Background: Efforts to reduce type 2 diabetes morbidity and mortality focus on reducing microvascular and macrovascular complications. Development of GLP-1 receptor agonists and SGLT2 inhibitors has furthered progress toward this goal. As these medication classes have distinct effects on complication risk, the optimal approach is not clear.

Methods: We evaluated the cost-effectiveness of 2 strategies to intensify treatment of patients with type 2 diabetes and cardiovascular disease: addition of 1 mg subcutaneous semaglutide weekly or 25 mg oral empagliflozin daily to usual diabetes treatment. A Markov decision model estimated the impact of each strategy; complications included nonfatal myocardial infarction, hospitalization for congestive heart failure, nonfatal stroke, new or worsening nephropathy, and death. The empagliflozin strategy also included possible genital mycotic infection. Complication rates were based on EMPA-REG and SUSTAIN-6 trials. Modeled cohorts began at age 66 and were followed for 3 years at 1 month intervals. Analyses took a healthcare perspective, discounting 3%/year. For the base case, all patients entered the model with no complications.

Results: Compared to empagliflozin, semaglutide gained 0.053 quality-adjusted life year (QALY) at a cost of $1,006, or $18,897 per QALY gained. In one-way sensitivity analysis, only a semaglutide cost >$38/day (base case $18.04) resulted in empagliflozin being preferred at a willingness-to-pay threshold of $50,000/QALY. In probabilistic sensitivity analysis, semaglutide was preferred in 55% of model iterations at a $50,000/QALY threshold and in 57% at $100,000/QALY. When patients entered the model in complication states based on trial cohorts, semaglutide remained the preferred strategy at $23,518 per QALY gained.

Conclusion: For patients with type 2 diabetes mellitus with cardiovascular disease, semaglutide is likely more cost-effective than empagliflozin as an addition to usual treatment.


M. Zupa: None. R. Codario: None. K. J. Smith: None.


National Institute of Diabetes and Digestive and Kidney Diseases (5T32DK007052-45)

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