Cost-effectiveness of second-line antihyperglycemic therapy in patients with type 2 diabetes mellitus inadequately controlled on metformin

Adverse drug events in cost-effectiveness models of pharmacological interventions for diabetes, diabetic retinopathy, and diabetic macular edema: a scoping review

OBJECTIVE

The objective of this review was to examine the role of adverse drug events (ADEs) caused by pharmacological interventions in cost-effectiveness models for diabetes mellitus, diabetic retinopathy, and diabetic macular edema.

INTRODUCTION

Guidelines for economic evaluation recognize the importance of including ADEs in the analysis, but in practice, consideration of ADEs in cost-effectiveness models seem to be vague. Inadequate inclusion of these harmful outcomes affects the reliability of the results, and the information provided by economic evaluation could be misleading. Reviewing whether and how ADEs are incorporated in cost-effectiveness models is necessary to understand the current practices of economic evaluation.

INCLUSION CRITERIA

Studies included were published between 2011-2022 in English, representing cost-effectiveness analyses using modeling framework for pharmacological interventions in the treatment of diabetes mellitus, diabetic retinopathy, or diabetic macular edema. Other types of analyses and other types of conditions were excluded.

METHODS

The databases searched included MEDLINE (PubMed), CINAHL (EBSCOhost), Scopus, Web of Science Core Collection, and NHS Economic Evaluation Database. Gray literature was searched via the National Institute for Health and Care Excellence, European Network for Health Technology Assessment, the National Institute for Health and Care Research, and the International Network of Agencies for Health Technology Assessment. The search was conducted on January 1, 2023. Titles and abstracts were screened for inclusion by 2 independent reviewers. Full-text review was conducted by 3 independent reviewers. A data extraction form was used to extract and analyze the data. Results were presented in tabular format with a narrative summary, and discussed in the context of existing literature and guidelines.

RESULTS

A total of 242 reports were extracted and analyzed in this scoping review. For the included analyses, type 2 diabetes was the most common disease (86%) followed by type 1 diabetes (10%), diabetic macular edema (9%), and diabetic retinopathy (0.4%). The majority of the included analyses used a health care payer perspective (88%) and had a time horizon of 30 years or more (75%). The most common model type was a simulation model (57%), followed by a Markov simulation model (18%). Of the included cost-effectiveness analyses, 26% included ADEs in the modeling, and 13% of the analyses excluded them. Most of the analyses (61%) partly considered ADEs; that is, only 1 or 2 ADEs were included. No difference in overall inclusion of ADEs between the different conditions existed, but the models for diabetic retinopathy and diabetic macular edema more often omitted the ADE-related impact on quality of life compared with the models for diabetes mellitus. Most analyses included ADEs in the models as probabilities (55%) or as a submodel (40%), and the most common source for ADE incidences were clinical trials (65%).

CONCLUSIONS

The inclusion of ADEs in cost-effectiveness models is suboptimal. The ADE-related costs were better captured than the ADE-related impact on quality of life, which was most pronounced in the models for diabetic retinopathy and diabetic macular edema. Future research should investigate the potential impact of ADEs on the results, and identify the criteria and policies for practical inclusion of ADEs in economic evaluation.

Common treatment strategies for calcium hydroxyapatite deposition disease: a cost-effectiveness analysis

OBJECTIVE

To determine the cost-effectiveness of rotator cuff hydroxyapatite deposition disease (HADD) treatments.

METHOD

A 1-year time horizon decision analytic model was created from the US healthcare system perspective for a 52-year-old female with shoulder HADD failing conservative management. The model evaluated the incremental cost-effectiveness ratio (ICER) and net monetary benefit (NMB) of standard strategies, including conservative management, ultrasound-guided barbotage (UGB), high- and low-energy extracorporeal shock wave therapy (ECSW), and surgery. The primary effectiveness outcome was quality-adjusted life years (QALY). Costs were estimated in 2022 US dollars. The willingness-to-pay (WTP) threshold was $100,000.

RESULTS

For the base case, UGB was the preferred strategy (0.9725 QALY, total cost, $2199.35, NMB, $95,048.45, and ICER, $33,992.99), with conservative management (0.9670 QALY, NMB $94,688.83) a reasonable alternative. High-energy ECSW (0.9837 QALY, NMB $94,805.72), though most effective, had an ICER of $121, 558.90, surpassing the WTP threshold. Surgery (0.9532 QALY, NMB $92,092.46) and low-energy ECSW (0.9287 QALY, NMB $87,881.20) were each dominated. Sensitivity analysis demonstrated that high-energy ECSW would become the favored strategy when its cost was < $2905.66, and conservative management was favored when the cost was < $990.34. Probabilistic sensitivity analysis supported the base case results, with UGB preferred in 43% of simulations, high-energy ECSW in 36%, conservative management in 20%, and low-energy ECSW and surgery in < 1%.

CONCLUSION

UGB appears to be the most cost-effective strategy for patients with HADD, while surgery and low-energy ECSW are the least cost-effective. Conservative management may be considered a reasonable alternative treatment strategy in the appropriate clinical setting.

Pharmacoeconomic Aspects of Diabetes Mellitus: Outcomes and Analysis of Health Benefits Approach

Pharmacoeconomics is an important tool for investigating and restructuring healthcare policies. In India, recent statistical studies have shown that the number of diabetic patients is rapidly increasing in the rural, middle and upper-class settings. The aim of this review is to call attention towards the need to carry out pharmacoeconomic studies for diabetes mellitus and highlight the outcome of these studies on healthcare. A well-structured literature search from PubMed, Embase, Springer, ScienceDirect, and Cochrane was done. Studies that evaluated the cost-effectiveness of various anti-diabetic agents for type 2 diabetes were eligible for inclusion in the analysis and review. Two independent reviewers sequentially assessed the titles, abstracts, and full articles to select studies that met the predetermined inclusion and exclusion criteria for data abstraction. Any discrepancies between the reviewers were resolved through consensus. By employing search terms such as pharmacoeconomics, diabetes mellitus, cost-effective analysis, cost minimization analysis, cost-utility analysis, and cost-benefit analysis, a total of 194 papers were gathered. Out of these, 110 papers were selected as they aligned with the defined search criteria and underwent the removal of duplicate entries. This review outlined four basic pharmacoeconomic studies carried out on diabetes mellitus. It gave a direction that early detection, patient counseling, personalized medication, appropriate screening intervals, and early start of pharmacotherapy proved to be a cost-effective as well as health benefits approach.

Cost-Effectiveness of Newer Antidiabetic Drugs as Second-Line Treatment for Type 2 Diabetes: A Systematic Review

INTRODUCTION

Evidence from cardiovascular outcome trials (CVOTs) for newer antidiabetic drugs is increasingly influencing revised recommendations for second-line therapy in type 2 diabetes (T2D). This systematic review aimed to compare the cost-effectiveness of newer antidiabetic drugs specified as sodium-glucose cotransporter 2 inhibitor (SGLT2i), glucagon-like peptide 1 receptor agonist (GLP-1RA), and dipeptidyl peptidase 4 inhibitor (DPP-4i) for T2D in a second-line setting.

METHODS

A systematic review was conducted following the Preferred Reporting Items for Systematic Reviews (PRISMA) guidelines, and all relevant published studies were searched comprehensively in electronic databases, including PubMed, Embase, Web of Science, and International Health Technology Assessment database published from April 2023. The quality of the included studies was evaluated using Consolidated Health Economic Evaluation Reporting Standards (CHEERS) 2022 reporting checklists.

RESULTS

We included 28 studies that met the inclusion criteria. Overall reporting of the identified studies largely met CHEERS 2022 recommendations. The CORE and Cardiff models were the most frequently utilized for pharmacoeconomic evaluation in T2D. Four studies consistently discovered that SGLT2i was more cost-effective than GLP-1RA in T2D who were not adequately controlled by metformin monotherapy. Four studies compared GLP-1RA with DPP-4i, sufonylurea (SU), or insulin. Except for one that demonstrated SU was cost-effective, all were GLP-1RA. Five studies revealed that SGLT2i was more cost-effective than DPP-4i or SU. Eleven studies indicated that DPP-4i was more cost-effective than traditional antidiabetic drugs. Four additional studies explored the cost-effectiveness of various antidiabetic drugs as second-line options, indicating that SU, SGLT2i, or meglitinides were more economically advantageous. The most common driven factors were the cost of new antidiabetic drugs.

CONCLUSION

Newer antidiabetic drugs as second line are the cost-effective option for T2D from the cost-effectiveness perspective, especially SGLT2i.

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.

Health Utilities in Patients with Type 2 Diabetes in Taiwan

We aimed to measure health utilities in patients with diabetes mellitus (DM) in Taiwan and to estimate the impact of common DM-related complications and adverse effects (AEs) on health utilities. The present study was a cross-sectional survey of DM patients at a metropolitan hospital. Respondents’ health-related quality of life (HRQoL) was assessed by the EQ-5D-5L, and ordinary least-squares (OLS) regression was used to estimate the impact of self-reported DM-related complications and AEs on health utilities after controlling for age, gender, and duration of DM. A total of 506 eligible adults with type 2 DM (T2DM) were enrolled. The EQ-5D index values in our study sample ranged from −0.13 to 1, with a mean ± standard deviation of 0.88 ± 0.20. As indicated by the negative regression coefficients, the presence of any complication or AE was associated with lower EQ-5D index values, and the greatest impact on the score was made by amputation (−0.276), followed by stroke (−0.211), and blindness (−0.203). In conclusion, the present study elicited health utilities in patients with T2DM in Taiwan using the EQ-5D-5L. These estimated utility decrements provided essential data for future DM cost–utility analyses that are needed as a result of the increasing prevalence and health expenditures of DM.

Glucodynamics and glucocracy in type 2 diabetes mellitus: clinical evidence and practice-based opinion on modern sulfonylurea use, from an International Expert Group (South Asia, Middle East & Africa) via modified Delphi method

Type 2 diabetes mellitus (T2DM) is a global epidemic. According to international guidelines, the management protocol of T2DM includes lowering of blood glucose, along with preventing disease-related complications and maintaining optimal quality of life. Further, the guidelines recommend the use of a patient-centric approaches for the management of T2DM; however, Asian population is underrepresented in landmark cardiovascular outcome trials (CVOTs). There are several guidelines available today for the diagnosis and management of T2DM, and hence there is much confusion among practitioners about which guidelines to follow. A group of thirty international clinical experts comprising of endocrinologists, diabetologists and cardiologist from South Asia, Middle East and Africa met at New Delhi, India on February 8 and 9, 2020 and developed an international expert opinion statements via a structured modified Delphi method on the glucodynamic properties of OADs and the glucocratic treatment approach for the management of T2DM. In this modified Delphi consensus report, we document the glucodynamic properties of Modern SUs in terms of glucoconfidence, glucosafety, and gluconomics. According to glucodynamics theory, an ideal antidiabetic drug should be efficacious, safe, and affordable. Modern SUs as a class of OADs that have demonstrated optimal glucodynamics in terms of glucoconfidence, glucosafety, and gluconomics. Hence, modern SUs are most suitable second line drug after metformin for developing countries. Based on the current evidence, we recommend a glucocratic approach for the treatment of T2DM, where an individualized treatment plan with phenotype, lifestyle, environmental, social, and cultural factors should be considered for persons with T2DM in the South Asian, Middle Eastern and African regions.

Cost-Effectiveness of Saxagliptin Compared With Glibenclamide as a Second-Line Therapy Added to Metformin for Type 2 Diabetes Mellitus in Ethiopia

Background. Metformin is a widely accepted first-line pharmacotherapy for patients with type 2 diabetes mellitus (T2DM). Treatment of T2DM with glibenclamide, saxagliptin, or one of the other second-line treatment agents is recommended when the first-line treatment (metformin) cannot control the disease. However, there is little evidence on the additional cost and cost-effectiveness of adding second-line drugs. Therefore, this study aimed to estimate the cost-effectiveness of saxagliptin and glibenclamide as second-line therapies added to metformin compared with metformin only in T2DM in Ethiopia. Methods. This cost-effectiveness study was conducted in Ethiopia using a mix of primary data on cost and best available data from the literature on the effectiveness. We measured the interventions' cost from the providers' perspective in 2019 US dollars. We developed a Markov model for T2DM disease progression with five health states using TreeAge Pro 2020 software. Disability-adjusted life year (DALY) was the health outcome used in this study, and we calculated the incremental cost-effectiveness ratio (ICER) per DALY averted. Furthermore, one-way and probabilistic sensitivity analysis were performed. Results. The annual unit cost per patient was US$70 for metformin, US$75 for metformin + glibenclamide, and US$309 for metformin + saxagliptin. The ICER for saxagliptin + metformin was US$2259 per DALY averted. The ICER results were sensitive to various changes in cost, effectiveness, and transition probabilities. The ICER was driven primarily by the higher cost of saxagliptin relative to glibenclamide. Conclusion. Our study revealed that saxagliptin is not a cost-effective second-line therapy in patients with T2DM inadequately controlled by metformin monotherapy based on a gross domestic product per capita per DALY averted willingness-to-pay threshold in Ethiopia (US$953).

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.

Cost-effectiveness of Interventions to Manage Diabetes: Has the Evidence Changed Since 2008?

OBJECTIVE

To synthesize updated evidence on the cost-effectiveness (CE) of interventions to manage diabetes, its complications, and comorbidities.

RESEARCH DESIGN AND METHODS

We conducted a systematic literature review of studies from high-income countries evaluating the CE of diabetes management interventions recommended by the American Diabetes Association (ADA) and published in English between June 2008 and July 2017. We also incorporated studies from a previous CE review from the period 1985-2008. We classified the interventions based on their strength of evidence (strong, supportive, or uncertain) and levels of CE: cost-saving (more health benefit at a lower cost), very cost-effective (≤$25,000 per life year gained [LYG] or quality-adjusted life year [QALY]), cost-effective ($25,001-$50,000 per LYG or QALY), marginally cost-effective ($50,001-$100,000 per LYG or QALY), or not cost-effective (>$100,000 per LYG or QALY). Costs were measured in 2017 U.S. dollars.

RESULTS

Seventy-three new studies met our inclusion criteria. These were combined with 49 studies from the previous review to yield 122 studies over the period 1985-2017. A large majority of the ADA-recommended interventions remain cost-effective. Specifically, we found strong evidence that the following ADA-recommended interventions are cost-saving or very cost-effective: In the cost-saving category are 1) ACE inhibitor (ACEI)/angiotensin receptor blocker (ARB) therapy for intensive hypertension management compared with standard hypertension management, 2) ACEI/ARB therapy to prevent chronic kidney disease and/or end-stage renal disease in people with albuminuria compared with no ACEI/ARB therapy, 3) comprehensive foot care and patient education to prevent and treat foot ulcers among those at moderate/high risk of developing foot ulcers, 4) telemedicine for diabetic retinopathy screening compared with office screening, and 5) bariatric surgery compared with no surgery for individuals with type 2 diabetes (T2D) and obesity (BMI ≥30 kg/m²). In the very cost-effective category are 1) intensive glycemic management (targeting A1C <7%) compared with conventional glycemic management (targeting an A1C level of 8-10%) for individuals with newly diagnosed T2D, 2) multicomponent interventions (involving behavior change/education and pharmacological therapy targeting hyperglycemia, hypertension, dyslipidemia, microalbuminuria, nephropathy/retinopathy, secondary prevention of cardiovascular disease with aspirin) compared with usual care, 3) statin therapy compared with no statin therapy for individuals with T2D and history of cardiovascular disease, 4) diabetes self-management education and support compared with usual care, 5) T2D screening every 3 years starting at age 45 years compared with no screening, 6) integrated, patient-centered care compared with usual care, 7) smoking cessation compared with no smoking cessation, 8) daily aspirin use as primary prevention for cardiovascular complications compared with usual care, 9) self-monitoring of blood glucose three times per day compared with once per day among those using insulin, 10) intensive glycemic management compared with conventional insulin therapy for T2D among adults aged ≥50 years, and 11) collaborative care for depression compared with usual care.

CONCLUSIONS

Complementing professional treatment recommendations, our systematic review provides an updated understanding of the potential value of interventions to manage diabetes and its complications and can assist clinicians and payers in prioritizing interventions and health care resources.

Management of Type 2 Diabetes in Developing Countries: Balancing Optimal Glycaemic Control and Outcomes with Affordability and Accessibility to Treatment

With the growing prevalence of type 2 diabetes, particularly in emerging countries, its management in the context of available resources should be considered. International guidelines, while comprehensive and scientifically valid, may not be appropriate for regions such as Asia, Latin America or Africa, where epidemiology, patient phenotypes, cultural conditions and socioeconomic status are different from America and Europe. Although glycaemic control and reduction of micro- and macrovascular outcomes remain essential aspects of treatment, access and cost are major limiting factors; therefore, a pragmatic approach is required in restricted-resource settings. Newer agents, such as sodium-glucose cotransporter 2 inhibitors and glucagon-like peptide 1 receptor agonists in particular, are relatively expensive, with limited availability despite potentially being valuable for patients with insulin resistance and cardiovascular complications. This review makes a case for the role of more accessible second-line treatments with long-established efficacy and affordability, such as sulfonylureas, in the management of type 2 diabetes, particularly in developing or restricted-resource countries.

A systematic review of economic evaluations in non-insulin antidiabetic treatments for patients with type 2 diabetes mellitus

The approval of new non-insulin treatments has broadened the therapeutic arsenal, but it has also increased the complexity of choice for the treatment of type 2 diabetes mellitus (DM2). The objective of this study was to systematically review the literature on economic evaluations associated with non-insulin antidiabetic drugs (NIADs) for DM2. We searched in Medline, IBECS, Doyma and SciELO databases for full economic evaluations of NIADs in adults with DM2 applied after the failure of the first line of pharmacological treatment, published between 2010 and 2017, focusing on studies that incorporated quality-adjusted life years (QALYs). The review included a total of 57 studies, in which 134 comparisons were made between NIADs. Under an acceptability threshold of 25,000 euros per QALY gained, iSLGT-2 were preferable to iDPP-4 and sulfonylureas in terms of incremental cost-utility. By contrast, there were no conclusive comparative results for the other two new NIAD groups (GLP-1 and iDPP-4). The heterogeneity of the studies’ methodologies and results hindered our ability to determine under what specific clinical assumptions some NIADs would be more cost-effective than others. Economic evaluations of healthcare should be used as part of the decision-making process, so multifactorial therapeutic management strategies should be established based on the patients’ clinical characteristics and preferences as principal criteria.

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.

The Standard of Care in Type 2 Diabetes: Re-evaluating the Treatment Paradigm

There is currently a worldwide epidemic of type 2 diabetes (T2D) that is predicted to increase substantially in the next few years. With 80% of the global T2D population living in low to middle-income countries, there are issues with cost and of access to appropriate medicines. The objective of this symposium was to provide an overview of the efficacy and safety of glucose-lowering drugs, focussing in particular on sulfonylureas (SUs) in patients with T2D using data taken from both randomised controlled trials (RCTs) and real-world studies, the application of strategies to ensure optimal patient adherence and clinical outcomes, and the optimal use of SUs in terms of dose adjustment and agent choice to ensure the best clinical outcome. The symposium began by exploring a profile of the typical patient seen in diabetes clinical practice and the appropriate management of such a patient in the real world, before moving on to an overview of the risks associated with T2D and how the currently available agents, including newer antidiabetic medications, mitigate or exacerbate those risks. The final presentation provided an overview of real-world studies, the gap between RCTs and the real world, and the use of available glucose-lowering agents in daily clinical practice. Clinical evidence was presented demonstrating that tight glucose control improved both microvascular and macrovascular outcomes, but that aggressive treatment in patients with a very high cardiovascular risk could lead to adverse outcomes. Real-world data suggest that older agents such as SUs and metformin are being used in a large proportion of patients with T2D with demonstrable effectiveness, indicating that they still have a place in modern T2D management. The symposium, while acknowledging the need for newer antidiabetic drugs in specific situations and patient groups, recommended the continuation of SUs and metformin as the primary oral antidiabetic agents in resource-constrained regions of the world.Funding:Servier.

Primary Care Management of Patients With Type 2 Diabetes: Overcoming Inertia and Advancing Therapy With the Use of Injectables

Type 2 diabetes (T2D) is a progressive disease caused by insulin resistance and associated progressive β-cell functional decline, as well as multiple other related metabolic and pathophysiologic changes. Left unchecked, T2D increases the risk of long-term microvascular and cardiovascular complications and is associated with excess morbidity and mortality. Despite multiple effective options for reducing hyperglycemia, patients are not optimally managed, largely due to delays in appropriate and timely advancement of therapy. Glucagon-like peptide-1 receptor agonists and basal insulin are recommended by treatment guidelines as effective options for advancing therapy to achieve glycemic control. However, injected therapies often face resistance from patients and clinicians. Glucagon-like peptide-1 receptor agonists are associated with weight loss, low risk of hypoglycemia, and potential beneficial cardiovascular effects. The class is recommended for patients across the spectrum of disease severity and represents an attractive option to add to basal insulin therapy when additional control is needed. Newer second-generation basal insulin analogues offer advantages over first-generation basal insulins in terms of lower hypoglycemia rates and greater flexibility in dosing. Incorporating injectable therapy into patient care in a timely manner has the potential to improve outcomes and must not be overlooked. Primary care clinicians play a significant role in managing patients with T2D, and they must be able to address and overcome patient resistance and their own barriers to advancing therapy if optimal treatment outcomes are to be achieved. The purpose of this expert opinion article was to provide a commentary on the key principle of advancing therapy with injectables to control hyperglycemia.

Cost-effectiveness of incisional negative pressure wound therapy compared with standard care after caesarean section in obese women: a trial-based economic evaluation

OBJECTIVE

To evaluate the cost-effectiveness of incisional negative pressure wound therapy (iNPWT) in preventing surgical site infection in obese women after caesarean section.

DESIGN

A cost-effectiveness analysis conducted alongside a clinical trial.

SETTING

Five obstetric departments in Denmark.

POPULATION

Women with a pregestational body mass index (BMI) ≥30 kg/m² .

METHOD

We used data from a randomised controlled trial of 876 obese women who underwent elective or emergency caesarean section and were subsequently treated with iNPWT (n = 432) or a standard dressing (n = 444). Costs were estimated using data from four Danish National Databases and analysed from a healthcare perspective with a time horizon of 3 months after birth.

MAIN OUTCOME MEASURES

Cost-effectiveness based on incremental cost per surgical site infection avoided and per quality-adjusted life-year (QALY) gained.

RESULTS

The total healthcare costs per woman were €5793.60 for iNPWT and €5840.89 for standard dressings. Incisional NPWT was the dominant strategy because it was both less expensive and more effective; however, no statistically significant difference was found for costs or QALYs. At a willingness-to-pay threshold of €30,000, the probability of the intervention being cost-effective was 92.8%. A subgroup analysis stratifying by BMI shows that the cost saving of the intervention was mainly driven by the benefit to women with a pre-pregnancy BMI ≥35 kg/m² .

CONCLUSION

Incisional NPWT appears to be cost saving compared with standard dressings but this finding is not statistically significant. The cost savings were primarily found in women with a pre-pregnancy BMI ≥35 kg/m² .

TWEETABLE ABSTRACT

Prophylactic incisional NPWT reduces the risk of SSI after caesarean section and is probably dominant compared with standard dressings #healtheconomics.

Cost-effectiveness and budget impact of liraglutide in type 2 diabetes patients with elevated cardiovascular risk: a US-managed care perspective

BACKGROUND

The Liraglutide Effect and Action in Diabetes: Evaluation of Cardiovascular Outcomes Results (LEADER) clinical trial demonstrated that liraglutide added to standard-of-care (SoC) therapy for type 2 diabetes (T2D) with established cardiovascular disease (CVD) or elevated cardiovascular (CV) risk was associated with lower rates of death from CVD, nonfatal myocardial infarction (MI), or nonfatal stroke than SoC alone.

OBJECTIVE

The objective of this study was to assess the cost-effectiveness (CE) and budget impact of liraglutide vs SoC in T2D patients with established CVD or elevated CV risk, over a lifetime horizon from a US managed care perspective.

METHODS

A cohort state-transition model (costs and benefits discounted at 3% per year) was used to predict diabetes-related complications and death (CV and all-cause). Events, treatment effects, and discontinuation rates were from LEADER trial; utility and cost data (US$, 2017) were from literature. Sensitivity analysis explored the impact of uncertainty on results. Additionally, a budget impact analysis was conducted to evaluate the financial impact of liraglutide use in this population, with displacement from dulaglutide, assuming a health care plan with 1 million members.

RESULTS

Liraglutide patients experienced 6.3% fewer events, had event-related cost-savings of $15,182, gained additional life-years of 0.67 and quality-adjusted life-years (QALYs) of 0.57, and had additional total costs ($60,928) vs SoC. Liraglutide was cost-effective with an incremental CE ratio of $106,749/QALY which was below the willingness-to-pay threshold of $150,000/QALY accepted by the Institute of Clinical and Economic Research. Liraglutide was cost-effective across all sensitivity analyses, except when the hazard ratio for all-cause mortality varied. The budget impact was neutral, with a per-plan-per-year and per-member-per-month cost-savings of $266,334 and $0.02, respectively.

CONCLUSION

From a US-managed care perspective, for T2D patients with established CVD or elevated CV risk, liraglutide is a cost-effective and a budget neutral treatment option for health care plans.

Do sulphonylureas still have a place in clinical practice?

Sulphonylureas have been commercially available since the 1950s, but their use continues to be associated with controversy. Although adverse cardiovascular outcomes in some observational studies have raised concerns about sulphonylureas, findings from relatively recent, robust, and high-quality systematic reviews have indicated no increased risk of all-cause mortality associated with sulphonylureas compared with other active treatments. Results from large, multicentre, randomised controlled trials such as the UK Prospective Diabetes Study and ADVANCE have confirmed the microvascular benefits of sulphonylureas, a reduction in the incidence or worsening of nephropathy and retinopathy, and no increase in all-cause mortality, although whether these benefits were due to sulphonylurea therapy and not an overall glucose-lowering effect could not be confirmed. A comparison of sulphonylureas and pioglitazone in the TOSCA.IT trial also confirmed the efficacy and cardiovascular safety of sulphonylureas. Investigators of randomised controlled trials have reported an increased risk of hypoglycaemia and weight gain with sulphonylureas, but data from observational studies suggest that the incidence of severe hypoglycaemia is lower in people taking sulphonylurea than in people taking insulin, and weight gain with sulphonylureas has been relatively modest in large cohort studies. 80% of people with diabetes live in low-to-middle income countries, so the effectiveness, affordability, and safety of sulphonylureas are particularly important considerations when prescribing glucose-lowering therapy. Results of ongoing head-to-head studies with new drugs, such as the comparison of glimepiride with linagliptin in the CAROLINA study and the comparison of various therapies (including sulphonylureas) for glycaemic control in the GRADE study, will determine the place of sulphonylureas in glucose-lowering therapy algorithms for patients with type 2 diabetes.

Pharmacotherapy of type 2 diabetes: An update

Type 2 diabetes (T2DM) is a leading cause of morbidity and mortality worldwide and a major economic burden. The prevalence of T2DM is rising, suggesting more effective prevention and treatment strategies are necessary. The aim of this narrative review is to summarize the pharmacologic treatment options available for patients with T2DM. Each therapeutic class is presented in detail, outlining medication effects, side effects, glycemic control, effect on weight, indications and contraindications, and use in selected populations (heart failure, renal insufficiency, obesity and the elderly). We also present representative cost for each antidiabetic category. Then, we provide an individualized guide for initiation and intensification of treatment and discuss the considerations and rationale for an individualized glycemic goal.

Managing glycaemia in older people with type 2 diabetes: A retrospective, primary care-based cohort study, with economic assessment of patient outcomes

AIMS

To describe the relative health and economic outcomes associated with different second-line therapeutic approaches to manage glycaemia in older type 2 diabetes patients requiring escalation from metformin monotherapy.

MATERIALS AND METHODS

The Clinical Practice Research Datalink database was used to inform a retrospective observational cohort study of patients with type 2 diabetes treated with metformin monotherapy requiring escalation (addition or switch) to a second-line oral regimen from January 1, 2008 to December 31, 2014. Primary outcomes included time to first event (any event, myocardial infarction [MI], stroke, or composite of MI/stroke [major adverse cardiovascular event; MACE]) and total event rate. The health economic consequences associated with the choice of second-line treatment in older patients were assessed using the CORE Diabetes Model.

RESULTS

A total of 10 484 patients were included; the majority escalated to second-line treatment with metformin + sulphonylurea (SU; 42%) or switched to SU monotherapy (28%). In multivariate adjusted analyses, total event rates for MACE with metformin + dipeptidyl peptidase-4 (DPP-4) inhibitor were significantly lower than with metformin + SU (0.61, 95% confidence interval [CI] 0.39-0.98), driven by a lower MI rate in the metformin + DPP-4 inhibitor group (0.52, 95% CI 0.27-0.99). Economic analyses estimated that metformin + DPP-4 inhibitor treatment was associated with the largest gain in health benefit, and cost-effectiveness ratios were favourable (<£30 000 per quality-adjusted life-year) for all second-line treatment scenarios.

CONCLUSIONS

With respect to treatment choice, data from the present study support the notion of prescribing beyond metformin + SU, as alternative regimens have been shown to be associated with reduced outcomes risk and value for money.

The cost-effectiveness of changes to the care pathway used to identify depression and provide treatment amongst people with diabetes in England: a model-based economic evaluation

BACKGROUND

Diabetes is associated with premature death and a number of serious complications. The presence of comorbid depression makes these outcomes more likely and results in increased healthcare costs. The aim of this work was to assess the health economic outcomes associated with having both diabetes and depression, and assess the cost-effectiveness of potential policy changes to improve the care pathway: improved opportunistic screening for depression, collaborative care for depression treatment, and the combination of both.

METHODS

A mathematical model of the care pathways experienced by people diagnosed with type-2 diabetes in England was developed. Both an NHS perspective and wider social benefits were considered. Evidence was taken from the published literature, identified via scoping and targeted searches.

RESULTS

Compared with current practice, all three policies reduced both the time spent with depression and the number of diabetes-related complications experienced. The policies were associated with an improvement in quality of life, but with an increase in health care costs. In an incremental analysis, collaborative care dominated improved opportunistic screening. The incremental cost-effectiveness ratio (ICER) for collaborative care compared with current practice was £10,798 per QALY. Compared to collaborative care, the combined policy had an ICER of £68,017 per QALY.

CONCLUSIONS

Policies targeted at identifying and treating depression early in patients with diabetes may lead to reductions in diabetes related complications and depression, which in turn increase life expectancy and improve health-related quality of life. Implementing collaborative care was cost-effective based on current national guidance in England.

The Cost-Effectiveness of Alogliptin Versus Sulfonylurea as Add-on Therapy to Metformin in Patients with Uncontrolled Type 2 Diabetes Mellitus

INTRODUCTION

ENDURE (ClinicalTrials.gov identifier, NCT00856284), a multicenter, double-blind, active-controlled study of 2639 patients with uncontrolled type 2 diabetes mellitus (T2DM), found that metformin in combination with alogliptin (12.5 and 25 mg doses), when compared to standard add-on therapy (sulfonylurea, SU), exerted sustained antihyperglycemic effects over 2 years. This economic analysis of ENDURE aimed to quantify the relationship between increased glycemic durability and cost-effectiveness of alogliptin in the UK clinical setting, and communicate its sustained glycemic benefit in economic terms.

METHODS

Using baseline characteristics and treatment effects from the ENDURE trial population, between-group cost-effectiveness analyses compared the combined use of metformin and alogliptin (MET + ALO_12.5/25) in patients with inadequately controlled T2DM, as an alternative to metformin and SU (MET + SU). In scenario analyses, an intragroup cost-effectiveness analysis compared MET + ALO_12.5/25 with MET + SU; a between-group cost-effectiveness analysis also compared MET + ALO_12.5/25 versus MET + SU within a subpopulation of patients who achieved HbA1c control (<7.5%) at 2 years on study drug.

RESULTS

Compared with baseline profiles of patients, combination therapies with alogliptin or SU were associated with improvements in length and quality of life and were cost-effective at established norms. Despite increased drug acquisition costs, alogliptin at 12.5 mg and 25 mg doses resulted in greater predicted lifetime quality-adjusted life year (QALY) gains with associated incremental cost-effectiveness ratios (ICERs) of £10,959/QALY and £7217/QALY compared to SU, respectively.

CONCLUSION

The ENDURE trial and the present cost-effectiveness analysis found that the glycemic durability of alogliptin therapy was associated with improved long-term patient outcomes, QALY gains, and ICERs that were cost-effective when evaluated against standard threshold values. Alogliptin therefore represents a cost-effective treatment alternative to SU as add-on therapy to metformin in patients with poorly managed T2DM.

FUNDING

Takeda Development Centre Europe Ltd.

Hypoglycaemia when adding sulphonylurea to metformin: a systematic review and network meta-analysis

AIMS

The risk of hypoglycaemia may differ among sulphonylureas (SUs), but evidence from head-to-head comparisons is sparse. Performing a network meta-analysis to use indirect evidence from randomized controlled trials (RCTs), we compared the relative risk of hypoglycaemia with newer generation SUs when added to metformin.

METHODS

A systematic review identified RCTs lasting 12-52 weeks and evaluating SUs added to inadequate metformin monotherapy (≥1000 mg/day) in type 2 diabetes. Adding RCTs investigating the active comparators from the identified SU trials, we established a coherent network. Hypoglycaemia of any severity was the primary end point.

RESULTS

Thirteen trials of SUs and 14 of oral non-SU antihyperglycaemic agents (16 260 patients) were included. All reported hypoglycaemia only as adverse events. Producing comparable reductions in HbA_1C of -0.66 to -0.84% (-7 to -9 mmol/mol), the risk of hypoglycaemia was lowest with gliclazide compared to glipizide (OR 0.22, CrI: 0.05 to 0.96), glimepiride (OR 0.40, CrI: 0.13 to 1.27), and glibenclamide (OR 0.21, CrI: 0.03 to 1.48). A major limitation is varying definitions of hypoglycaemia across studies.

CONCLUSIONS

When added to metformin, gliclazide was associated with the lowest risk of hypoglycaemia between the newer generation SUs. Clinicians should consider the risk of hypoglycaemia agent-specific when selecting an SU agent.

Severe hypoglycemia in the Look AHEAD Trial

OBJECTIVE

The Look AHEAD trial was a multi-center, randomized controlled trial, to determine whether weight loss reduces cardiovascular morbidity and mortality in overweight individuals with type 2 diabetes. The objective of this study was to evaluate the incidence of severe hypoglycemia in patients enrolled in Look AHEAD. Research Design and Methods 5,145 subjects were randomized to diabetes support and education (DSE) or intensive lifestyle intervention (ILI). Instances of severe hypoglycemia were recorded. Regression analysis was used to compare the development of severe hypoglycemia between groups.

RESULTS

Over the entire study, the severe hypoglycemia rate was not different between ILI and DSE groups (0.49 ILI, 0.51 DSE/100 person-years, rate ratio=1.12, p=0.41), but was greater in ILI during year 1 (p=0.008 for year by intervention interaction). During follow-up, severe hypoglycemia risk was higher with insulin, sulfonylurea or glitinide use at baseline (p<0.0001). The intervention effect differed by post-randomization insulin use (ILI to DSE HR=1.45 in insulin users versus HR=0.71 in non-users, p=0.009). Insulin use reduced by 3% in ILI in year 1. Compared to DSE, ILI participants in the lower 50% of weight loss in year 1 had similar percent insulin use and incident hypoglycemia, but ILI participants in the upper 50% of weight loss had lower percent insulin use and incident hypoglycemia.

CONCLUSIONS

Reduction in insulin is necessary during intensive weight loss to avoid episodes of hypoglycemia. Although limited by self-reported evaluation of hypoglycemia, greater weight loss in ILI during year 1 was associated with reduced insulin use and lower rates of hypoglycemia later in the trial.

Telemonitoring and Protocolized Case Management for Hypertensive Community-Dwelling Seniors With Diabetes: Protocol of the TECHNOMED Randomized Controlled Trial

Background

Diabetes and hypertension are devastating, deadly, and costly conditions that are very common in seniors. Controlling hypertension in seniors with diabetes dramatically reduces hypertension-related complications. However, blood pressure (BP) must be lowered carefully because seniors are also susceptible to low BP and attendant harms. Achieving “optimal BP control” (ie, avoiding both undertreatment and overtreatment) is the ultimate therapeutic goal in such patients. Regular BP monitoring is required to achieve this goal. BP monitoring at home is cheap, convenient, widely used, and guideline endorsed. However, major barriers prevent proper use. These may be overcome through use of BP telemonitoring—the secure teletransmission of BP readings to a health portal, where BP data are summarized for provider and patient use, with or without protocolized case management.

Objective

To examine the incremental effectiveness, safety, cost-effectiveness, usability, and acceptability of home BP telemonitoring, used with or without protocolized case management, compared with “enhanced usual care” in community-dwelling seniors with diabetes and hypertension.

Methods

A 300-patient, 3-arm, pragmatic randomized controlled trial with blinded outcome ascertainment will be performed in seniors with diabetes and hypertension living independently in seniors’ residences in greater Edmonton. Consenting patients will be randomized to usual care, home BP telemonitoring alone, or home BP telemonitoring plus protocolized pharmacist case management. Usual care subjects will receive a home BP monitor but neither they nor their providers will have access to teletransmitted data. In both telemonitored arms, providers will receive telemonitored BP data summaries. In the case management arm, pharmacist case managers will be responsible for reviewing teletransmitted data and initiating guideline-concordant and protocolized changes in BP management.

Results

Outcomes will be ascertained at 6 and 12 months. Within-study-arm change scores will be calculated and compared between study arms. These include: (1) clinical outcomes: proportion of subjects with a mean 24-hour ambulatory systolic BP in the optimal range (110-129 mmHg in patients 65-79 years and 110-139 mmHg in those ≥80 years: primary outcome); additional ambulatory and home BP outcomes; A1c and lipid profile; medications, cognition, health care use, cardiovascular events, and mortality. (2) Safety outcomes: number of serious episodes of hypotension, syncope, falls, and electrolyte disturbances (requiring third party assistance or medical attention). (3) Humanistic outcomes: quality of life, satisfaction, and medication adherence. (4) Economic outcomes: incremental costs, incremental cost-utility, and cost per mmHg change in BP of telemonitoring ± case management compared with usual care (health payor and societal perspectives). (5) Intervention usability and acceptability to patients and providers.

Conclusion

The potential benefits of telemonitoring remain largely unstudied and unproven in seniors. This trial will comprehensively assess the impact of home BP telemonitoring across a range of outcomes. Results will inform the value of implementing home-based telemonitoring within supportive living residences in Canada.

Trial Registration

Clinicaltrials.gov NCT02721667; https://clinicaltrials.gov/ct2/show/NCT02721667 (Archived by Webcite at http://www.webcitation.org/6i8tB20Mc)

The Association between Sulfonylurea Use and All-Cause and Cardiovascular Mortality: A Meta-Analysis with Trial Sequential Analysis of Randomized Clinical Trials

BACKGROUND

Sulfonylureas are an effective and inexpensive treatment for type 2 diabetes. There is conflicting data about the safety of these drugs regarding mortality and cardiovascular outcomes. The objective of the present study was to evaluate the safety of the sulfonylureas most frequently used and to use trial sequential analysis (TSA) to analyze whether the available sample was powered enough to support the results.

METHODS AND FINDINGS

Electronic databases were reviewed from 1946 (Embase) or 1966 (MEDLINE) up to 31 December 2014. Randomized clinical trials (RCTs) of at least 52 wk in duration evaluating second- or third-generation sulfonylureas in the treatment of adults with type 2 diabetes and reporting outcomes of interest were included. Primary outcomes were all-cause and cardiovascular mortality. Additionally, myocardial infarction and stroke events were evaluated. Data were summarized with Peto odds ratios (ORs), and the reliability of the results was evaluated with TSA. Forty-seven RCTs with 37,650 patients and 890 deaths in total were included. Sulfonylureas were not associated with all-cause (OR 1.12 [95% CI 0.96 to 1.30]) or cardiovascular mortality (OR 1.12 [95% CI 0.87 to 1.42]). Sulfonylureas were also not associated with increased risk of myocardial infarction (OR 0.92 [95% CI 0.76 to 1.12]) or stroke (OR 1.16 [95% CI 0.81 to 1.66]). TSA could discard an absolute difference of 0.5% between the treatments, which was considered the minimal clinically significant difference. The major limitation of this review was the inclusion of studies not designed to evaluate safety outcomes.

CONCLUSIONS

Sulfonylureas are not associated with increased risk for all-cause mortality, cardiovascular mortality, myocardial infarction, or stroke. Current evidence supports the safety of sulfonylureas; an absolute risk of 0.5% could be firmly discarded.

REVIEW REGISTRATION

PROSPERO CRD42014004330.

What's next after metformin? focus on sulphonylurea: add-on or combination therapy

Introduction:

The pathophysiology of type 2 diabetes (T2DM) mainly focused on insulin resistance and insulin deficiency over the past decades. Currently, the pathophysiologies expanded to ominous octet and guidelines were updated with newer generation of antidiabetic drug classes. However, many patients had yet to achieve their target glycaemic control. Although all the guidelines suggested metformin as first line, there was no definite consensus on the second line drug agents as variety of drug classes were recommended.

Objectives:

The aim of this review was to evaluate the drug class after metformin especially sulphonylurea and issues around add-on or fixed dose combination therapy.

Methods:

Extensive literature search for English language articles, clinical practice guidelines and references was performed using electronic databases.

Results:

Adding sulphonylurea to metformin targeted both insulin resistance and insulin deficiency. Sulphonylurea was efficacious and cheaper than thiazolidinedione, dipeptidyl peptidase-4 inhibitor, glucagon-like peptide 1 analogue and insulin. The main side effect of sulphonylurea was hypoglycaemia but there was no effect on the body weight when combining with metformin. Fixed dose sulphonylurea/metformin was more efficacious at lower dose and reported to have fewer side effects with better adherence. Furthermore, fixed dose combination was cheaper than add-on therapy.

In conclusion, sulphonylurea was feasible as the second line agent after metformin as the combination targeted on two pathways, efficacious, cost-effective and had long safety history. Fixed dose combination tablet could improve patient’s adherence and offered an inexpensive and more efficacious option regardless of original or generic product as compared to add-on therapy.

Cost effectiveness of dipeptidyl peptidase-4 inhibitors for type 2 diabetes

BACKGROUND

Dipeptidyl peptidase-4 (DPP-4) inhibitors are a new class of antidiabetic drugs used for treating type 2 diabetes mellitus. While many studies have reported on the cost-effectiveness of DPP-4 inhibitors for treating type 2 diabetes, a systematic review of economic evaluations of DPP-4 inhibitors is currently lacking.

OBJECTIVES

The aim of this systematic review was to assess the cost effectiveness of DPP-4 inhibitors for patients with type 2 diabetes.

DATA SOURCES

MEDLINE, EMBASE, National Health Service Economic Evaluation Database (NHS EED), Web of Science, EconLit databases, and the Cochrane Library were searched in November 2013.

STUDY ELIGIBILITY CRITERIA, PARTICIPANTS AND INTERVENTIONS

Studies assessing the cost effectiveness of DPP-4 inhibitors for type 2 diabetes were eligible for analysis. DPP-4 inhibitor monotherapy or combinations with other antidiabetic agents were included in the review. The DPP-4 inhibitors were all marketed drugs. Two reviewers independently reviewed titles, abstracts, and articles sequentially to select studies for data abstraction based on the inclusion and exclusion criteria. Disagreements were resolved by consensus.

STUDY APPRAISAL AND SYNTHESIS METHODS

The quality of included studies was assessed according to the 24-item checklist of the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) statement. The costs reported by the included studies were converted to US dollars via purchasing power parities (PPP) in the year 2013 using the CCEMG-EPPI-Center Cost Converter.

RESULTS

A total of 11 published studies were selected for inclusion; all were cost-utility analyses. Nine studies were conducted from a payer perspective and one used a societal perspective; however, the perspective of the other study was unclear. Four studies were of good quality, six were of moderate quality, and one was of low quality. Of the seven studies comparing DPP-4 inhibitors plus metformin with sulfonylureas plus metformin, six concluded that DPP-4 inhibitors were cost effective in patients with type 2 diabetes who were no longer adequately controlled by metformin monotherapy. Five studies compared DPP-4 inhibitors with thiazolidinediones, and whether DPP-4 inhibitors were cost effective was uncertain. Only two economic evaluations provided data to compare DPP-4 inhibitors versus insulin, and the results favored the use of DPP-4 inhibitors as second-line therapy.

LIMITATIONS

Synthesis of the data was impossible because of heterogeneity in the methodology and data sources of the economic evaluations, and the inclusion criteria excluded conference abstracts. It was difficult to find reliable weightings for each of the items of the CHEERS checklist, and the ratings were dichotomous.

CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS

This study provides the first systematic evaluation of DPP-4 inhibitors for patients with type 2 diabetes. It found that, in patients with type 2 diabetes who do not achieve glycemic targets with antidiabetic monotherapy, DPP-4 inhibitors as add-on treatment may represent a cost-effective option compared with sulfonylureas and insulin. However, high-quality cost-effectiveness analyses that utilize long-term follow-up data and have no conflicts of interest are still needed.

The addition of E (Empowerment and Economics) to the ABCD algorithm in diabetes care

The ABCD (Age, Body weight, Complications, Duration of disease) algorithm was proposed as a simple and practical tool to manage patients with type 2 diabetes. Diabetes treatment, as for all chronic diseases, relies on patients' ability to cope with daily problems concerning the management of their disease in accordance with medical recommendations. Thus, it is important that patients learn to manage and cope with their disease and gain greater control over actions and decisions affecting their health. Healthcare professionals should aim to encourage and increase patients' perception about their ability to take informed decisions about disease management and to improve patient self-esteem and feeling of self-efficacy to become agents of their own health. E for Empowerment is therefore an additional factor to take into account in the management of patients with type 2 diabetes. E stands also for Economics to be considered in diabetes care. Attention should be paid to public health policies as well as to the physician faced with the dilemma of delivering the best possible care within the problem of limited resources. The financial impact of the new treatment modalities for diabetes represents an issue that needs to be addressed at multiple strata both globally and nationally.

Effectiveness and safety of glimepiride and iDPP4, associated with metformin in second line pharmacotherapy of type 2 diabetes mellitus: systematic review and meta-analysis

OBJECTIVE

Our review analyses the studies that have specifically compared the association iDPP4/metformin with glimepiride/metformin, both in second line pharmacotherapy of type 2 diabetes mellitus (DM2).

METHODS

Systematic literature review with a meta-analysis of clinical trials comparing glimepiride with any iDPP4, both used together with metformin as a second line treatment of DM2. The effectiveness variables used were as follows: %HbA1c variation, fasting plasma glucose variation, patients achieving the therapeutic objective of HbA1c <7%, treatment dropouts due to lack of effectiveness and rescue treatments needed. The safety variables included were as follows: weight variation at the end of treatment; presentation of any type of adverse event; presentation of serious adverse events; patients who experienced any type of hypoglycaemia; patients who experienced severe hypoglycaemia; treatments suspended due to adverse effects; and deaths for any reason.

RESULTS

Four studies met the inclusion criteria. The group treated with glimepiride showed better results in all effectiveness variables. Regarding safety variables, the main differences observed were in the greater number of cases with hypoglycaemia in the group treated with glimepiride, and the serious adverse events or treatment discontinuations due to these which occurred in slightly over 2% more cases in this group compared to the iDPP4 group. The remaining adverse events, including mortality, did not show any differences between both groups. The variation in the weight difference between groups (2.1 kg) is not considered clinically relevant.

CONCLUSIONS

A greater effectiveness is seen in the glimepiride/metformin association, which should not be diminished by slight differences in adverse effects, with absence of severe hypoglycaemia in over 98% of patients under treatment. The association of glimepiride/metformin, both due to cost as well as effectiveness and safety, may be the preferential treatment for most DM2 patients, and it offers a potential advantage in refractory hyperglycemic populations, tolerant to treatment.

Comparative analysis of therapeutic efficiency and costs (experience in Bulgaria) of oral antidiabetic therapies based on glitazones and gliptins

Type 2 diabetes mellitus is a serious, chronic, progressive and widespread disease. Metformin is the most commonly prescribed initial therapy, but combination with other antidiabetic agents usually becomes necessary due to the progression of the disease. Pioglitazone is recommended as a second-line therapy because of its strong antihyperglycemic effect and its ability to reduce insulin resistance. Treatment with pioglitazone is associated with a significantly lower risk of cardiovascular complications and hypoglycemia, while simultaneously improving the lipid profile and the symptomatic and histological changes in the liver. Gliptins (sitagliptin and vildagliptin) are a new class of oral antidiabetic drugs which reduce glycated hemoglobin by a different mechanism. Although the efficacy of sitagliptin and vildagliptin is close to that of pioglitazone, the lack of long-term safety data and the higher price question their predominant use. The objective of this review is to highlight the advantages of mono- and combination therapy with pioglitazone in comparison with gliptins and to underline the inconsistencies in the medicinal and reimbursement policy in Bulgaria.

Should sulfonylureas remain an acceptable first-line add-on to metformin therapy in patients with type 2 diabetes? Yes, they continue to serve us well!

Since their introduction to clinical practice in the 1950s, sulfonylureas have been widely prescribed for use in patients with type 2 diabetes. Of all the other medications currently available for clinical use, only metformin has been used more frequently. However, several new drug classes have emerged that are reported to have equal glucose-lowering efficacy and greater safety when added to treatment of patients in whom metformin monotherapy is no longer sufficient. Moreover, current arguments also suggest that the alternative drugs may be superior to sulfonylureas with regard to the risk of cardiovascular complications. Thus, while there is universal agreement that metformin should remain the first-line pharmacologic therapy for those in whom lifestyle modification is insufficient to control hyperglycemia, there is no consensus as to which drug should be added to metformin. Therefore, given the current controversy, we provide a Point-Counterpoint on this issue. In the point narrative presented below, Dr. Abrahamson provides his argument suggesting that avoiding use of sulfonylureas as a class of medication as an add-on to metformin is not appropriate as there are many patients whose glycemic control would improve with use of these drugs with minimal risk of adverse events. In the following counterpoint narrative, Dr. Genuth suggests there is no longer a need for sulfonylureas to remain a first-line addition to metformin for those patients whose clinical characteristics are appropriate and whose health insurance and/or financial resources make an alternative drug affordable.

Antidiabetic effects of isolated sterols from Ficus racemosa leaves

Isolation and structure confirmation through NMR and MS. Antidiabetic and hypolipidemic activities using streptozotocin induced albino rats. Toxicological assessments. Mechanistic study to PPAR_γ through molecular docking.

Clinical outcomes and health care costs combining metformin with sitagliptin or sulphonylureas or thiazolidinediones in uncontrolled type 2 diabetes patients

Objectives

To compare clinical outcomes and health care costs across three cohorts of uncontrolled diabetic patients who initiated treatment with one of the following: sulphonylureas (SU), thiazolidinediones (TZD) or sitagliptin (SITA).

Materials and methods

We performed a retrospective study based on a linkage between administrative and laboratory databases maintained by three Italian local health units. The index period ranged from July 2008–June 2010. Patients were treatment-naïve to either SU, TZD, or SITA, but they were already treated with other oral hypoglycemic agents. Demographics and clinical characteristics were assessed at baseline. Adherence was measured by the medication possession ratio and adherent was defined as a patient with a medication possession ratio of 80% or greater. We used a Poisson regression model to estimate the risk ratios for disease-related hospitalizations that occurred during the 18-month follow-up period. The total annual costs included all the pharmacological treatments and the direct costs due to hospitalizations and outpatient services.

Results

We identified 928 patients treated with SU, 330 patients treated with TZD, and 83 patients treated with SITA. SITA patients were significantly younger and with fewer previous hospital discharges. The baseline mean glycated hemoglobin level was 8.1% for SU, 8.0% for TZD, and 8.3% for SITA patients. SITA-naïve patients were more adherent than the SU- and TZD-naïve patients (79.5% versus 53.2% and 62.8%, respectively; P<0.001). The SU and TZD group showed a significant increased risk of disease-related hospitalizations compared with the SITA group (the unadjusted rate was 10.42 and 7.16 per 100 person-years versus 1.64 per 100 person-years, P=0.003; compared with SU, the adjusted incidence rate ratio for SITA was 0.21, P=0.030). The total annual costs per patient were €972 for SITA, €706 for SU, and €908 for those treated with TZD.

Conclusion

Uncontrolled diabetic patients who initiated – as a second-line therapy in addition to metformin – treatment with SITA, compared to those who initiated treatment with SU or TZD, showed a reduced risk of disease-related hospitalizations. The total annual costs per patient were not significantly different among the three groups.

We can change the natural history of type 2 diabetes

As diabetes develops, we currently waste the first ∼10 years of the natural history. If we found prediabetes and early diabetes when they first presented and treated them more effectively, we could prevent or delay the progression of hyperglycemia and the development of complications. Evidence for this comes from trials where lifestyle change and/or glucose-lowering medications decreased progression from prediabetes to diabetes. After withdrawal of these interventions, there was no "catch-up"-cumulative development of diabetes in the previously treated groups remained less than in control subjects. Moreover, achieving normal glucose levels even transiently during the trials was associated with a substantial reduction in subsequent development of diabetes. These findings indicate that we can change the natural history through routine screening to find prediabetes and early diabetes, combined with management aimed to keep glucose levels as close to normal as possible, without hypoglycemia. We should also test the hypothesis with a randomized controlled trial.

HTA agencies facing model biases: the case of type 2 diabetes

When evaluating new drugs or treatments eligible for reimbursement, health technology assessment (HTA) agencies are repeatedly faced with cost-effectiveness analyses that evidence lack of adequate data and modeling biases. The case of type 2 diabetes illustrates this difficulty. In spite of its high disease burden, type 2 diabetes is poorly documented through existing cost-effectiveness analyses. We support this statement by an exhaustive literature review that enables us to precisely pinpoint the limitations of models used for the assessment of newly marketed (and expensive) drugs. We find that models are mostly restricted to surrogate endpoints and based on non-inferiority clinical trial data; they also show biases in the choice of comparators and inclusion criteria. Such limitations undermine the scope and applicability of HTA practice guidelines based on cost-effectiveness evidence. Nevertheless, cost-effectiveness models remain an opportunity to better inform decision makers and to reduce the uncertainty surrounding their decisions. HTA agencies are best placed to provide incentives for companies to improve the quality of the cost-effectiveness studies submitted for pricing and reimbursement decisions. One such incentive is to include stages of discussion between the company and the health authority during the evaluation process.

Cost-effectiveness of insulin glargine versus sitagliptin in insulin-naïve patients with type 2 diabetes mellitus

PURPOSE

In the EASIE (Evaluation of Insulin Glargine Versus Sitagliptin in Insulin-Naïve Patients) trial, insulin glargine found a significant reduction in glycosylated hemoglobin compared with sitagliptin in patients with type 2 diabetes who are inadequately controlled with metformin. The objective of this study was to assess the cost-effectiveness of insulin glargine compared with sitagliptin in type 2 diabetes patients, from the perspective of the publicly funded Canadian health care system.

METHODS

The IMS CORE Diabetes Model, a standard Markov structure and Monte Carlo simulation model, was used. The model used a lifetime horizon to capture the long-term complications associated with type 2 diabetes. The efficacy of insulin glargine and sitagliptin in terms of glycosylated hemoglobin reduction and corresponding rates of hypoglycemia were obtained from the EASIE trial. Health utility and cost data were obtained from recently published Canadian publications. Univariate and probabilistic sensitivity analyses were conducted.

FINDINGS

In the lifetime base-case analysis, treatment with insulin glargine resulted in cost savings of $1434 CAD in 2012 and a gain of 0.08 quality-adjusted life years per patient. A probabilistic sensitivity analysis found the robustness of the base-case analysis, with 88% probability of insulin glargine being dominant (ie, cost savings and more quality-adjusted life years).

IMPLICATIONS

Insulin glargine is a clinically superior and cost-effective alternative to sitagliptin in patients with type 2 diabetes who are inadequately controlled with metformin.

Assessment of the relative effectiveness and tolerability of treatments of type 2 diabetes mellitus: a network meta-analysis

PURPOSE

The relative effectiveness and tolerability of treatments for type 2 diabetes mellitus (T2DM) is not well understood because few randomized, controlled trials (RCTs) have compared these treatments directly. The purpose of the present study was to evaluate the relative effectiveness and tolerability of treatments of T2DM.

METHODS

We performed a network meta-analysis of available RCTs with pharmacologic interventions in T2DM and compared antidiabetic drugs and combination regimens with metformin (the reference drug). Glycemic control (proportion achieving HbA1c goal) and tolerability (risk of hypoglycemia) were the primary outcomes of interest. Direct and indirect relative effects (unadjusted) were expressed as odds ratios and 95% CIs.

FINDINGS

Eight treatments (glucagon-like peptide-1 [GLP-1] agonists plus metformin, sulfonylureas plus metformin, dipeptidyl peptidase-4 [DPP-4] inhibitors] plus metformin, colesevelan plus metformin, thiazolidinediones plus metformin, meglitinides plus metformin, α-glucosidase inhibitor plus metformin, and rosiglitazone monotherapy) outperformed metformin (direct effects). Triple combinations of GLP-1, thiazolinedione, insulin, metiglinide, or sulfonylureas added to a metformin backbone improved glycemic control (indirect effects). Higher risk of hypoglycemia was noted for sulfonylureas, α-glycosidases, and metiglinides when added to metformin (direct effects). Across indirect effects, only 17% of comparisons yielded less risk of hypoglycemia (70% were worse and 13% were comparable).

IMPLICATIONS

Our results point out the relative superiority of 2- and 3-drug combination regimens over metformin and summarize treatment effects and tolerability in a comprehensive manner, which adds to our knowledge regarding T2DM treatment options.

Management of type 2 diabetes and its prescription drug cost before and during the economic crisis in Greece: an observational study

BACKGROUND

The aim of the present study is to examine the clinical indices related to cardiovascular risk management of Greek patients with type 2 diabetes, before and after the major economic crisis that emerged in the country.

METHODS

In this retrospective database study, the medical records of patients with type 2 diabetes treated at three diabetes outpatient centers of the national health system during 2006 and 2012 were examined. Only patients with at least six months of follow-up prior to the recorded examination were included. The prescription cost was calculated in Euros per patient-year (€PY).

RESULTS

A total of 1953 medical records (938 from 2006 and 1015 from 2012) were included. There were no significant differences in adjusted HbA1c, systolic blood pressure and HDL-C, while significant reductions were observed in LDL-C and triglycerides. In 2012, a higher proportion of patients were prescribed glucose-lowering, lipid-lowering and antihypertensive medications. Almost 4 out of 10 patients were prescribed the new incretin-based medications, while the use of older drugs, except for metformin, decreased. A significant increase in the adjusted glucose-lowering prescription cost (612.4 [586.5-638.2] €PY vs 390.7 [363.5-418.0]; p < 0.001) and total prescription cost (1306.7 [1264.6-1348.7] €PY vs 1122.3[1078.1-1166.5]; p < 0.001) was observed. The cost of antihypertensive prescriptions declined, while no difference was observed for lipid-lowering and antiplatelet agents.

CONCLUSIONS

During the economic crisis, the cardiovascular risk indices of Greek patients with type 2 diabetes being followed in public outpatient diabetes clinics did not deteriorate and in the case of lipid profile improved. However, the total prescription cost increased, mainly due to the higher cost of glucose-lowering prescriptions.

Review of models used in economic analyses of new oral treatments for type 2 diabetes mellitus

BACKGROUND

Economic models are considered to be important, as they help evaluate the long-term impact of diabetes treatment. To date, it appears that no article has reviewed and critically appraised the cost-effectiveness models developed to evaluate new oral treatments [glucagon-like peptide-1 (GLP-1) receptor agonists and dipeptidyl peptidase-4 (DPP-4) inhibitors] for type 2 diabetes mellitus (T2DM).

OBJECTIVES

This study aimed to provide insight into the utilization of cost-effectiveness modelling methods. The focus of our study was aimed at the applicability of these models, particularly around the major assumptions related to the clinical parameters (glycated haemoglobin [A1c], systolic blood pressure [SBP], lipids and weight) used in the models, and subsequent clinical outcomes.

METHODS

MEDLINE and EMBASE were searched from 1 January 2004 to 14 February 2013 in order to identify published cost-effectiveness evaluations for the treatment of T2DM by new oral treatments (GLP-1 receptor agonists and DPP-4 inhibitors). Once identified, the articles were reviewed and grouped together according to the type of model. The following data were captured for each study: comparators; country; evaluation and key cost drivers; time horizon; perspective; discounting rates; currency/year; cost-effectiveness threshold, sensitivity analysis; and cost-effectiveness analysis curves.

RESULTS

A total of 15 studies were identified in our review. Nearly all of the models utilized a health care payer perspective and provided a lifetime horizon. The CORE Diabetes Model, UK Prospective Diabetes Study (UKPDS) Outcomes Model, Cardiff Diabetes Model, Centers for Disease Control and Prevention (CDC) Diabetes Cost-Effectiveness Group Model and Diabetes Mellitus Model were cited. With the exception of two studies, all of the studies made significant assumptions surrounding the impact of GLP-1 receptor agonists or DPP-4 inhibitors on clinical parameters and subsequent short- and long-term outcomes. Moreover, often the differences in the clinical parameters were relatively small (e.g. 1 or 2 mmHg in blood pressure) and would not be considered by many as clinically important. Yet, the impact of these small clinical changes often resulted in large lifetime changes in health outcomes in the models. In particular, many studies assumed that changes in weight associated with the therapies would equate to improved outcomes, despite limited evidence for this assumption. Although the new oral treatments were regarded as cost effective in most studies based upon the studies reviewed, the validity of these projections, particularly for the longer time frames, is questionable. Indeed, although most of these studies have been conducted in the last 5 years, recent trial evidence has already questioned the validity of most of these studies.

CONCLUSION

It is clear that a number of changes are required in the evaluation of diabetes therapies. First and foremost, the basic models need to be updated to include contemporary important clinical trial data assessing hard clinical outcomes in patients with diabetes. Second, there should be less emphasis on 40-year or lifetime costs and consequences of the therapies and a greater focus on short-term (5-year) and intermediate-term (10-year) outcomes. Practice is continually evolving, and the probability that these models would provide any valid predictions beyond 10 years is remote. Third, all modellers should immediately remove the basic assumption that small clinically inconsequential changes in A1c, SBP, lipids and weight result in major clinical improvements in patients. Future models should aim to include all relevant treatment outcomes, whether these relate to effects on underlying diabetes and its complications or to short- or long-term side effects of treatment. We need to explore why cost-saving interventions could benefit further from adding patient characteristics, which may be able to better predict the use of lower-cost alternatives. Moreover, the vast array of different clinical, cost and utility data used in the different models reviewed makes it apparent that a uniform methodology should be developed for diabetes economic models. In this manner, future models could be run using the same data, which would allow for more acceptable comparability between studies.

Clinical and economic benefits associated with the achievement of both HbA1c and LDL cholesterol goals in veterans with type 2 diabetes

OBJECTIVE

This study compared the clinical and economic benefits associated with dual-goal achievement, glycated hemoglobin (HbA1c)<7% (53 mmol/mol) and LDL cholesterol (LDL-C)<100 mg/dL, with achievement of only the LDL-C goal or only the HbA1c goal in veterans with type 2 diabetes mellitus (T2DM).

RESEARCH DESIGN AND METHODS

This retrospective cohort analysis evaluated electronic medical records (Veterans Integrated Service Network 16) in adult T2DM patients with two or more measurements of LDL-C and HbA1c between 1 January 2004 and 30 June 2010 (N=75,646). Cox proportional hazards models were used to compare microvascular and cardiovascular outcomes by goal achievement status; generalized linear regression models were used to assess diabetes-related resource utilization (hospitalization days and number of outpatient visits) and medical service costs.

RESULTS

Relative to achievement of only the LDL-C goal, dual-goal achievement was associated with lower risk of microvascular complications (adjusted hazard ratio [aHR] 0.79), acute coronary syndrome (0.88), percutaneous coronary intervention (0.78), and coronary artery bypass graft (CABG) (0.74); it was also associated with fewer hospitalization days (adjusted incidence rate ratio [aIRR] 0.93) and outpatient visits (0.88), as well as lower diabetes-related annual medical costs (-$130.89). Compared with achievement of only the HbA1c goal, dual-goal achievement was associated with lower risk of the composite cardiovascular-related end point (aHR 0.87) and CABG (aHR 0.62), as well as fewer outpatient visits (aIRR 0.98).

CONCLUSIONS

Achieving both HbA1c and LDL-C goals in diabetes care is associated with additional clinical and economic benefits, as compared with the achievement of either goal alone.

Annual Medical Costs of Swedish Patients with Type 2 Diabetes Before and After Insulin Initiation

INTRODUCTION

Although insulin is one of the most effective interventions for the treatment of type 2 diabetes, its disadvantages incur substantial medical cost. This study was designed to evaluate the medical costs of Swedish type 2 diabetic patients initiating insulin on top of metformin and/or sulfonylurea (SU), and to evaluate if costs before and after insulin initiation differ for patients where insulin is initiated above or below the recommended glycosylated hemoglobin (HbA1c) level (7.5%).

METHODS

This was a register-based retrospective cohort study in which patients were identified from the Sörmland county council diabetes register. Patients being prescribed at least one prescription of metformin and/or SU from 2003 to 2010, and later prescribed insulin, were included.

RESULTS

One hundred patients fulfilled the inclusion criteria and had at least 1 year of follow-up. The mean age was 61 years and 59% of patients were male. Mean time since diagnosis was 4.1 years, and since initiation of insulin was 2.2 years. The mean HbA1c level at index date was 8.0%. Total mean costs for the whole cohort were SEK 17,230 [standard deviation (SD) 17,228] the year before insulin initiation, and SEK 31,656 (SD 24,331) the year after insulin initiation (p < 0.0001). When stratifying by HbA1c level, patients with HbA1c <7.5% had total healthcare costs of SEK 17,678 (SD 12,946) the year before the index date and SEK 35,747 (SD 30,411) the year after (p < 0.0001). Patients with HbA1c levels ≥7.5% had total healthcare costs of SEK 16,918 (SD 19,769) the year before the index date and SEK 28,813 (SD 18,779) the year after (p < 0.0001).

CONCLUSION

Despite the small sample size, this study demonstrates that mean annual medical costs almost double the year after patients are initiated on insulin. The costs increased the year after insulin initiation, regardless of the HbA1c level at initiation of insulin, and the largest increase in costs were due to increased filled prescriptions.

Progression through diabetes therapies among new elderly users of metformin: a population-based study

AIMS

To examine temporal changes in progression to second-line therapies among older patients with diabetes newly treated with metformin.

METHODS

We conducted a population-based study among residents of Ontario, Canada aged 66 years and older with diabetes newly treated with metformin monotherapy in 1997, 2000, 2003 or 2006. Each annual cohort was followed until progression to a second oral hypoglycaemic agent, insulin or until 31 December 2010. Time to progression to a second oral hypoglycaemic agent or insulin was compared across the cohorts.

RESULTS

In the four annual cohorts, we identified a total of 46 104 people newly treated with metformin monotherapy. The median time to progression to any second diabetes therapy lengthened significantly over time, from 5.0 years in 1997 to 6.1 years in 2003 (P < 0.0001). Similarly, the time to progression to insulin lengthened over the study period (P = 0.03). Furthermore, the choice of second-line therapy changed over time. While 80.7% of new metformin users in 1997 progressed to glyburide therapy as second-line treatment, the corresponding figure by 2006 was only 45.1% as newer treatment options emerged.

CONCLUSIONS

Although recent guidelines recommend aggressive intensification of oral therapy for patients with Type 2 diabetes, older Ontarians with diabetes who started metformin in 2006 remained on monotherapy for longer than those who started in 1997. Furthermore, although there is no consensus regarding a preferred second-line therapy, the introduction of new alternatives has led to greater variation in the selection of second-line therapies in this population.