Comparing Cost-Effectiveness of Antidiabetic Therapies with Cardiovascular Benefit

Gregory Weiss, MD

This year clinicians and researchers across all disciplines of medicine have witnessed many firsts. As we navigate a perilous landscape dominated by the global COVID-19 pandemic, we have seen an extraordinary adaptation in the academic community. Science, medicine, and humanity itself must go on.

In keeping with this idea, the American Heart Association (AHA) has just completed its first virtual annual meeting from which the global academic community has introduced the latest research and insight in the field of cardiovascular science. In light of the incredible strain the pandemic has had on the global economy we present four sessions from the AHA Scientific Sessions 2020 highlighting the cost versus benefit of the latest drugs that treat type II diabetes mellitus that are also known to reduce cardiovascular (CV) risk.

On November 13th, 2020, Joseph Azuri, MD, and colleagues from Tel Aviv, Israel presented, in session P2007, a comparison between empagliflozin, an inhibitor of the sodium-glucose cotransporter 2 (SGLT2) and oral semaglutide, the first oral glucagon-like peptide 1 (GLP-1) receptor agonist. In keeping with the AHA strategic goal of reducing cardiovascular mortality by 20% these two drugs have been shown to significantly reduce the incidence of CV mortality in patients with type 2 diabetes mellitus and known CVD.¹

In light of the potential cost burden adding a new drug to a diabetes treatment regimen creates, Azuri sought to determine which drug would be most cost-effective while still reducing CV risk in type 2 diabetics. The research team went on to calculate the cost needed to treat (CNT) and prevent one case of CV mortality using either drug. They found the annual costs for empagliflozin and semaglutide were $4,572 and $6,680, respectively.¹ In light of the similarity between the drugs with regards to efficacy and CV risk reduction, Azuri’s team recommends empagliflozin as the more cost-effective treatment.¹

In a second session on November 13th, 2020, P2013, Azuri and colleagues went on to compare three popular GLP-1 receptor agonists. With regards to semaglutide, dulaglutide, and liraglutide, the American Diabetes Association recommends providing one of these GLP-1 therapies to patients with type 2 diabetes and established CVD regardless of glycemic control.² Concerned about the staggering costs associated with these new drugs Azuri sought to compare the 3 drugs for cost-effectiveness.

Azuri again calculated the annual cost needed to prevent one major adverse cardiovascular event (MACE) utilizing each of the three drugs in patients with type 2 diabetes and established CVD. The relative costs were $557,000 for semaglutide, $1,179,360 for liraglutide and $1,605,904 for dulaglutide.2 The research team concluded that, for secondary prevention of MACE in patients with type 2 diabetes and established CVD, semaglutide provides more value than the other two medications.²

In session P1146 on November 13th, a colleague of Azuri’s, Ronen Arbel, PhD, further breaks down the cost effectiveness of two different preparations of the GLP-1 drug semaglutide. With an oral preparation of semaglutide now available, Arbel imagined that patients may prefer it over a subcutaneous injection for prevention of MACE in patients with type 2 diabetes.³

Following the previous model, Arbel calculated the average annual cost for both preparations needed to prevent one MACE. The research team found that the average costs per year were $641,823 and $855,040 for the subcutaneous and oral preparations respectively.³ They further looked at the cost relationship between the two preparations and the endpoints of MACE versus cardiovascular mortality (CVM) alone. They concluded that the subcutaneous preparation of semaglutide was more cost-effective for the prevention of MACE in patients with type 2 diabetes but that for the prevention of CVM the oral preparation provided a significantly better monetary value.³

Finally, in session MP463, also on November 13th, Arbel and colleagues looked at the cost-effectiveness of icosapent ethyl, a prescription omega-3 fatty acid supplement known to aid in prevention of MACE in patients with hypertriglyceridemia. The team looked specifically at the difference in cost when used for secondary prevention in diabetic patients with known CVD and for primary prevention in those with risk factors for CVD.

Arbel analyzed the cost of icosapent ethyl to prevent one MACE per year when prescribed for either primary or secondary prevention. The average cost of icosapent ethyl annually was $874,500 versus $206,965 when used for primary and secondary prevention respectively.⁴ The team found that the cost needed to treat was four times higher in the primary prevention group when compared to the secondary prevention group concluding that prescribing icosapent ethyl for diabetic patients with known CVD is significantly more cost effective.⁴

We as clinicians often overlook the cost of the therapies we prescribe focusing solely on the most effective and proven treatments for our specific patients. These reports show that, when given choices between equally efficacious treatments, cost can play a significant role in our decision making and should. Of final note, we should all consider the enormous monetary amounts reported above. Reread those annual costs and consider the relative burdens such numbers place on patients and the health care system overall. A discussion for another time.