First-line Treatment with Empagliflozin and Metformin Combination Versus Standard Care for Patients with Type 2 Diabetes Mellitus and Cardiovascular Disease in Qatar. A Cost-Effectiveness Analysis

Decision-Analytical Modelling of Medicines in the Middle East: A Systematic Review of Economic Evaluation Studies

BACKGROUND

Economic evaluations through decision-analytical models have played a limited role in shaping healthcare resource optimisation and reimbursement decisions in the Middle East.

OBJECTIVE

This review aims to systematically examine economic evaluation studies focusing on decision-analytical models of medicines in the Middle East, defining methodological characteristics and appraising the quality of the identified models.

METHODS

A systematic review approach was employed to identify published decision-analytical models of medicines in the Middle East. Six databases were searched (MEDLINE, EMBASE, Econlit, Web of Science, Global Health Cost-Effectiveness Analysis Registry and the Global Index Medicus) from 1998 to July 2024. Studies meeting the inclusion criteria-full economic evaluations of medicines using decision-analytical models in the Middle East-were considered. Data were extracted and tabulated to include study characteristics and methodological specifications, and data were narratively analysed. The Philips checklist was used to assess the quality of studies.

RESULTS

Sixty-three decision-analytical modelling studies of medicines were identified and reviewed, from eight Middle Eastern countries, with the majority (90%) conducted in Iran, Saudi Arabia, Qatar and Egypt. The cost-effectiveness of medications for non-communicable diseases was explored in 77% of the models. Gross domestic product-based cost-effectiveness thresholds were commonly used, and international sources provided data on intervention effectiveness and health outcomes, while national sources were mainly used for the costs of resource use. Most models incorporated an assessment of parameter uncertainty, whereas other types of uncertainty were not explored. Studies from high-income countries were generally of higher quality than those from middle-income countries.

CONCLUSIONS

The number of published decision-analytical models in the Middle East was low, considering the available medicinal products and disease burden. Key elements related to the quality of decision-analytical models, including analysis of the model structure, appropriateness of model inputs and uncertainty assessment, were not consistently fulfilled. Recommendations are provided to enhance the quality of future economic evaluation studies. This includes strengthening the existing health economics capacities, establishing country-specific health technology assessment systems (where possible), and initiating collaborations to generate national cost and outcome data. PROSPERO registration: CRD42021283904.

Clinical effectiveness and cost-effectiveness of first-line early combination of dipeptidyl peptidase 4 inhibitors and metformin in patients with type 2 diabetes in Taiwan: A modelling study

AIMS

Early dipeptidyl peptidase-4 inhibitors and metformin (DPP4i-Met) combination has been shown to extend the time to treatment failure and provide better glycaemic control for newly diagnosed type 2 diabetes (T2D) patients; however, the long-term clinical and economic outcomes of early DPP4i-Met combination remain unknown. We seek to assess the comparative long-term clinical and cost-effectiveness of DPP4i-Met versus Met for treatment-naïve T2D patients with inadequately controlled HbA1c (i.e., ≥8.5%).

METHODS

The IQVIA CORE Diabetes Model was used to simulate the quality-adjusted life years (QALYs) and healthcare costs over a lifetime from Taiwan's National Health Insurance Administration's perspective, with both QALYs and costs discounted at 3% annually. Model inputs were taken from the analyses of Taiwanese or Asian populations. Primary outcomes included the number needed to treat (NNT) to prevent one case of a clinical event and the incremental cost-effectiveness ratios (ICERs). Costs are presented in 2023 US dollars.

RESULTS

Over 40 years of projection, Met-DPP4i-treated patients had fewer complications than those using Met alone (e.g., lowering the incidence of stroke by 2.21% [2.68, 1.74]). The NNT using DPP4i-Met versus Met alone to prevent one case of stroke, microalbuminuria, neuropathy and background retinopathy was 45, 135, 65 and 182, respectively. Such long-term benefits in reducing costly complications offset the higher treatment cost of DDP4i-Met versus Met ($5796 vs. $5484/person). As a result, using DPP4i-Met versus Met yielded 0.086 QALYs gained and savings of $489 for overall treatment-naïve T2D patients and 0.064 QALYs gained and savings of $714 for young-onset T2D patients.

CONCLUSIONS

Early DPP4i-Met provides long-term clinical and economic benefits compared to Met alone for newly diagnosed T2D patients, including those with young-onset T2D.

Dihydropyrimidine Dehydrogenase Deficiency (DPYD) Genotyping-Guided Fluoropyrimidine-Based Adjuvant Chemotherapy for Breast Cancer. A Cost-Effectiveness Analysis

BACKGROUND AND OBJECTIVE

While standard doses of adjuvant fluoropyrimidine-based chemotherapies are generally safe for most patients, the risk of severe adverse drug reactions (ADRs) is increased for those with dihydropyrimidine dehydrogenase deficiency (DPYD), a genetic variation that affects drug metabolism. The objective of this study was to examine the cost effectiveness of offering DPYD pharmacogenetic-guided care, where genetic testing informs personalized dosing versus the current standard of care (SoC), which involves administering fluoropyrimidine-based therapies without prior genetic screening, for local or metastatic breast cancer patients in Qatar.

METHODS

We developed a two-stage decision analysis, with an analytic tree model over a 6-month period, followed by a life-table Markov model over a lifetime horizon. We compared the current SoC with the alternate strategy of DPYD genetic screening in patients living in Qatar with local or metastatic breast cancer who were eligible for adjuvant fluoropyrimidine therapy. Clinical outcomes and utilities were obtained from published studies, while healthcare costs were estimated from Hamad Medical Corporation, Qatar. The short-term outcome included the incremental cost-effectiveness ratio (ICER), defined as cost per success (survival without grade III/IV ADRs) at 6 months. The long-term outcome was the ICER, defined as cost per quality-adjusted life year (QALY) gained, with a 3% annual discount rate. The study adopted a public healthcare perspective in Qatar. Sensitivity analyses were conducted to explore the impact of key input parameters on the robustness of the model.

RESULTS

In the short-term model, at its base case, DPYD genomic screening was dominant over SoC with a mean cost-saving of QAR84,585 (95% confidence interval [CI], 45,270-151,657). This cost saving reflects the overall economic benefits associated with the implementation of DPYD genomic screening. In the long-term model, compared to the current SoC, DPYD genetic screening would result in an ICER of QAR21,107 (95% CI -59,382-145,664) per QALY gained.

CONCLUSION

Based on our model, implementing DPYD genetic screening to detect DPYD mutations in breast cancer patients before therapy initiation seems to be a cost-saving and cost-effective strategy in Qatar.

Adverse drug events in cost-effectiveness models of pharmacological interventions for diabetes, diabetic retinopathy, and diabetic macular edema: a scoping review

OBJECTIVE

The objective of this review was to examine the role of adverse drug events (ADEs) caused by pharmacological interventions in cost-effectiveness models for diabetes mellitus, diabetic retinopathy, and diabetic macular edema.

INTRODUCTION

Guidelines for economic evaluation recognize the importance of including ADEs in the analysis, but in practice, consideration of ADEs in cost-effectiveness models seem to be vague. Inadequate inclusion of these harmful outcomes affects the reliability of the results, and the information provided by economic evaluation could be misleading. Reviewing whether and how ADEs are incorporated in cost-effectiveness models is necessary to understand the current practices of economic evaluation.

INCLUSION CRITERIA

Studies included were published between 2011-2022 in English, representing cost-effectiveness analyses using modeling framework for pharmacological interventions in the treatment of diabetes mellitus, diabetic retinopathy, or diabetic macular edema. Other types of analyses and other types of conditions were excluded.

METHODS

The databases searched included MEDLINE (PubMed), CINAHL (EBSCOhost), Scopus, Web of Science Core Collection, and NHS Economic Evaluation Database. Gray literature was searched via the National Institute for Health and Care Excellence, European Network for Health Technology Assessment, the National Institute for Health and Care Research, and the International Network of Agencies for Health Technology Assessment. The search was conducted on January 1, 2023. Titles and abstracts were screened for inclusion by 2 independent reviewers. Full-text review was conducted by 3 independent reviewers. A data extraction form was used to extract and analyze the data. Results were presented in tabular format with a narrative summary, and discussed in the context of existing literature and guidelines.

RESULTS

A total of 242 reports were extracted and analyzed in this scoping review. For the included analyses, type 2 diabetes was the most common disease (86%) followed by type 1 diabetes (10%), diabetic macular edema (9%), and diabetic retinopathy (0.4%). The majority of the included analyses used a health care payer perspective (88%) and had a time horizon of 30 years or more (75%). The most common model type was a simulation model (57%), followed by a Markov simulation model (18%). Of the included cost-effectiveness analyses, 26% included ADEs in the modeling, and 13% of the analyses excluded them. Most of the analyses (61%) partly considered ADEs; that is, only 1 or 2 ADEs were included. No difference in overall inclusion of ADEs between the different conditions existed, but the models for diabetic retinopathy and diabetic macular edema more often omitted the ADE-related impact on quality of life compared with the models for diabetes mellitus. Most analyses included ADEs in the models as probabilities (55%) or as a submodel (40%), and the most common source for ADE incidences were clinical trials (65%).

CONCLUSIONS

The inclusion of ADEs in cost-effectiveness models is suboptimal. The ADE-related costs were better captured than the ADE-related impact on quality of life, which was most pronounced in the models for diabetic retinopathy and diabetic macular edema. Future research should investigate the potential impact of ADEs on the results, and identify the criteria and policies for practical inclusion of ADEs in economic evaluation.

SUPPLEMENTAL DIGITAL CONTENT

A Finnish-language version of the abstract of this review is available: http://links.lww.com/SRX/A68 .

Cost-effectiveness analysis of genotype-guided optimization of major depression treatment in Qatar

Background

Pharmacogenetic testing improves the efficacy and safety of antidepressant pharmacotherapy for moderate-severe major depressive disorder by identifying genetic variations that influence medication metabolism, and adjusting treatment regimens accordingly. This study aims to assess the cost-effectiveness of implementing a pharmacogenetic testing approach to guide the prescription of antidepressants.

Methods

From the public hospital perspective, we developed a two-stage decision tree diagram of a short-term 6-week follow up, and a lifetime Markov model with 3-month cycles. The analysis compared the current standard of care with the alternative strategy of Pharmacogenetic-guided (multi-gene panel) testing in adult patients with moderate-severe major depressive disorder. Clinical outcomes and utilities were obtained from published studies, while healthcare costs were locally available. The short-term incremental cost-effectiveness ratio was against treatment response without side effects and without relapse, and against treatment response with/without side effects and without relapse. The long-term incremental cost-effectiveness ratio was against the quality-adjusted life year gained and years of life saved.

Results

Adopting the pharmacogenetic-guided therapy for adult patients with moderate-severe major depressive disorder in Qatar resulted in cost savings of Qatari Riyal 2,289 (95% confidence interval, -22,654-26,340) for the health system. In the short term, the pharmacogenetic-guided testing was associated with higher response rates without side effects and without relapse (mean difference 0.10, 95% confidence interval 0.09-0.15) and higher response rates with or without side effects and without relapse (mean difference 0.05, 95% confidence interval 0.04-0.06). For long term, the pharmacogenetic-guided testing resulted in 0.13 years of life saved and 0.06 quality-adjusted life year gained, per person, along with cost savings of Qatari Riyal 46,215 (95% confidence interval-15,744-101,758). The sensitivity analyses confirmed the robustness of the model results.

Conclusion

Implementing pharmacogenetic testing to guide antidepressant use was found to improve population health outcomes, while also significantly reducing health system costs.

A cost-effectiveness analysis for high versus standard (low) dose caffeine for the treatment of apnea in neonatal intensive care unit

Objective

Preterm babies are prone to experiencing apnea of prematurity (AOP), mostly characterised by a pause in breathing lasting a minimum of 20 seconds. Recent literature supported higher maintenance doses of caffeine, indicating benefits. This study evaluated the cost-effectiveness of high maintenance dose (HD) versus low maintenance dose (LD) caffeine for AOP in neonates.

Methods

From the hospital perspective of Hamad Medical Corporation (HMC), Qatar, a cost-effectiveness decision-analytic model was constructed to follow the use of a HD maintenance caffeine of 20 mg/kg/dose versus a LD maintenance caffeine of 10 mg/kg/dose, in a simulated cohort of AOP neonates, over a therapy follow-up duration of six weeks, until neonatal intensive care (NICU) discharge. The clinical inputs were primarily literature-based, while the resource cost and utilisation were locally extracted in HMC. The cost-effectiveness outcome measure was calculated per therapy success, defined as survival with no apnea and successful extubation removal within 72 hours, with or without adverse events. One-way and multivariate sensitivity analyses were performed to confirm the robustness of the results.

Results

With 0.23 (95% CI, 0.23-0.23) enhancement in success rate, at United States dollar (US$) 3869 (95% CI, US$ 3823-3915) added infant cost, the HD caffeine was between dominant (34.8%) and cost-effective (63.7%), with an average incremental cost-effectiveness ratio of US $16,895 (95% CI, US$ 15,242-18,549) relative to LD caffeine per additional case of success. The hospitalisation contributed the most to the total infant cost, and the probability of patent ductus arteriosus was the model input that influenced the results most.

Conclusion

This is the first literature economic evaluation of caffeine for AOP. Despite increasing the cost of therapy, HD maintenance caffeine seems to be a cost-effective alternative to LD caffeine in Qatar. Our results support the recent global trends of increased use of HD caffeine for AOP in NICU.

A Systematic Review of Methodologies Used in Models of the Treatment of Diabetes Mellitus

BACKGROUND

Diabetes mellitus is a chronic and complex disease, increasing in prevalence and consequent health expenditure. Cost-effectiveness models with long time horizons are commonly used to perform economic evaluations of diabetes' treatments. As such, prediction accuracy and structural uncertainty are important features in cost-effectiveness models of chronic conditions.

OBJECTIVES

The aim of this systematic review is to identify and review published cost-effectiveness models of diabetes treatments developed between 2011 and 2022 regarding their methodological characteristics. Further, it also appraises the quality of the methods used, and discusses opportunities for further methodological research.

METHODS

A systematic literature review was conducted in MEDLINE and Embase to identify peer-reviewed papers reporting cost-effectiveness models of diabetes treatments, with time horizons of more than 5 years, published in English between 1 January 2011 and 31 of December 2022. Screening, full-text inclusion, data extraction, quality assessment and data synthesis using narrative synthesis were performed. The Philips checklist was used for quality assessment of the included studies. The study was registered in PROSPERO (CRD42021248999).

RESULTS

The literature search identified 30 studies presenting 29 unique cost-effectiveness models of type 1 and/or type 2 diabetes treatments. The review identified 26 type 2 diabetes mellitus (T2DM) models, 3 type 1 DM (T1DM) models and one model for both types of diabetes. Fifteen models were patient-level models, whereas 14 were at cohort level. Parameter uncertainty was assessed thoroughly in most of the models, whereas structural uncertainty was seldom addressed. All the models where validation was conducted performed well. The methodological quality of the models with respect to structure was high, whereas with respect to data modelling it was moderate.

CONCLUSIONS

Models developed in the past 12 years for health economic evaluations of diabetes treatments are of high-quality and make use of advanced methods. However, further developments are needed to improve the statistical modelling component of cost-effectiveness models and to provide better assessment of structural uncertainty.

Societal health and economic burden of cardiovascular diseases in the population with type 2 diabetes in Qatar. A 10-year forecasting model

AIMS

To predict the future health and economic burden of cardiovascular disease (CVD) in type 2 diabetes (T2D) in Qatar.

MATERIALS AND METHODS

A dynamic multistate model was designed to simulate the progression of fatal and non-fatal CVD events among people with T2D in Qatar aged 40-79 years. First CVD events [i.e. myocardial infarction (MI) and stroke] were calculated via the 2013 Pooled Cohort Equation, while recurrent CVD events were sourced from the REACH registry. Key model outcomes were fatal and non-fatal MI and stroke, years of life lived, quality-adjusted life years, total direct medical costs and total productivity loss costs. Utility and cost model inputs were drawn from published sources. The model adopted a Qatari societal perspective. Sensitivity analyses were performed to test the robustness of estimates.

RESULTS

Over 10 years among people with T2D, model estimates 108 195 [95% uncertainty interval (UI) 104 249-112 172] non-fatal MIs, 62 366 (95% UI 60 283-65 520) non-fatal strokes and 14 612 (95% UI 14 472-14 744) CVD deaths. The T2D population accrued 4 786 605 (95% UI 4 743 454, 4 858 705) total years of life lived and 3 781 833 (95% UI 3 724 718-3 830 669) total quality-adjusted life years. Direct costs accounted for 57.85% of the total costs, with a projection of QAR41.60 billion (US$11.40 billion) [95% UI 7.53-147.40 billion (US$2.06-40.38 billion)], while the total indirect costs were expected to exceed QAR30.31 billion (US$8.30 billion) [95% UI 1.07-162.60 billion (US$292.05 million-44.55 billion)].

CONCLUSIONS

The findings suggest a significant economic and health burden of CVD among people with T2D in Qatar and highlight the need for more enhanced preventive strategies targeting this population group.

Cost-Effectiveness of Glucose-Lowering Therapies as Add-on to Standard Care for People With Type 2 Diabetes in Malaysia

OBJECTIVES

This study aims to evaluate the cost-effectiveness of various glucose-lowering therapies as add-on to standard care for people with type 2 diabetes (T2D) in Malaysia.

METHODS

A state-transition microsimulation model was developed to compare the clinical and economic outcomes of 4 treatments: standard care, dipeptidyl peptidase-4 inhibitors, sodium-glucose cotransporter-2 inhibitors (SGLT2is), and glucagon-like peptide-1 receptor agonists. Cost-effectiveness was assessed from a healthcare provider's perspective over a lifetime horizon with 3% discount rate in a hypothetical cohort of people with T2D. Data input were informed from literature and local data when available. Outcome measures include costs, quality-adjusted life-years, incremental cost-effectiveness ratios, and net monetary benefits. Univariate and probabilistic sensitivity analyses were performed to assess uncertainties.

RESULTS

Over a lifetime horizon, the costs to treat a person with T2D ranged from RM 12 494 to RM 41 250, whereas the QALYs gains ranged from 6.155 to 6.731, depending on the treatment. Based upon a willingness-to-pay threshold of RM 29 080 per QALY, we identified SGLT2i as the most cost-effective glucose-lowering treatment, as add-on to standard care over patient's lifetime, with the net monetary benefit of RM 176 173 and incremental cost-effectiveness ratios of RM 12 279 per QALY gained. The intervention also added 0.577 QALYs and 0.809 LYs compared with standard care. Cost-effectiveness acceptability curve showed that SGLT2i had the highest probability of being cost-effective in Malaysia across varying willingness-to-pay threshold. The results were robust to various sensitivity analyses.

CONCLUSIONS

SGLT2i was found to be the most cost-effective intervention to mitigate diabetes-related complications.

Projecting the Health and Economic Burden of Cardiovascular Disease Among People with Type 2 Diabetes, 2022-2031

OBJECTIVE

The aim was to project the health and economic outcomes of cardiovascular disease (CVD) among people with type 2 diabetes from Australian public healthcare and societal perspectives over the next decade.

METHODS

A dynamic multistate model with yearly cycles was developed to project cardiovascular events among Australians with type 2 diabetes aged 40-89 years from 2022 to 2031. CVD risk (myocardial infarction [MI] and stroke) in the type 2 diabetes population was estimated using the 2013 pooled cohort equation, and recurrent cardiovascular event rates in the type 2 diabetes with established CVD population were obtained from the global Reduction of Atherothrombosis for Continued Health (REACH) registry. Costs and utilities were derived from published sources. Outcomes included fatal and non-fatal MI and stroke, years of life lived, quality-adjusted life years (QALYs), total healthcare costs, and total productivity losses. The annual discount rate was 5%, applied to outcomes and costs.

RESULTS

Between 2022 and 2031, a total of 83,618 non-fatal MIs (95% uncertainty interval [UI] 83,170-84,053) and 58,774 non-fatal strokes (95% UI 58,458-59,013) were projected. Total years of life lived and QALYs (discounted) were projected to be 9,549,487 (95% UI 9,416,423-9,654,043) and 6,632,897 (95% UI 5,065,606-7,591,679), respectively. Total healthcare costs and total lost productivity costs (discounted) were projected to be 9.59 billion Australian dollars (AU$) (95% UI 1.90-30.45 billion) and AU$9.07 billion (95% UI 663.53 million-33.19 billion), respectively.

CONCLUSIONS

CVD in people with type 2 diabetes will substantially impact the Australian healthcare system and society over the next decade. Future work to investigate different strategies to optimize the control of risk factors for the prevention and treatment of CVD in type 2 diabetes in Australia is warranted.

The societal impact of early intensified treatment in patients with type 2 diabetes mellitus

Aim: The current study estimates the societal impact of early intensified treatment compared with initial monotherapy with subsequent treatment intensification in newly diagnosed adults with type 2 diabetes mellitus in Mexico. Methods: An individual patient-level simulation and a static cohort model were employed to simulate the treatment pathway and the probability of experiencing complications of diabetes. The avoided number of events was translated into avoided productivity losses, which were monetized using wages. Results: Patients on early intensified treatment experienced approximately 13,000 fewer complication events over 10 years. This was translated into a societal impact of $54 million (USD). Conclusion: Early treatment intensification is likely to be of particular benefit to health outcomes and productivity losses.

Cost-effectiveness analysis of sacubitril/valsartan for reducing the use of implantable cardioverter-defibrillator (ICD) and the risk of death in ICD-eligible heart failure patients with reduced ejection fraction

Although previous cost-effectiveness evaluations of sacubitril/valsartan have demonstrated cardiovascular and economic benefits in heart failure patients with reduced ejection fraction (HFrEF), whether sacubitril/valsartan is cost-effective for reducing the need for implantable cardioverter-defibrillator (ICD) implantation and the risk of death in ICD-eligible patients has not been investigated in patients with HFrEF. Herein, we evaluated the cost-effectiveness of sacubitril/valsartan versus standard of care in reducing the need for ICD implantation and the death rate in HFrEF. A Markov model was developed from the Qatari hospital perspective, comprised of 'survival' and 'death' health states, and was based on 1-monthly Markovian cycles, a 20-years follow-up horizon, and a 3% discount rate. The model inputs were obtained from the literature and local sources. Sacubitril/valsartan resulted in a relative increase of 0.04 quality-adjusted life year (QALY) and 0.67 years of life lived (YLL)/person, with an incremental cost increase of QAR13,952 (USD3,832). Sacubitril/valsartan was associated with incremental cost-effectiveness ratio of QAR341,113 (USD93,687)/QALYs gained and QAR24,431 (USD6,710)/YLL. Sensitivity analyses confirmed robustness, with the cost effectiveness maintained in ≥96.5% of simulated cases. To conclude, sacubitril/valsartan is a cost-effective alternative to standard care against QALY gained and YLL in reducing the need for an ICD therapy and the rate of death among ICD-eligible HFrEF patients.

Stimulation of glucose uptake by glycosides from Alectra parasitica subsp. chitrakutensis (M.A. Rau) K.K. Khanna & An. Kumar: An in-vitro study of TNF-α induced insulin resistance in L6 myoblasts

Alectra parasitica subsp. chitrakutensis (M.A. Rau) K.K. Khanna & An. Kumar (Orobanchaceae) is a parasitic plant indigenous to India. Locally, the plant is known as 'Midaki and Nirgundikand'. It is used to treat fever, piles, cardiovascular disorders, and blood-borne non-infectious diseases by ethnic communities. The phytochemical investigation of A. parasitica subsp. chitrakutensis rhizome led to the isolation of azafrin (1), rehmaionoside-C (2), and mussaenoside (3). Compounds (2) and (3) are being reported for the first time from this plant. Compounds were evaluated for their intercellular glucose uptake activity in basal and insulin-TNF-α-stimulated L6 muscle cells. In particular, rehmaionoside C exhibited activity comparative to metformin, increasing uptake by basal- and insulin-TNF-α-stimulated cells by 4.88- and 3.90-fold and 5.04- and 4.04-fold. While azafrin and mussaenoside have produced 3.03- and 2.36-fold; 4.03- and 3.22-fold increase in intercellular glucose uptake. Compounds did not show toxicities in rat L6 myoblast cells. The study suggests that rehmaionoside-C from A. parasitica subsp. chitrakutensis might activate glucose uptake by insulin mimics and could be a nontoxic anti-diabetes lead for drug discovery.

Current gaps in management and timely referral of cardiorenal complications among people with type 2 diabetes mellitus in the Middle East and African countries: Expert recommendations

The upsurge of type 2 diabetes mellitus is a major public health concern in the Middle East and North Africa (MENA) and Africa (AFR) region, with cardiorenal complications (CRCs) being the predominant cause of premature morbidity and mortality. High prevalence of cardiometabolic risk factors, lack of awareness among patients and physicians, deficient infrastructure, and economic constraints lead to a cascade of CRCs at a significantly earlier age in MENA and AFR. In this review, we present consensus recommendations by experts in MENA and AFR, highlighting region-specific challenges and potential solutions for management of CRCs. Health professionals who understand sociocultural barriers can significantly increase patient awareness and encourage health-seeking behavior through simple educational tools. Increasing physician knowledge on early identification of CRCs and personalized treatment based on risk stratification, alongside optimum glycemic control, can mitigate therapeutic inertia. Early diagnosis of high-risk people with regular and systematic monitoring of cardiorenal parameters, development of region-specific care pathways for timely referral to specialists, followed by guideline-recommended care with novel antidiabetics are imperative. Adherence to guideline-recommended care can catalyze utilization of sodium glucose cotransporter 2 inhibitors and glucagon-like peptide 1 receptor agonists with demonstrated cardiorenal benefits-thus paving the way for overcoming care gaps in a cost-effective manner. Leveraging digital technology like electronic medical records can help generate real-world data and provide insights on voids in adoption of newer antidiabetic medications. A patient-centric approach, collaborative care among physicians from different specialties, alongside involvement of policy makers are key for improving patient outcomes and quality of care in MENA and AFR.

A Systematic Review of Cost-Effectiveness of Non-Statin Lipid-Lowering Drugs for Primary and Secondary Prevention of Cardiovascular Disease in Patients with Type 2 Diabetes Mellitus

Although studies of non-statin lipid-lowering therapies (NSLLTs) have demonstrated cardiovascular benefits; whether these benefits provide good value has not been evaluated in type 2 diabetes mellitus (T2DM) patients. A systematic review was performed to include studies on the cost-effectiveness of NSLLTs in T2DM patients with/without cardiovascular disease (CVD). Thirteen studies were included; ezetimibe (n=8), proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors (n=4), fenofibrate (n=2), nicotinic acid (n=1), extended-release niacin/laropiprant (ER- ERN/LRPT) (n=1), and icosapent ethyl (n=1). Six studies considered ezetimibe+statin to be a cost-effective compared to statins monotherapy, three studies suggested that PCSK9 inhibitors+statins were not cost-effective compared to statin+ezetimibe. Fenofibrate was a cost-effective either as monotherapy or combined with a statin compared to statin or fenofibrate monotherapy. Nicotinic acid and ER- ERN/LRPT compared to statin monotherapy were also cost-effective. Icosapent ethyl using the solid-state relay was cost-effective compared to standard care but not using the wholesale acquisition cost.

Cost-Effectiveness of Empagliflozin and Metformin Combination Versus Standard Care as First-Line Therapy in Patients with Type 2 Diabetes Mellitus

OBJECTIVE

Sodium-glucose cotransporter 2 (SGLT2) inhibitors have been shown to reduce cardiovascular events, but are currently not used as first-line therapy. This study was conducted to evaluate the cost-effectiveness of first-line empagliflozin plus metformin versus metformin monotherapy among Australians with type 2 diabetes mellitus (T2DM) and existing cardiovascular disease (CVD).

METHODS

A Markov model with one-year cycles and a five-year time horizon was constructed to simulate the occurrence of recurrent cardiovascular events among Australians aged 50 to 84 years with T2DM and CVD. Efficacy results were derived from the EMPA-REG OUTCOME trial. Costs and utilities were drawn from published sources. The evaluation adopted both healthcare and societal perspectives, with the latter ascribing the Australian Government's 'value of statistical life year' (VoSLY, AUD 213,000) to each year lived by a person. Future outcomes were discounted at 5% annually. Sensitivity analyses were conducted to enhance robustness of conclusions.

RESULTS

Compared to metformin monotherapy, first-line empagliflozin plus metformin reduced overall cardiovascular events by 0.82% and overall deaths by 7.72% over five years. There were 0.2 years of life saved (YoLS) per person and 0.16 quality-adjusted life years (QALYs) gained, at a net healthcare cost of AUD 4,408. These equated to incremental cost-effectiveness ratios of AUD 22,076 per YoLS and AUD 28,244 per QALY gained. The gains in VoSLY equated to AUD 42,530 per person, meaning that from a societal perspective, the intervention was cost saving.

CONCLUSION

First-line empagliflozin plus metformin may represent a cost-effective strategy for the management of T2DM and CVD in Australia.