Hybrid closed-loop may be more cost-effective than immune therapies for type 1 diabetes
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Key takeaways:
- Hybrid closed-loop insulin delivery was most cost-effective for treating type 1 diabetes in most simulation models.
- Antithymocyte globulin is more cost-effective than teplizumab for type 1 diabetes prevention.
Hybrid closed-loop insulin delivery systems are more cost-effective for treating type 1 diabetes than immune therapies unless the effects of immune therapies are persistent over a lifetime after one course, according to a speaker.
Several immune therapies are either FDA approved, are under investigation or have been investigated in the past for the treatment and prevention of new-onset type 1 diabetes, according to Michael J. Haller, MD, professor and chief of pediatric endocrinology at the University of Florida. However, Haller said, the costs of immune therapies may be too much for patients and payors. He said providers will need to consider to cost-effectiveness of immune therapies compared with a hybrid closed-loop insulin delivery system to determine what is the best treatment for each patient.
“With the current cost of hybrid closed-loop systems ... and if the effects of immune therapy were sustained after a single course of immune therapy, low-dose antithymocyte globulin (ATG) would be the most cost-effective, but that’s a big assumption,” Haller said during a presentation at the International Conference on Advanced Technologies & Treatments for Diabetes. “If the effects of the immune therapies wane or you need to treat again, which I think is more likely, hybrid closed-loop won out in a cost-effectiveness analysis every time. It’s disappointing for someone who likes immune therapies and wants to develop these treatments.”
Incremental cost-effectiveness ratio is defined as the difference between the cost of a therapy and the cost of standard care, divided by the difference in the efficacy of a therapy compared with standard care. Haller said as the cost of a therapy increases, a larger improvement in efficacy is needed to make the therapy cost-effective.
Haller presented data from a microsimulation that compared the cost-effectiveness of nine type 1 diabetes immune therapies with hybrid closed-loop therapy and usual care. The simulation included a hypothetical group of 1,000 people aged 12 to 43 years with stage 3 type 1 diabetes. Health care costs included the costs of the drug and infusions, adverse events management, diabetes management and management of diabetes-related complications. Treatment effectiveness was defined as quality-adjusted life-years. Incremental cost-effectiveness ratio was examined at 2 years, 5 years, 10 years and across a lifetime.
Hybrid closed-loop vs. immunotherapies
In a model where immunotherapies were assumed to have a persistent effect through an entire life, usual care was more cost-effective than a hybrid closed-loop system or any immune therapy at 2 years. At 5 years and 10 years, verapamil was the most cost-effective treatment strategy. Across a lifetime, low-dose ATG therapy was the most cost-effective treatment.
Haller noted that teplizumab-mzwv (Tzield, Provention Bio) was not the most cost-effective therapy at any point in the study. Haller attributed the drug’s current high cost of $193,000 per course as a factor in that finding.
“[Teplizumab] didn’t outperform [other therapies] on any of these models,” Haller said. “It’s an important thing we have to acknowledge, even though we’re excited about using it and I’ve prescribed it myself several times, cost is an important thing to consider as we begin to offer these things to all of our patients.”
In a second model, researchers examined cost-effectiveness if immune therapy must be repeated five times over 20 years. In that model, diabetes management with a hybrid cost-loop system was more cost-effective than verapamil and low-dose ATG.
Researchers also simulated two models with a single course of an immune therapy, and the efficacy of the therapies dropped by either 10% per year or 20% per year. In both of those models, hybrid closed-loop insulin delivery outperformed all immune therapies.
When drug efficacy was compared with the annual cost of hybrid closed-loop systems, Haller said, a 57.4% preservation of C-peptide is required for verapamil to be more cost-effective than a hybrid closed-loop system, and 68% C-peptide preservation is needed for low-dose ATG to be more cost-effective than hybrid closed-loop.
“As hybrid closed-loop becomes more effective, cheaper and more accessible, these immune therapies are going to have to outperform and also come into alignment with costs so that people can justify using them,” Haller said. “Otherwise, we’re going to struggle to have payors who want to cover these drugs.”
Cost-effectiveness for prevention
Teplizumab, which was approved by the FDA in November 2022 to delay the onset of type 1 diabetes for children and adults aged 8 years and older, may not be as cost-effective as low-dose ATG for preventing or delaying type 1 diabetes. Researchers created a model comparing projected lifetime health costs for people receiving low-dose ATG, teplizumab or no treatment to delay type 1 diabetes.
In a model where the efficacy of low-dose ATG was equal to teplizumab’s efficacy, ATG saved $187,701 in health costs per patient compared with teplizumab and $43,950 per patient compared with no treatment. In a second model where low-dose ATG’s efficacy was equal to half of teplizumab’s efficacy, neither therapy was cost-effective compared with no treatment.
Haller said providers will need to consider each patient’s preference for type 1 diabetes treatment and the costs. That process will need to consider any changes in both costs or efficacy of immune therapies and hybrid closed-loop systems in the future.
“There are some families and some patients who, as hybrid closed-loops and automated insulin delivery get better, will say that is a perfectly good treatment or cure.” Haller said. “There are others who feel strongly that [hybrid closed-loop therapy] is never going to be close to anything they would call a cure and they only want a therapy that will result in them not needing to use insulin for the rest of their life. Obviously, we’re going to be far away from that for some time, but I do think those two things will eventually merge. Then the question will be, what do the patients want to choose and how do we justify them from a health economics point of view?”
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Haller MJ. Cost-effectiveness of immune therapies in type 1 diabetes. Presented at: International Conference on Advanced Technologies & Treatments for Diabetes; March 6-9, 2024; Florence, Italy (hybrid meeting).
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