Introduction: There are multiple antidiabetic drugs for type 2 diabetes in China, which vary in efficacy and cost. Chinese guideline recommends a stepwise escalation treatment strategy in diabetes care which consists of 3 therapy lines; and using combination therapy of antidiabetic drug + metformin (MET) for patients failed on MET. This study aims to develop 10 alternative drug combination strategies and compare their cost-effectiveness.

Method: Based on Chinese guideline, 8 classes of antidiabetic drugs were included: 1st line drug (MET), 2nd line drug (α glycosidase inhibitor=AGI, sulfonylurea=SU, glinide=NIDE, DPP-4 inhibitor=DPP-4I, thiazolidinedione=TZD), 3rd line drug (insulin=INS, GLP-1 receptor agonist=GLP-1RA); 10 drug combination strategies were developed: use MET as 1st therapy line, one of the five 2nd line drug + MET as 2nd therapy line, one of the two 3rd line drug + MET as 3rd therapy line. From societal perspective, Cardiff model was used to estimate cost-effectiveness of 10 drug combination strategies vs. non-drug treatment. Clinical data on Chinese patients were obtained from systematic literature review and meta-analysis of 325 studies. Costs were obtained from claims database study of 1164 patients. Utilities were obtained from EQ-5D survey of 868 patients. Simulation was 40 years. Discount rate was 3%. Sensitivity analysis was performed.

Result: All drug combination strategies were cost saving (increase QALYs but save costs) vs. non-drug treatment. Ranking strategies by considering incremental QALY and cost, strategy 5b (MET, MET+NIDE, MET+INS) was optimal, followed by strategy 6b (MET, MET+NIDE, MET+GLP-1RA), strategy 3b (MET, MET+SU, MET+INS), strategy 1b (MET, MET+AGI, MET+INS), strategy 4b (MET, MET+SU, MET+GLP-1RA), strategy 2b (MET, MET+AGI, MET+GLP-1RA), strategy 7b (MET, MET+DPP-4I, MET+INS), strategy 10b (MET, MET+TZD, MET+GLP-1RA), strategy 8b (MET, MET+DPP-4I, MET+GLP-1RA), strategy 9b (MET, MET+TZD, MET+INS).

Conclusion: Strategy 5b is worthy of clinical use.


S. Gu: None. Y. Shen: None. L. Shi: None. H. Dong: None.

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