Cost-effectiveness of second-line antihyperglycemic therapy in patients with type 2 diabetes mellitus inadequately controlled on metformin

Department of Medicine, University of Alberta, Edmonton, Alta.
Canadian Medical Association Journal (Impact Factor: 5.96). 11/2011; 183(16):E1213-20. DOI: 10.1503/cmaj.110178
Source: PubMed

ABSTRACT Metformin is widely accepted as first-line pharmacotherapy for patients with type 2 diabetes mellitus when glycemic control cannot be achieved by lifestyle interventions alone. However, uncertainty exists regarding the optimal second-line therapy for patients whose diabetes is inadequately controlled by metformin monotherapy. Increased use of newer, more costly agents, along with the rising incidence of type 2 diabetes, carries significant budgetary implications for health care systems. We conducted this analysis to determine the relative costs, benefits and cost-effectiveness of options for second-line treatment of type 2 diabetes.
We used the United Kingdom Prospective Diabetes Study Outcomes Model to forecast diabetes-related complications, quality-adjusted life-years and costs of alternative second-line therapies available in Canada for adults with type 2 diabetes inadequately controlled by metformin. We obtained clinical data from a systematic review and mixed treatment comparison meta-analysis, and we obtained information on costs and utilities from published sources. We performed extensive sensitivity analyses to test the robustness of results to variation in inputs and assumptions.
Sulphonylureas, when added to metformin, were associated with the most favourable cost-effectiveness estimate, with an incremental cost of $12 757 per quality-adjusted life-year gained, relative to continued metformin monotherapy. Treatment with other agents, including thiazolidinediones and dipeptidyl peptidase-4 inhibitors, had unfavourable cost-effectiveness estimates compared with sulphonylureas. These results were robust to extensive sensitivity analyses.
For most patients with type 2 diabetes that is inadequately controlled with metformin monotherapy, the addition of a sulphonylurea represents the most cost-effective second-line therapy.

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Available from: Chris Cameron, Mar 30, 2014
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    • "Cost-effectiveness of the new therapies is under investigation [26,27]. It has been repeatedly reported that the largest components of medical expenditures attributed to diabetes are associated with treatment of complications (hospital inpatient care and medications to treat these complications) rather than direct prescription cost to treat hyperglycemia [28,29]. "
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    ABSTRACT: The aim of the present study is to examine the clinical indices related to cardiovascular risk management of Greek patients with type 2 diabetes, before and after the major economic crisis that emerged in the country. In this retrospective database study, the medical records of patients with type 2 diabetes treated at three diabetes outpatient centers of the national health system during 2006 and 2012 were examined. Only patients with at least six months of follow-up prior to the recorded examination were included. The prescription cost was calculated in Euros per patient-year ([euro sign]PY). A total of 1953 medical records (938 from 2006 and 1015 from 2012) were included. There were no significant differences in adjusted HbA1c, systolic blood pressure and HDL-C, while significant reductions were observed in LDL-C and triglycerides. In 2012, a higher proportion of patients were prescribed glucose-lowering, lipid-lowering and antihypertensive medications. Almost 4 out of 10 patients were prescribed the new incretin-based medications, while the use of older drugs, except for metformin, decreased. A significant increase in the adjusted glucose-lowering prescription cost (612.4[586.5-638.2][euro sign]PY vs 390.7[363.5-418.0]; p < 0.001) and total prescription cost (1306.7[1264.6-1348.7] [euro sign]PY vs 1122.3[1078.1-1166.5]; p < 0.001) was observed. The cost of antihypertensive prescriptions declined, while no difference was observed for lipid-lowering and antiplatelet agents. During the economic crisis, the cardiovascular risk indices of Greek patients with type 2 diabetes being followed in public outpatient diabetes clinics did not deteriorate and in the case of lipid profile improved. However, the total prescription cost increased, mainly due to the higher cost of glucose-lowering prescriptions.
    BMC Endocrine Disorders 03/2014; 14(1):23. DOI:10.1186/1472-6823-14-23 · 1.71 Impact Factor
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    • "The results in our study demonstrate that increased medical healthcare costs the year before and after initiation of insulin are comparable with the results of previous studies [16–19]. Together these data concur that the initiation of insulin treatment in type 2 diabetic patients increases medical costs, both in terms of increased costs due to filled prescriptions of medications and of devices, but also due to increased costs due to health care visits. "
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    ABSTRACT: Although insulin is one of the most effective interventions for the treatment of type 2 diabetes, its disadvantages incur substantial medical cost. This study was designed to evaluate the medical costs of Swedish type 2 diabetic patients initiating insulin on top of metformin and/or sulfonylurea (SU), and to evaluate if costs before and after insulin initiation differ for patients where insulin is initiated above or below the recommended glycosylated hemoglobin (HbA1c) level (7.5%). This was a register-based retrospective cohort study in which patients were identified from the Sörmland county council diabetes register. Patients being prescribed at least one prescription of metformin and/or SU from 2003 to 2010, and later prescribed insulin, were included. One hundred patients fulfilled the inclusion criteria and had at least 1 year of follow-up. The mean age was 61 years and 59% of patients were male. Mean time since diagnosis was 4.1 years, and since initiation of insulin was 2.2 years. The mean HbA1c level at index date was 8.0%. Total mean costs for the whole cohort were SEK 17,230 [standard deviation (SD) 17,228] the year before insulin initiation, and SEK 31,656 (SD 24,331) the year after insulin initiation (p < 0.0001). When stratifying by HbA1c level, patients with HbA1c <7.5% had total healthcare costs of SEK 17,678 (SD 12,946) the year before the index date and SEK 35,747 (SD 30,411) the year after (p < 0.0001). Patients with HbA1c levels ≥7.5% had total healthcare costs of SEK 16,918 (SD 19,769) the year before the index date and SEK 28,813 (SD 18,779) the year after (p < 0.0001). Despite the small sample size, this study demonstrates that mean annual medical costs almost double the year after patients are initiated on insulin. The costs increased the year after insulin initiation, regardless of the HbA1c level at initiation of insulin, and the largest increase in costs were due to increased filled prescriptions.
    08/2013; 4(2). DOI:10.1007/s13300-013-0035-x
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    • "People have been shown to self-select which medications should be underused (Piette et al., 2004a; Piette et al., 2004b). Research has shown that low-cost medication (Gibson et al., 2010; Kennedy & Erb, 2002; Reed, 2005; Schoen et al., 2001), the use of generic medication (Briesacher et al., 2009), and thoughtful planning of an individually tailored medication program (Klarenbach et al., 2011) may increase a person's access and adherence to a medication regimen. "
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