Management of type 2 diabetes (T2D) needs different treatment strategies to achieve the individualized glycemic goal. This study evaluated the long-term cost effectiveness of strategies involving pathway 1: metformin followed by intensification with dipeptidyl peptidase-4 inhibitors (DPP-4i), sodium-glucose co-transporter 2 inhibitors (SGLT2i) and insulin vs. pathway 2: metformin followed by intensification with sulfonylurea (SU) and insulin in the U.S. Cost-effectiveness analysis was performed using the validated QuintilesIMS CORE Diabetes Model from a U.S. payer perspective. Clinical and economic outcomes were modeled over a lifetime for a cohort of T2D patients who fail to achieve glycemic goal on metformin monotherapy. Clinical data were obtained from clinical trials. Direct medical costs [e.g., medications (whole sale acquisition costs), diabetes management, adverse events, and complications] were obtained from published sources. Despite higher direct medical costs for pathway 1 compared to pathway 2 ($117,779 vs. $93,196 respectively); pathway 1 improved total quality-adjusted life years (QALY) by 0.28 vs. pathway 2. Pathway 1 also led to cost offsets from fewer diabetes-related complications and delayed initiation of insulin. The incremental cost-effectiveness ratio (ICER) was favorable for pathway 1 at $89,038/QALY. Most of the scenario analysis (changes in treatment effect, hypoglycemia, and cardiovascular protective effects of SGLT2is) resulted in ICERs under $100,000/QALY except for the population with baseline HbA1c of 7%, and older age (65+ years). Negotiated discounts on branded medications resulted in significant improvement in ICERs (ICER of $69,554/QALY for 15% discount and $0/QALY for 75% discount). Among patients failing metformin monotherapy in the U.S, additional intensification with DPP-4i followed by SGLT2i may be considered more cost effective compared to intensification with SU followed by insulin.

Disclosure

M. Pawaskar: Employee; Self; Merck & Co., Inc. S. Bilir: Consultant; Self; Merck & Co., Inc.. A. Graber-Naidich: None. C.D. Gonzalez: Employee; Self; Merck & Co., Inc. S. Rajpathak: Employee; Self; Merck & Co., Inc. G.M. Davies: Employee; Self; Merck & Co., Inc..

© 2018 by the American Diabetes Association.
2018
Readers may use this article as long as the work is properly cited, the use is educational and not for profit, and the work is not altered. More information is available at http://www.diabetesjournals.org/content/license.