Estimating the real world daily usage and cost for exenatide twice daily and liraglutide in Germany, the Netherlands, and the UK based on volumes dispensed by pharmacies

Costs and its drivers for diabetes mellitus type 2 patients in France and Germany: a systematic review of economic studies

BACKGROUND

Type 2 diabetes represents an increasingly critical challenge for health policy worldwide. It absorbs massive resources from both patients and national economies to sustain direct costs of the treatment of type 2 diabetes and its complications and indirect costs related to work loss and wages. More recently, there are innovations based on remote control and personalised programs that promise a more cost-effective diabetes management while reducing diabetes-related complications. In such a context, this work attempts to update cost analysis reviews on type 2 diabetes, focusing on France and Germany, in order to explore most significant cost drivers and cost-saving opportunities through innovations in diabetes care. Although both countries approach care delivery differently, France and Germany represent the primary European markets for diabetes technologies.

METHODS

A systematic review of the literature listed in MEDLINE, Embase and EconLit has been carried out. It covered interventional, observational and modelling studies on expenditures for type 2 diabetes management in France or Germany published since 2012. Included articles were analysed for annual direct, associated and indirect costs of type 2 diabetes patients. An appraisal of study quality was performed. Results were summarised narratively.

RESULTS

From 1260 records, the final sample was composed of 24 papers selected according to predefined inclusion/exclusion criteria. Both France and Germany revealed a predominant focus on direct costs. Comparability was limited due to different study populations and cost categories used. Indirect costs were only available in Germany. According to prior literature, reported cost drivers are hospitalisation, prescriptions, higher HbA1c and BMI, treatment with insulin and complications, all indicators of disease severity. The diversity of available data and included costs limits the results and may explain the differences found.

CONCLUSIONS

Complication prevention and glycaemic control are widely recognized as the most effective ways to control diabetes treatment costs. The value propositions of self-based supports, such as hybrid closed-loop metabolic systems, already implemented in type 1 diabetes management, are the key points for further debates and policymaking, which should involve the perspectives of caregivers, patients and payers.

Coating of PLA-nanoparticles with cyclic, arginine-rich cell penetrating peptides enables oral delivery of liraglutide

Until today, the oral delivery of peptide drugs is hampered due to their instability in the gastrointestinal tract and low mucosal penetration. To overcome these hurdles, PLA (polylactide acid)-nanoparticles were coated with a cyclic, polyarginine-rich, cell penetrating peptide (cyclic R9-CPP). These surface-modified nanoparticles showed a size and polydispersity index comparable to standard PLA-nanoparticles. The zeta potential showed a significant increase indicating successful CPP-coupling to the surface of the nanoparticles. Cryo-EM micrographs confirmed the appropriate size and morphology of the modified nanoparticles. A high encapsulation efficiency of liraglutide could be achieved. In vitro tests using Caco-2 cells showed high viability indicating the tolerability of this novel formulation. A strongly enhanced mucosal binding and penetration was demonstrated by a Caco-2 binding and uptake assay. In Wistar rats, the novel nanoparticles showed a substantial, 4.5-fold increase in the oral bioavailability of liraglutide revealing great potential for the oral delivery of peptide drugs.

Real-world impact on monthly glucose-lowering medication cost, HbA1c, weight, and polytherapy after initiating a GLP-1 receptor agonist

OBJECTIVE

Glucagon-like peptide-1 (GLP-1) receptor agonists are preferred injectable therapies for type 2 diabetes, but their high cost is an area of concern. This study evaluated monthly glucose-lowering medication cost and clinical impact after initiating a GLP-1 receptor agonist.

DESIGN

A retrospective, pre-post cohort study evaluated monthly glucose-lowering medication cost, glycated hemoglobin (HbA_1c), weight, and polytherapy impact (name, dose, and number of daily doses or injections) when a GLP-1 receptor agonist was initiated (baseline) and after 6-12 months (follow-up). The population was analyzed overall and as subgroups, based on baseline medication regimen and demographics.

SETTING AND PARTICIPANTS

The study was performed at 8 ambulatory care sites (7 federally qualified health centers and a Program of All-Inclusive Care for the Elderly) in the greater Boston, MA, area. Patients were included in the analyses (n = 120) if they had a documented diagnosis of type 2 diabetes, were 18 years of age or older, had an HbA_1c ≥ 7.5% measured within 3 months prior to the initiation of a GLP-1 receptor agonist, and an HbA_1c measured 6 to 12 months following the initiation of a GLP-1 receptor agonist.

OUTCOME MEASURES

Primary outomes were changes in glucose-lowering medication cost, HbA_1c, and weight. Secondary outcome analyses included the impact to the glucose-lowering medication regimen in terms of dose, number of medications, and number of daily doses or injections.

RESULTS

The study population was largely female, aged 55.8 ± 11.7 years, obese, 76% non-Caucasian, equally English and non-English speaking, had a high tablet and injection burden, and had an average baseline HbA_1c of 10%. After the addition of a GLP-1 receptor agonist, monthly glucose-lowering medication cost increased $586.86 (overall), $741.69 (oral only baseline regimen), and $530.55 (insulin ± oral baseline regimen) (all P < 0.001). Mean decrease in HbA_1c was 1.7% (18 mmol/mol) (P < 0.001) and was similar across all subgroups. Weight decreased overall (-1.8 kg, P < 0.001), and there was a significant shift toward taking fewer oral agents and insulin and fewer daily injections. No statistically significant differences in the primary outcomes were noted in terms of age, gender, English-speaking status, or race.

CONCLUSION

Although a positive impact was observed in glycemic control, weight, and reduced polytherapy 6-12 months after initiating a GLP-1 receptor agonist, the increase in monthly glucose-lowering medication cost was significant and may serve as a barrier to treatment.

Utilization patterns of glucagon-like peptide-1 receptor agonists in patients with type 2 diabetes mellitus in Germany: a retrospective cohort study

OBJECTIVE

This retrospective database analysis complements previous research to understand treatment patterns for German patients newly-initiating or switching to subsequent GLP-1 RAs.

METHODS

Adult patients (≥18 years) initiating GLP-1 RA (Cohort 1 [C1]) or switching from a previous GLP-1 RA (Cohort 2 [C2]) to exenatide twice-daily (exBID), exenatide once-weekly (exQW), dulaglutide (DULA), or liraglutide (LIRA) were included in this analysis using IQVIA LRx from January 1, 2014-March 31, 2017. Patients were required to have ≥1 oral anti-hyperglycemic prescription during the 6-month pre-index period and ≥12 months follow-up. Persistence and treatment modifications were assessed within and beyond 12 months follow-up. Average daily/weekly dosage (ADD/AWD) was calculated during persistence.

RESULTS

C1 included 13,417 patients, while C2 included 4,264 patients. Mean ± standard deviation (SD) age was similar (57.7 ± 11.1 years [C1], 58.9 ± 10.1 years [C2]). Most patients using DULA in C2 had switched from LIRA (56.6%). For C1, mean ADD for LIRA was 1.41 ± 0.10 mg, slightly higher in C2, and increased over time. ADD for exBID was 16.9 ± 1.0 mcg, slightly greater in C2. AWD was 2.00 ± 0.05 mg for exQW users and 1.42 ± 0.03 mg for DULA users in C1, similar to C2. For C1, 27.0% exBID, 35.3% exQW, 50.9% DULA, and 48.1% LIRA users remained persistent at 12 months. Patients using DULA had a higher probability of remaining persistent over time (Kaplan-Meier) for both cohorts.

CONCLUSIONS

Patients using DULA had the highest probability of remaining persistent over time, followed by LIRA. ADD/AWD for DULA, exQW, and exBID were aligned with the recommended combination therapy dose; LIRA ADD suggests some patients use the 1.8 mg dose.

Successful treatment of prediabetes in clinical practice using physiological assessment (STOP DIABETES)

BACKGROUND

Of the 84 million American adults with prediabetes, over 5 to 7 years, about 28 million progress to type 2 diabetes. We aimed to assess whether a real-world, pathophysiology-based, therapeutic approach could prevent development of type 2 diabetes in high-risk individuals.

METHODS

We did a retrospective observational study of people at increased risk of type 2 diabetes from a community practice in southern California, USA. Participants had an oral glucose tolerance test and were assigned a risk stratification on the basis of presence and severity of insulin resistance, impaired β-cell function, and glycaemia (ie, 1-h plasma glucose concentration of more than 8·6 mmol/L during an oral glucose tolerance test). Treatment was recommended on the basis of risk: metformin, pioglitazone, glucagon-like peptide-1 (GLP-1) receptor agonist, and lifestyle therapy for participants at high risk of diabetes, and metformin, pioglitazone, and lifestyle therapy for those at intermediate risk. Individuals who refused pharmacological therapy were assigned to lifestyle therapy only. Participants were followed up every 6 months and oral glucose tolerance tests were repeated at 6 months and subsequently every 2 years or sooner. The primary outcome of our analysis was incidence of type 2 diabetes according to the American Diabetes Association criteria, within the study period (2009-16). This study is registered with ClinicalTrials.gov, number NCT03308773.

FINDINGS

Between Jan 1, 2009 and Dec 31, 2016, we assessed 1769 people at increased risk of diabetes, of which 747 (42%) were identified at high or intermediate risk and were recommended pharmacological treatment. Of 422 participants analysed, 28 (7%) progressed to type 2 diabetes (seven [5%] of 141 participants who received metformin, pioglitazone, and lifestyle therapy, none [0%] of 81 who received metformin, pioglitazone, GLP-1 receptor agonist, and lifestyle therapy, and 21 [11%] of 200 who received lifestyle therapy only) after mean follow-up of 32·09 months (SEM 1·24). Compared with participants who received lifestyle therapy only, the adjusted hazard ratio for progression to type 2 diabetes was 0·29 (95% CI 0·11-0·78, p=0·0009) in participants who received metformin and pioglitazone, and 0·12 (95% CI 0·02-0·94, p=0·04) in participants who received metformin, pioglitazone, and GLP-1 receptor agonist. Improved β-cell function was the strongest predictor of type 2 diabetes prevention.

INTERPRETATION

Progression to type 2 diabetes in people at high risk of diabetes can be markedly reduced with interventions designed to correct underlying pathophysiological disturbances (ie, impaired insulin secretion and resistance) in a real-world setting.

FUNDING

None.

Utilization Patterns of Glucagon-Like Peptide-1 Receptor Agonists in Patients with Type 2 Diabetes Mellitus in Italy: A Retrospective Cohort Study

INTRODUCTION

Real-world evidence on glucagon-like peptide-1 receptor agonist (GLP-1 RAs) usage is emerging in different European countries but is lacking in Italy. This retrospective cohort study aimed to describe the real-world drug utilization patterns in patients initiating GLP-1 RAs for treating T2DM in Italy.

METHODS

Adults aged ≥ 20 years and with ≥ 1 oral antidiabetic drug (alone or in combination with insulin) other than GLP-1 RAs in the 6 months prior to initiating exenatide twice daily (exBID), exenatide once weekly (exQW), dulaglutide once weekly (DULA), liraglutide once daily (LIRA) or lixisenatide once daily (LIXI) between March and July 2016 were retrospectively identified in the Italian IMS LifeLink™ longitudinal prescriptions database (retail pharmacy data). Patients with ≥ 6-month follow-up (defined as evidence of any prescription activity) were included. Proportions of patients who remained persistent (continued treatment until discontinuation/switch) in the first 6 months and of those who discontinued or switched to a different GLP-1 RA over the entire follow-up were recorded. For each treatment, the average daily/weekly dosage (ADD/AWD) while persistent during the available follow-up was calculated.

RESULTS

We identified 7319 patients: 92 exBID, 970 exQW, 3368 DULA, 2573 LIRA and 316 LIXI. Across treatments, 89% patients were ≥ 50 years old, 54% were males, and the median follow-up duration ranged between 8.1 and 8.7 months. At 6 months, 35% exBID, 47% exQW, 62% DULA, 50% LIRA and 40% LIXI patients remained persistent. Over the entire follow-up, median persistence days varied from 73 (exBID) to > 300 days (DULA). The mean ± SD ADD/AWD was exBID: 17.7 ± 2.1 µg/day; exQW: 2.1 ± 0.1 mg/week; DULA: 1.5 ± 0.2 mg/week; LIRA: 1.5 ± 0.2 mg/day; LIXI: 21.0 ± 5.5 µg/day.

CONCLUSIONS

This real-world analysis suggests differences exist in persistence between patients treated with various GLP-1 RAs. Among the investigated treatments, patients prescribed exBID recorded the lowest and those prescribed DULA the highest persistence with therapy.

FUNDING

Eli Lilly and Co., Indianapolis, IN, USA.

GLP-1 RA Treatment Patterns Among Type 2 Diabetes Patients in Five European Countries

INTRODUCTION

Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) are a relatively new class of injectable drugs used in the treatment of type 2 diabetes (T2D). This retrospective database study evaluated real-world treatment patterns of T2D patients initiating GLP-1 RAs in Belgium (BE), France (FR), Germany (DE), The Netherlands (NL) and Sweden (SE).

METHODS

Adult T2D patients initiating exenatide twice daily (exBID), exenatide once weekly (exQW), liraglutide (LIRA) or lixisenatide (LIXI) during 2013 were identified using the QuintilesIMS (QuintilesIMS, Durham, NC, and Danbury, CT, USA) longitudinal retail pharmacy databases (LRx; BE/FR/DE/NL) and national health register data (SE). Therapy initiation date was termed 'index date.' Eligible patients had ≥180-day pre- and variable follow-up (minimum ≥360 days post-index). Baseline patient and treatment characteristics were assessed. Treatment modification and persistence were evaluated over the 1-year follow-up. Kaplan-Meier (KM) survival curves evaluated stopping of the index therapy (first of discontinuation or switch) over the available follow-up.

RESULTS

A total of 4339 exBID, 1499 exQW, 20,955 LIRA and 1751 LIXI patients were included in the analysis (45.1-61.9% female; mean age range 57.1-62.9 years). Mean follow-up ranged from 17.7 to 30.7 months. Across countries/databases, the proportion experiencing a treatment modification at 1-year ranged from 84.1 to 93.8% for exBID, 53.3-73.4% for exQW and 59.5-80.5% for LIRA patients. The proportion of LIXI patients with treatment modification was 55.0% in Belgium (N = 20) and 96.9% in Germany (LIXI taken off the German market in April 2014). In KM analyses, LIRA patients had the lowest proportion stopping therapy, while exBID patients had the highest proportion stopping therapy, across databases, with the exception of LIXI patents.

CONCLUSION

Treatment patterns varied among GLP-1 RA patients, and persistence was generally highest among LIRA and lowest among exBID across countries. Longer term data would be useful, given the recent approval of several GLP-1 RA therapies.

FUNDING

Eli Lilly and Co., Indianapolis, IN, USA.

Long-Term Effectiveness and Cost-Effectiveness of Metformin Combined with Liraglutide or Exenatide for Type 2 Diabetes Mellitus Based on the CORE Diabetes Model Study

BACKGROUND

Type 2 diabetes mellitus (T2DM) is associated with β cell impairment. Agonists of the glucagon-like peptide 1 (GLP-1) receptor (such as liraglutide and exenatide) can increase the number of pancreatic β cells and improve cell function. These drugs contribute to the long-term control of T2DM.

OBJECTIVE

To evaluate the cost-effectiveness of metformin combined with liraglutide or exenatide in Chinese patient with T2DM.

METHODS

Patients with T2DM from the Third Hospital of Hebei Medical University were treated with oral metformin combined with liraglutide (0.6 mg/day, could be increased by 0.6 mg weekly until 1.2 or 1.8 mg) or exenatide (5 μg bid for four weeks, increased to 10 μg bid). The computer simulation model CORE was used to calculate the 30-year expected life expectancy, quality-adjusted life years (QALY), direct costs, HbA1c levels, body mass index (BMI), and the incidence of cardiovascular, renal, and ocular complications of T2DM. Patients were followed up for 52 weeks. Medication costs were calculated according to retail prices in China. A 3% annual discount was adopted in this study.

RESULTS

The 30-year simulation showed that the total direct medical costs were lower using liraglutide compared to exenatide by 2130 RMB/QALY yearly, while the expected life expectancy and QALY were increased by 0.471 years and 0.388, respectively, using liraglutide with an incremental cost-effectiveness of -11,550 RMB/QALYs.

CONCLUSION

Liraglutide 1.2 mg/day was superior to exenatide 10 μg bid with respect to cost-effectiveness in Chinese patients with T2DM.