medwireNews: Reducing the cost of sodium-glucose cotransporter (SGLT)2 inhibitors by around 17% would make them cost-effective for use in people with type 2 diabetes in low- and middle-income countries (LMICs), study findings indicate.
The cost of glucagon-like peptide (GLP)-1 inhibitors, however, would need to fall by more than 98% for them to be a cost-effective second-line alternative to sulfonylureas, report Sanjay Basu (Station Health, San Francisco, California, USA) and co-authors in The Lancet Diabetes & Endocrinology.
Basu and team used individual-level data for 23,678 people with diabetes from 67 LMICs to create a microsimulation to calculate the effect switching from sulfonylureas to alternative agents or from human insulin to insulin glargine would have on disability-adjusted life–years (DALYs) and the costs of cardiovascular events, heart failure, end-stage renal disease, vision loss, pressure sensation loss, severe hypoglycemia, and drug-specific side-effects.
They estimated that, among the countries studied, a 1-year supply of metformin 500 mg/day costs a median of US$ 24 (€ 21). The median costs of a sulfonylurea (gliclazide 80 mg/day), SGLT2 inhibitor (empagliflozin 5 mg/day), and GLP-1 receptor agonist (liraglutide 1.2 mg/day) were $ 26 (€ 22), $ 271 (€ 232), and $12,378 (€ 10,615), respectively. For human insulin, the median cost was $ 10 (€ 9) per 10 mL vial of 100 IU/mL while for glargine it was $ 29 (€ 25) per 10 mL vial of 100 IU/mL.
However, to be cost-effective relative to second-line sulfonylurea therapy, with a price per DALY averted of less than three times the national gross domestic product per capita, SGLT2 inhibitors would need to have a median price of $ 224 (€192) per person per year, a 17.4% cost reduction.
Commenting on the findings in a linked article, Ranjit Unnikrishnan and Viswanathan Mohan, both from Madras Diabetes Research Foundation in Chennai, India, say: “A price reduction of this magnitude is eminently feasible once these agents go off patent; indeed, this situation has already arisen with dapagliflozin in India, where generic brands that are more than 50% cheaper than the original have been introduced.”
But GLP-1 receptor agonists would need to cost a median $ 208 (€ 178) per person per year to be cost-effective relative to second-line sulfonylurea therapy, equivalent to a 98.3% reduction, which Unnikrishnan and Viswanathan say “seems too high to be practical and is unlikely to be achieved even if these molecules go off patent.”
For insulin glargine to be a cost-effective replacement for human insulin, the median cost would need to fall by 31.0% to $ 20 (€ 17) per vial, according to the investigators.
Basu and team also looked at a glycemia-agnostic pathway where SGLT2 inhibitors and GLP-1 receptor agonists were added to existing therapies among people with a history of heart or kidney disease. This approach produced a fourfold greater impact on DALYs compared with the use of these agents as sulfonylurea substitutes, with 92% and 72% reductions in incremental cost-effectiveness ratios for SGLT2 inhibitors and GLP-1 receptor agonists, respectively. Indeed, in this case, no price reduction would be needed to make SLGT2 inhibitors cost-effective.
The authors conclude: “Our estimates provide important context and potential targets for policy makers, for whom cost has been cited as a key barrier to the inclusion of SGLT2 inhibitors and GLP-1 receptor agonists in treatment guidelines.”
They add that the data “support the broader inclusion of such therapies in practice, particularly through a glycaemia-agnostic treatment pathway.”
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Lancet Diabetes Endocrinol 2021; doi:10.1016/S2213-8587(21)00240-0
Lancet Diabetes Endocrinol 2021; doi:10.1016/S2213-8587(21)00264-3