Cost-effectiveness and budget impact of liraglutide in type 2 diabetes patients with elevated cardiovascular risk: a US-managed care perspective

Swiss recommendations of the Society for Endocrinology and Diabetes (SGED/SSED) for the treatment of type 2 diabetes mellitus (2023)

As a first step, the authors emphasise lifestyle changes (increased physical activity, stopping smoking), blood pressure control, and lowering cholesterol). The initial medical treatment should always be a combination treatment with metformin and a sodium-glucose transporter 2 (SGLT-2) inhibitor or a glucagon-like 1 peptide (GLP-1) receptor agonist. Metformin is given first and up-titrated, followed by SGLT-2 inhibitors or GLP-1 receptor agonists. In persons with type 2 diabetes, if the initial double combination is not sufficient, a triple combination (SGLT-2 inhibitor, GLP-1 receptor agonist, and metformin) is recommended. This triple combination has not been officially tested in cardiovascular outcome trials, but there is more and more real-world experience in Europe and in the USA that proves that the triple combination with metformin, SGLT-2 inhibitor, and GLP-1 receptor agonist is the best treatment to reduce 3-point MACE, total mortality, and heart failure as compared to other combinations. The treatment with sulfonylurea is no longer recommended because of its side effects and higher mortality compared to the modern treatment with SGLT-2 inhibitors and GLP-1 receptor agonists. If the triple combination is not sufficient to reduce the HbA1c to the desired target, insulin treatment is necessary. A quarter of all patients with type 2 diabetes (sometimes misdiagnosed) require insulin treatment. If insulin deficiency is the predominant factor at the outset of type 2 diabetes, the order of medications has to be reversed: insulin first and then cardio-renal protective medications (SGLT-2 inhibitors, GLP-1 receptor agonists).

Cost-Utility of Liraglutide Plus Standard of Care Versus Standard of Care in People with Type 2 Diabetes and Cardiovascular Risk in Thailand

INTRODUCTION

Liraglutide has demonstrated a significant reduction in the primary major composite cardiovascular (CV) outcome (CV death, non-fatal myocardial infarction, non-fatal stroke). This study aimed to determine the cost-utility of adding liraglutide to the standard of care (SoC) for treating type 2 diabetes (T2D) in Thailand for three cohorts: people with atherosclerotic cardiovascular disease (ASCVD), with no ASCVD, and all people with T2D.

METHODS

A Markov model was developed to capture the long-term costs and outcomes under the perspective of the healthcare system. Costs were based on local data, the transitional probabilities were derived from the LEADER trial, and utilities were derived from published studies. Future costs and outcomes were discounted at 3% annually. A series of sensitivity analyses were performed.

RESULTS

Compared to SoC, adding liraglutide incurred higher costs and gained more quality-adjusted life-years (QALYs), yielding incremental cost-effectiveness ratios (ICERs) of above 1 million Thai baht (THB) for the three cohorts. The most influential parameter was the discount rate. When the annual cost of liraglutide reduced from 87,874 to 30,340 THB, 30,116 THB, and 31,617 THB for all people with T2D, people with ASCVD, and people without ASCVD, respectively, the ICER fell below the local threshold of 160,000 THB/QALY. Compared to the SoC treatment, the liraglutide group acquired more clinical benefit in terms of fewer CVD. Sensitivity analyses revealed that with an increase in the level of willingness-to-pay (WTP) threshold, adding liraglutide had an increased chance of being a cost-effective strategy.

CONCLUSION

Compared to the SoC treatment, adding liraglutide at the current cost is not cost-effective at the local WTP. People with T2D with ASCVD would have the most potential gain from adding liraglutide treatment compared to other populations.

Combination of Empagliflozin and Liraglutide protects heart against isoproterenol-induced myocardial infarction in rats

Cardiovascular benefit of new anti-hyperglycemic agent such as glucagon like peptide-1 receptor agonist (GLP-1RA) or sodium glucose co-transporter-2 inhibitor (SGLT2i) has been proven, with the proposed-mechanism that might be complementary. We investigated the effects of its combination on blood glucose profile and cardiac biomarkers. The rats were given lipid emulsion for 2 weeks, followed by a single dose of streptozotocin (STZ) 35 mg/kg BW, then treated with empagliflozin and/ liraglutide for 30 days while receiving isoproterenol (ISO) 85 mg/kg on day 29 and 30. The results showed no superior improvement on fasting blood glucose (FBG) and insulin sensitivity (KITT) in the combination group compared to empagliflozin/liraglutide group. However, the combination group showed a higher inhibition in almost all biomarkers, specifically against the elevation of CK-MB compared to one of these agents alone. The histopathological examination using H&E staining even showed a minimal inflammation and gap between cardiomyocytes. These findings may indicate the combination of empagliflozin and liraglutide has a better cardiac protection effect.

Economic evaluation of using polygenic risk score to guide risk screening and interventions for the prevention of type 2 diabetes in individuals with high overall baseline risk

Type 2 diabetes (T2D) with increasing prevalence is a significant global public health challenge. Obesity, unhealthy diet, and low physical activity are one of the major determinants of the rise in T2D prevalence. In addition, family history and genetic risk of diabetes also play a role in the process of developing T2D. Therefore, solutions for the early identification of individuals at high risk for T2D for early targeted detection of T2D, prevention, and intervention are highly preferred. Recently, novel genomic-based polygenic risk scores (PRSs) have been suggested to improve the accuracy of risk prediction supporting the targeting of preventive interventions to those at highest risk for T2D. Therefore, the aim of the present study was to assess the cost-utility of an additional PRS testing information (as a part of overall risk assessment) followed by a lifestyle intervention and an additional medical therapy when estimated 10-year overall risk for T2D exceeded 20% among Finnish individuals screened as at the high-risk category (i.e., 10%–20% 10-year overall risk of T2D) based on traditional risk factors only. For a cost-utility analysis, an individual-level state-transition model with probabilistic sensitivity analysis was constructed. A 1-year cycle length and a lifetime time horizon were applied in the base-case. A 3% discount rate was used for costs and QALYs. Cost-effectiveness acceptability curve (CEAC) and estimates for the expected value of perfect information (EVPI) were calculated to assist decision makers. The use of the targeted PRS strategy reclassified 12.4 percentage points of individuals to be very high-risk individuals who would have been originally classified as high risk using the usual strategy only. Over a lifetime horizon, the targeted PRS was a dominant strategy (i.e., less costly, more effective). One-way and scenario sensitivity analyses showed that results remained dominant in almost all simulations. However, there is uncertainty, since the probability (EVPI) of cost-effectiveness at a WTP of 0€/QALY was 63.0% (243€) indicating the probability that the PRS strategy is a dominant option. In conclusion, the results demonstrated that the PRS provides moderate additional value in Finnish population in risk screening leading to potential cost savings and better quality of life when compared with the current screening methods for T2D risk.

A budget impact analysis of substituting sitagliptin with liraglutide in type 2 diabetes from a private health insurance perspective in Egypt

Introduction

Type 2 diabetes mellitus causes a sizable burden globally from both health and economic points of view. This study aimed to assess the budget impact of substituting sitagliptin with liraglutide versus other glucose-lowering drugs from the private health insurance perspective in Egypt over a 3-year time horizon.

Methods

Two budget impact models were compared with the standard of care (metformin, pioglitazone, gliclazide, insulin glargine, repaglinide, and empagliflozin) administered in addition to liraglutide or sitagliptin versus the standard of care with placebo. A gradual market introduction of liraglutide or sitagliptin was assumed, and the existing market shares for the other glucose-lowering drugs were provided and validated by the Expert Panel. The event rates were extracted from the LEADER and TECOS trials. Direct and mortality costs were measured. Sensitivity analyses were performed.

Results

The estimated target population of 120,574 type 2 diabetic adult patients was associated with cardio vascular risk. The budget impact per patient per month for liraglutide is EGP29 ($6.7), EGP39 ($9), and EGP49 ($11.3) in the 1st, 2nd, and 3rd years, respectively. The budget impact per patient per month for sitagliptin is EGP11 ($2.5), EGP14 ($3.2), and EGP18 ($4.1) in the 1st, 2nd, and 3rd years, respectively. Furthermore, adoption of liraglutide resulted in 203 fewer deaths and 550 avoided hospitalizations, while sitagliptin resulted in 43 increased deaths and 14 avoided hospitalizations. The treatment costs of liraglutide use are mostly offset by substantial savings due to fewer cardiovascular-related events, avoided mortality and avoided hospitalizations over 3 years.

Conclusion

Adding liraglutide resulted in a modest budget impact, suggesting that the upfront drug costs were offset by budget savings due to fewer cardiovascular-related complications and deaths avoided compared to the standard of care. Sitagliptin resulted in a small budget impact but was associated with increased deaths and fewer hospitalizations avoided.

Budget Impact Analysis of Diabetes Drugs: A Systematic Literature Review

Background: Budget impact analysis (BIA) is an economic assessment that estimates the financial consequences of adopting a new intervention. BIA is used to make informed reimbursement decisions, as a supplement to cost-effectiveness analyses (CEAs). Objectives: We systematically reviewed BIA studies associated with anti-diabetic drugs and assessed the extent to which international BIA guidelines were followed in these studies. Methods: We conducted a literature search on PubMed, Web of Science, Econlit, Medline, China National Knowledge Infrastructure (CNKI), Wanfang Data knowledge Service platform from database inception to June 30, 2021. ISPOR good practice guidelines were used as a methodological standard for assessing BIAs. We extracted and compared the study characteristics outlined by the ISPOR BIA Task Force to evaluate the guideline compliance of the included BIA. Results: A total of eighteen studies on the BIA for anti-diabetic drugs were identified. More than half studies were from developed countries. Seventeen studies were based on model and one study was based on real-world data. Overall, analysis considered a payer perspective, reported potential budget impacts over 1-5 years. Assumptions were mainly made about target population size, market share uptake of new interventions, and scope of cost. The data used for analysis varied among studies and was rarely justified. Model validation and sensitivity analysis were lacking in the current BIA studies. Rebate analysis was conducted in a few studies to explore the price discount that was required for new interventions to demonstrate cost equivalence to comparators. Conclusion: Existing studies evaluating budget impact for anti-diabetic drugs vary greatly in methodology, some of which showed low compliance to good practice guidelines. In order for the BIA to be useful for assisting in health plan decision-making, it is important for future studies to optimize compliance to national or ISPOR good practice guidelines on BIA. Model validation and sensitivity analysis should also be improved in future BIA studies. Continued improvement of BIA using real-world data is necessary to ensure high-quality analyses and to provide reliable results.

Exploring Why People With Type 2 Diabetes Do or Do Not Persist With Glucagon-Like Peptide-1 Receptor Agonist Therapy: A Qualitative Study

OBJECTIVE

Despite the demonstrated benefits of glucagon-like peptide 1 (GLP-1) receptor agonist therapy, adherence and persistence with this therapy is often challenging. The purpose of this study was to expand current understanding of patients' experiences, motivations, and challenges relevant to their persistence with GLP-1 receptor agonist therapy.

DESIGN AND METHODS

This noninterventional, cross-sectional, qualitative study used face-to-face interviews with 36 adults with type 2 diabetes who had been treated with at least one GLP-1 receptor agonist medication. Inclusion criteria were: ≥18 years of age, diagnosed with type 2 diabetes, and currently treated with a GLP-1 receptor agonist for ≥1 month at the time of screening ("continuers") or discontinued use of a GLP-1 receptor agonist ≤1 year of screening but with a total ≥1 month of treatment ("discontinuers"). Interviews were conducted using a semi-structured qualitative interview guide that included open-ended questions and probes to obtain both spontaneous and prompted input from participants about their current and past treatment experiences with GLP-1 receptor agonist therapy.

RESULTS

Among continuers (n = 16), the most commonly identified facilitators supporting the decision to continue were the observations of improved glucose control (50%) and weight loss (55%). Among discontinuers (n = 20), the most commonly identified challenges leading to treatment discontinuation were side effects (55%) and high cost (50%). Continuers were more likely than discontinuers to receive clinically relevant information from their health care team, including facts about GLP-1 receptor agonist medications, likely treatment benefits, the importance of gradual dose titration, and the need to adjust diet after initiation.

CONCLUSION

Although cost is a major obstacle to treatment continuation, it can only be resolved through changes in ongoing reimbursement coverage and policies. However, many other obstacles could potentially be addressed (e.g., reducing side effects with gradual dosage titration and setting appropriate expectations regarding efficacy) through more collaborative patient-clinician interactions before initiating therapy.

Cardiovascular outcomes and healthcare costs of liraglutide versus basal insulin for type 2 diabetes patients at high cardiovascular risk

We aimed to compare the (1) clinical outcomes including composite cardiovascular outcomes, cardiovascular death, and all-cause death, and (2) healthcare costs of using liraglutide and basal insulin as an initial treatment for patients with type 2 diabetes mellitus (T2DM) and high cardiovascular diseases (CVD) risk. This is a retrospective cohort study using Taiwan’s Health and Welfare Database. A total of 1057 patients treated with liraglutide were identified and matched with 4600 patients treated with basal insulin. The liraglutide group had a lower risk of a composite CVD outcome (hazard ratio (HR) 0.65; 95% confidence interval (CI) 0.50–0.85; p < 0.01), all-cause mortality (HR 0.40; 95% CI 0.28–0.59; p < 0.0001), and nonfatal stroke (HR 0.54; 95% CI 0.34–0.87; p = 0.01). Compared to the basal insulin group, the liraglutide group had lower median per-patient-per-month (PPPM) inpatient, emergency room (ER), and total medical costs, but higher median PPPM outpatient, total pharmacy, and total costs (all p < 0.0001). In conclusion, compared to basal insulin, liraglutide was found to be associated with reduced risk of a composite CVD outcome, nonfatal stroke, and all-cause mortality among high CVD risk patients with T2DM. In addition, liraglutide users had lower inpatient, ER, and total medical costs, but they had higher outpatient and total pharmacy costs.

The cost-effectiveness of once-weekly semaglutide compared with other GLP-1 receptor agonists in type 2 Diabetes: a systematic literature review

Introduction: As a novel glucagon-like peptide-1receptor agonist (GLP-1 RA) for type 2 diabetes (T2D) treatment, the economic value of once-weekly semaglutide had been assessed in several country settings. The authors' objective was to systematically review the existing pharmacoeconomic literature evaluating the cost-effectiveness associated with once-weekly semaglutide compared with other GLP-1 RAs and provide implications for further researches.Areas covered: We conducted a systematic literature review of cost-effectiveness analysis (CEA) published up to 25 July 2020 in PubMed, web of science, and the ISPOR presentation database, compared once-weekly semaglutide with other GLP-1 RAs in T2D. Nineteen studies were identified, including 8 short-term and 11 long-term studies. General characteristics and main results of the included studies were summarized.Expert opinion: This review provided references for other countries to overview the value of once-weekly semaglutide compared with other GLP-1 RAs in T2D in the healthcare decision-making process and to conduct their CEA studies associated with once-weekly semaglutide. The authors found that the cardiovascular (CV) benefit of once-weekly semaglutide was under-estimated in current studies and suggested that the methods of economic evaluations for novel anti-diabetic drugs with CV benefit should be improved in future researches.

The cost-effectiveness of pharmacotherapy and lifestyle intervention in the treatment of obesity

BACKGROUND

The Food and Drug Administration has approved several pharmacotherapies for the treatment of obesity. This study assesses the cost-effectiveness of six pharmacotherapies and lifestyle intervention for people with mild obesity (body mass indices [BMIs] 30 to 35).

METHODS

A microsimulation model was constructed to compare seven weight loss strategies plus no treatment: intensive lifestyle intervention, orlistat, phentermine, phentermine/topiramate, lorcaserin, liraglutide, and semaglutide. Weight loss, quality-of-life scores, and costs were estimated using clinical trials and other published literature. Endpoints included costs, quality-adjusted life years (QALYs), and incremental cost-effectiveness ratios (ICERs) with a willingness-to-pay (WTP) threshold of $100 000/QALY. Results were analysed at 1-, 3-, and 5-year time horizons.

RESULTS

At each of the three follow-up periods, phentermine was the cost-effective strategy, with ICERs of $46 258/QALY, $20 157/QALY, and $17 880/QALY after 1, 3, and 5 years, respectively. Semaglutide was the most effective strategy in the 3- and 5-year time horizons, with total QALYs of 2.224 and 3.711, respectively. However, the ICERs were prohibitively high at $1 437 340/QALY after 3 years and $576 931/QALY after 5 years. Deterministic and probabilistic sensitivity analyses indicated these results were robust.

CONCLUSIONS

Phentermine is the cost-effective pharmacologic weight-loss strategy. Although semaglutide is the most effective, it is not cost-effective because of its high price.

Liraglutide Therapy in a Prediabetic State: Rethinking the Evidence

BACKGROUND

Prediabetes is defined as a state of glucose metabolism between normal glucose tolerance and type 2 diabetes. Continuous β-cell failure and death are the reasons for the evolution from normal glucose tolerance to prediabetes and finally type 2 diabetes.

INTRODUCTION

The necessity of new therapeutic approaches in order to prevent or delay the development of type 2 diabetes is obligatory. Liraglutide, a long-acting GLP-1 receptor agonist, has 97% homology for native GLP-1. Identification of the trophic and antiapoptotic properties of liraglutide in preclinical studies, together with evidence of sustained β-cell function longevity during its administration in type 2 diabetes individuals, indicated its earliest possible administration during this disease, or even before its development, so as to postpone or delay its onset.

METHODS

Pubmed and Google databases have been thoroughly searched and relevant studies were selected.

RESULTS

This paper explores the current evidence of liraglutide administration both in humans and animal models with prediabetes. Also, it investigates the safety profile of liraglutide treatment and its future role to postpone or delay the evolution of type 2 diabetes.

CONCLUSION

Liralgutide remains a valuable tool in our therapeutic armamentarium for individuals who are overweight or obese and have prediabetes. Future well designed studies will give valuable information that will help clinicians to stratify individuals who will derive the most benefit from this agent, achieving targeted therapeutic strategies.

The LEADER trial in type 2 diabetes: Were the characteristics and outcomes of the participants representative?

AIMS

To compare the characteristics and outcomes of people with type 2 diabetes recruited to the LEADER trial to those of participants in the contemporaneous community-based Fremantle Diabetes Study Phase II (FDS2) who fulfilled LEADER entry criteria.

METHODS

Baseline characteristics of LEADER and LEADER-eligible FDS2 participants were compared using bivariate methods. Incidence rates of the primary (nonfatal myocardial infarction, nonfatal stroke, cardiovascular disease (CVD) death) and other outcomes in the LEADER placebo group were compared with those in LEADER-eligible FDS2 participants during 3.8 years after entry, the median LEADER follow-up.

RESULTS

Of 1551 FDS2 type 2 participants, 323 (20.8%) were LEADER-eligible. Compared with the LEADER sample, they were an average 6 years older, and were less likely to be male, obese and to have prior CVD. There were 3.9 and 2.9 primary outcomes/100 patient-years in LEADER placebo-treated and FDS2 LEADER-eligible patients, respectively. Incidence rates for first myocardial infarction and stroke were 1.9 and 2.1 events/100 patient-years and 1.1 and 1.0 events/100 patient-years, respectively. FDS2 LEADER-eligible patients had a lower CVD death rate of 0.8 versus 1.6/100 patient-years in the LEADER placebo group, but their non-CVD mortality was greater (2.1 versus 1.0/100 patient-years).

CONCLUSIONS

These data suggest recruitment bias in type 2 diabetes CVD outcome trials.