SGLT2 inhibitors not cost-effective for glycemic management alone in type 2 diabetes
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SGLT2 inhibitors provide limited glycemic management benefits and may not be cost-effective for most people with type 2 diabetes, according to a study published in the Journal of Diabetes and Its Complications.
“This study examined the prescribing trends prior to published scientific evidence of benefits in some patients with heart failure and progressive renal disease,” Larry A. Weinrauch, MD, a clinical researcher at Joslin Diabetes Center and a part-time assistant professor at Harvard Medical School, told Healio. “Our study documented the changes in prescribing patterns and did not find major improvements in glycemic control associated with the availability of the newer drugs.”
Weinrauch and colleagues conducted a single-center, retrospective review of all patients diagnosed with type 2 diabetes and hypertension who had at least two visits to the Joslin Diabetes Center from 2010 to 2012 and 2014 to 2016. Demographic information, BMI, HbA1c, estimated glomerular filtration rate, blood pressure, smoking status and complete medication lists were obtained. Researchers compared medication use and effects from the first period before the approval of SGLT2 inhibitors in the U.S. and the second period after the drugs were approved for treatment of type 2 diabetes.
Of 10,191 people included in the analysis, 7,769 had data from 2010 to 2012, and 6,576 had at least one visit from 2014 to 2016. Compared with the 2010-2012 period, 2014-2016 saw a decrease in the use of biguanides (69.5% vs. 66.3%), sulfonylurea compounds (44.7% vs. 39.4%), thiazolidinediones (13.6% vs. 3.4%), amylin analogues (2.7% vs. 1.1%), meglitinide (3.9% vs. 2.5%) and thiazide diuretics (32.4% vs. 28.9), whereas there was an increase in use of GLP-1 receptor agonists (16% vs. 23.8%), SGLT2 inhibitors (0% vs. 14%), insulin (56.1% vs. 60.5%) and statins (78.4% vs. 81.5%).
Compared with 2010-2012, the study cohort had slight decreases in HbA1c (7.9% vs. 7.8%), BMI (32.5 kg/m2 vs. 32.1 kg/m2) and eGFR (80.6 mL per minute vs. 77.5 mL per minute) during 2014-2016. There was also a slight increase in systolic BP from 2010-2012 to 2014-2016 (130 mm Hg vs. 132 mm Hg).
“Based upon our reviews of current U.S. pricing, the monthly cost of high-dose metformin and glipizide are each less than $30 when compared to greater than $300 for liraglutide (Saxenda, Novo Nordisk) and greater than $450 for empagliflozin (Jardiance, Boehringer Ingelheim and Eli Lilly),” the researchers wrote. “This 10- to 15-fold increase in monthly glycemia control cost was associated with a fall of HbA1c from 7.9% to 7.8% in our study.”
Weinrauch said comparing the cost-effectiveness of SGLT2 inhibitors to the potential benefits in people with type 2 diabetes and hypertension is important for the consumer.
“Guidelines for the treatment of diabetes are written by clinicians for clinicians based upon scientific evidence, by insurers for payors, but not for the working people who must pay for medical insurance, copays and medications,” Weinrauch said. “These consumers/patients have a different value system not based on the significant differences in combined endpoints. Their question is always based on ‘what will this do for me?’ Patients in our study were already taking pills for high blood pressure and cholesterol, and 70% were taking two or more medications for control of blood sugars.”
Weinrauch said longer-term data are needed to assess whether SGLT2 inhibitors or GLP-1 receptor antagonists have glycemic control advantages over less-expensive medications. He added that future research should examine cost comparisons instead of cost-effectiveness.
“We need to know what benefits we are buying, for whom, and at what price, understanding that in patients with heart failure, the potential advantages may be worth the extra cost.” Weinrauch said.
For more information:
Larry A. Weinrauch MD, can be reached at lweinrauch@hms.harvard.edu.
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