 inhibitors and other treatments. Details of the study characteristics, economic model inputs, costs, and outcomes were extracted. Risk of bias was assessed using the biases in economic studies (ECOBIAS) checklist. The incremental net benefit was calculated with monetary units adjusting for purchasing power parity for 2017 US dollars. This was then pooled across studies stratified by the country's level of income using a random-effect model if heterogeneity was present and with a fixed-effect model otherwise. Heterogeneity was assessed using the Q test and I² statistic.

RESULTS

A total of 13 studies with 22 comparisons, mainly from high-income countries, were eligible. Six and 4 studies compared SGLT2 with dipeptidyl peptidase-4 inhibitors (DPP4i) and sulfonylureas, respectively. The pooled incremental net benefits (95% confidence interval) for these corresponding comparisons were $164.95 (-$534.71 to $864.61; I² = 0%) and $3675.09 ($1656.46-$5693.71; I² = 85.4%), respectively. These results indicate that SGLT2s were cost-effective in comparison with sulfonylureas but not DPP4i.

CONCLUSION

SGLT2s were cost-effective as compared with sulfonylureas but not DPP4i. Most of the evidence was from high-income countries with few comparative drug groups, and the results might not be representative of the actual global scenario. Further studies from middle and lower economies and other comparators are still required.

Cost Effectiveness of Sodium-Glucose Cotransporter-2 (SGLT2) Inhibitors, Glucagon-Like Peptide-1 (GLP-1) Receptor Agonists, and Dipeptidyl Peptidase-4 (DPP-4) Inhibitors: A Systematic Review

OBJECTIVE

This study aimed to systematically review cost-effectiveness studies of newer antidiabetic medications.

METHODS

The PubMed/MEDLINE, EMBASE, CINAHL Plus, Cochrane Library-NHS Economic Evaluation Database (Wiley), Cochrane Library-Health Technology Assessment Database (Wiley), Cochrane Library-Database of Abstracts of Reviews of Effects (Wiley), and the Cost-Effectiveness Analysis Registry databases (from 1 January 2000 to 1 June 2018) were searched. The search strategies included the Medical Subject Heading (MeSH) term 'economics', and the MeSH entry terms 'cost', 'cost effectiveness', 'value', and 'cost utility', as well as all names for GLP-1 receptor agonists, DPP-4 inhibitors, and SGLT2 inhibitors. Inclusion criteria included (1) cost-effectiveness studies of the newer antidiabetic medications, including sodium-glucose cotransporter-2 (SGLT2) inhibitors, glucagon-like peptide-1 (GLP-1) receptor agonists, and dipeptidyl peptidase-4 (DPP-4) inhibitors; and (2) full-text publications in English. Two reviewers independently screened the titles, abstracts, and full-text articles to select studies for data extraction. Discrepancies were resolved by discussion and consensus. The quality of reporting cost-effectiveness analyses was assessed using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) guideline.

RESULTS

Among 85 studies selected, 82 clearly stated the types of diabetes model used (e.g. CORE model), and 70 studied used validated diabetes models. Seventy-four (87%) studies were funded by pharmaceutical companies, and 72 (85%) studies were conducted from a payer's perspective. Seventy-six (89%) studies presented were of good quality (20-24 CHEERS items), and nine were of moderate quality (14-19 items). Thirty studies compared newer antidiabetic medications with insulin, 3 studies compared newer antidiabetic medications with thiazolidinediones (TZDs), 15 studies compared newer antidiabetic medications with sulfonylureas, 40 studies compared new antidiabetic medications with alternative newer antidiabetic medication, and 9 studies compared other antidiabetic agents that were not included above. Newer antidiabetic medications were reported to be cost-effective in 26 of 30 (87%) studies compared with insulin, and 13 of 15 (87%) studies compared with sulfonylureas.

CONCLUSIONS

Most economic evaluations of antidiabetic medications have good reporting quality and use validated diabetes models. The newer antidiabetic medications in most of the reviewed studies were found to be cost effective, compared with insulin, TZDs, and sulfonylureas.

Cost-effectiveness of first-line versus delayed use of combination dapagliflozin and metformin in patients with type 2 diabetes

The present study sought to evaluate the cost-effectiveness of first-line (immediate) versus delayed use of combination dapagliflozin and metformin in patients with type 2 diabetes, from the perspective of the Australian healthcare system. We developed a Markov model to simulate the progress of subjects with type 2 diabetes. Decision analysis was applied to assess the cost-effectiveness of first-line combination dapagliflozin and metformin versus first-line metformin monotherapy followed by gradual addition of dapagliflozin over time. Transition probabilities, costs (in Australian dollars) and utility data were derived from published sources. All costs, years of life lived and quality adjusted life years (QALYs) lived were discounted at an annual rate of 5%. Over a 20-year model period, first-line use of combination dapagliflozin and metformin was predicted to reduce the onset of hospitalisation of heart failure, cardiovascular deaths and all cause deaths by 5.5%, 57.6% and 29.6%, respectively. An additional 2.5 years of life (discounted) and 1.9 QALYs (discounted) would be gained per patient, at a cost of AUD $23,367 (discounted) per person. These figures equated to AUD $9,535 per years of life saved (YoLS) and AUD $12,477 per QALYs saved. Sensitivity analyses indicated the results to be robust. Compared to first-line metformin monotherapy followed by gradual addition of dapagliflozin, first-line use of combination dapagliflozin and metformin is likely to be a cost-effective approach to the management of Australians with type 2 diabetes mellitus.

Cost-Effectiveness Analysis of Canagliflozin 300 mg Versus Dapagliflozin 10 mg Added to Metformin in Patients with Type 2 Diabetes in the United States

INTRODUCTION

Agents that inhibit sodium glucose co-transporter 2 (SGLT2), including canagliflozin and dapagliflozin, are approved in the United States for the treatment of adults with type 2 diabetes mellitus (T2DM). SGLT2 inhibition lowers blood glucose by increasing urinary glucose excretion, which leads to a mild osmotic diuresis and a net loss of calories that are associated with reductions in body weight and blood pressure. This analysis evaluated the cost-effectiveness of canagliflozin 300 mg versus dapagliflozin 10 mg in patients with T2DM inadequately controlled with metformin in the United States.

METHODS

A 30-year cost-effectiveness analysis was performed using the validated Economic and Health Outcomes Model of T2DM (ECHO-T2DM) from the perspective of the third-party health care system in the United States. Patient demographics, biomarker values, and treatment effects for the ECHO-T2DM model were sourced primarily from a network meta-analysis (NMA) that included studies of canagliflozin and dapagliflozin in patients with T2DM on background metformin. Costs were derived from sources specific to the United States. Outcomes and costs were discounted at 3%. Sensitivity analyses that varied key model parameters were conducted.

RESULTS

Canagliflozin 300 mg dominated dapagliflozin 10 mg as an add-on to metformin over 30 years, with an estimated cost offset of $13,991 and a quality-adjusted life-year gain of 0.08 versus dapagliflozin 10 mg. Results were driven by the better HbA1c lowering achieved with canagliflozin, which translated to less need for insulin rescue therapy. Findings from sensitivity analyses were consistent with the base case.

CONCLUSION

These results suggest that canagliflozin 300 mg is likely to provide better health outcomes at a lower overall cost than dapagliflozin 10 mg in patients with T2DM inadequately controlled with metformin from the perspective of the United States health care system.

FUNDING

Janssen Scientific Affairs, LLC and Janssen Global Services, LLC.

Diabetes Drugs and Cardiovascular Event Reduction: A Paradigm Shift

This review article summarizes the recent cardiovascular outcome data for sodium–glucose cotransporter-2 inhibitors and glucagon-like peptide-1 analogues, which have been found to reduce cardiovascular events. We also detail the implications these new medications will have on clinical practice through a review of recent diabetes guidelines and cost-effectiveness data.

Validation of the Economic and Health Outcomes Model of Type 2 Diabetes Mellitus (ECHO-T2DM)

BACKGROUND

The Economic and Health Outcomes Model of Type 2 Diabetes Mellitus (ECHO-T2DM) was developed to address study questions pertaining to the cost-effectiveness of treatment alternatives in the care of patients with type 2 diabetes mellitus (T2DM). Naturally, the usefulness of a model is determined by the accuracy of its predictions. A previous version of ECHO-T2DM was validated against actual trial outcomes and the model predictions were generally accurate. However, there have been recent upgrades to the model, which modify model predictions and necessitate an update of the validation exercises.

OBJECTIVES

The objectives of this study were to extend the methods available for evaluating model validity, to conduct a formal model validation of ECHO-T2DM (version 2.3.0) in accordance with the principles espoused by the International Society for Pharmacoeconomics and Outcomes Research (ISPOR) and the Society for Medical Decision Making (SMDM), and secondarily to evaluate the relative accuracy of four sets of macrovascular risk equations included in ECHO-T2DM.

METHODS

We followed the ISPOR/SMDM guidelines on model validation, evaluating face validity, verification, cross-validation, and external validation. Model verification involved 297 'stress tests', in which specific model inputs were modified systematically to ascertain correct model implementation. Cross-validation consisted of a comparison between ECHO-T2DM predictions and those of the seminal National Institutes of Health model. In external validation, study characteristics were entered into ECHO-T2DM to replicate the clinical results of 12 studies (including 17 patient populations), and model predictions were compared to observed values using established statistical techniques as well as measures of average prediction error, separately for the four sets of macrovascular risk equations supported in ECHO-T2DM. Sub-group analyses were conducted for dependent vs. independent outcomes and for microvascular vs. macrovascular vs. mortality endpoints.

RESULTS

All stress tests were passed. ECHO-T2DM replicated the National Institutes of Health cost-effectiveness application with numerically similar results. In external validation of ECHO-T2DM, model predictions agreed well with observed clinical outcomes. For all sets of macrovascular risk equations, the results were close to the intercept and slope coefficients corresponding to a perfect match, resulting in high R ² and failure to reject concordance using an F test. The results were similar for sub-groups of dependent and independent validation, with some degree of under-prediction of macrovascular events.

CONCLUSION

ECHO-T2DM continues to match health outcomes in clinical trials in T2DM, with prediction accuracy similar to other leading models of T2DM.

How Consistent is the Relationship between Improved Glucose Control and Modelled Health Outcomes for People with Type 2 Diabetes Mellitus? a Systematic Review

BACKGROUND

There are an increasing number of studies using simulation models to conduct cost-effectiveness analyses for type 2 diabetes mellitus.

OBJECTIVE

To evaluate the relationship between improvements in glycosylated haemoglobin (HbA_1c) and simulated health outcomes in type 2 diabetes cost-effectiveness studies.

METHODS

A systematic review was conducted on MEDLINE and EMBASE to collect cost-effectiveness studies using type 2 diabetes simulation models that reported modelled health outcomes of blood glucose-related interventions in terms of quality-adjusted life-years (QALYs) or life expectancy (LE). The data extracted included information used to characterise the study cohort, the intervention's treatment effects on risk factors and model outcomes. Linear regressions were used to test the relationship between the difference in HbA_1c (∆HbA_1c) and incremental QALYs (∆QALYs) or LE (∆LE) of intervention and control groups. The ratio between the ∆QALYs and ∆LE was calculated and a scatterplot between the ratio and ∆HbA_1c was used to explore the relationship between these two.

RESULTS

Seventy-six studies were included in this research, contributing to 124 pair of comparators. The pooled regressions indicated that the marginal effect of a 1% HbA_1c decrease in intervention resulted in an increase in life-time QALYs and LE of 0.371 (95% confidence interval 0.286-0.456) and 0.642 (95% CI 0.494-0.790), respectively. No evidence of heterogeneity between models was found. An inverse exponential relationship was found and fitted between the ratio (∆QALY/∆LE) and ∆HbA_1c.

CONCLUSION

There is a consistent relationship between ∆HbA_1c and ∆QALYs or ∆LE in cost-effectiveness analyses using type 2 diabetes simulation models. This relationship can be used as a diagnostic tool for decision makers.

A review of clinical efficacy and safety of canagliflozin 300 mg in the management of patients with type 2 diabetes mellitus

Currently available antihyperglycemic agents, despite being effective, provide inadequate glycemic control and/or are associated with side effects or nonadherence. Canagliflozin, a widely used orally active inhibitor of sodium-glucose cotransporter 2 (SGLT2), is a new addition to the therapeutic armamentarium of glucose-lowering drugs. This review summarizes findings from different clinical and observational studies of canagliflozin 300 mg in patients with type 2 diabetes mellitus (T2DM). By inhibiting SGLT2, canagliflozin reduces reabsorption of filtered glucose, thereby increasing urinary glucose excretion in patients with T2DM. Canagliflozin 300 mg has been shown to be effective in lowering glycated hemoglobin, fasting plasma glucose, and postprandial glucose in patients with T2DM. Canagliflozin 300 mg also demonstrated significant reductions in body weight and blood pressure and has a low risk of causing hypoglycemia, when not used in conjunction with insulin and insulin secretagogues. Canagliflozin 300 mg was generally well tolerated in clinical studies. The most frequently reported adverse events include genital mycotic infections, urinary tract infections, osmotic diuresis, and volume depletion-related events.