A recent cost-utility analysis conducted in Thailand reveals that adding sodium-glucose cotransporter-2 (SGLT2) inhibitors to the standard of care for patients with type 2 diabetes and heart failure (T2D-HF) is not cost-effective at current prices. The study, which utilized data from the National Health Security Office (NHSO), suggests that significant price reductions are necessary for these drugs to be economically viable within the Thai healthcare system.
The research, published in SpringerMedizin, aimed to assess the cost-utility of adding SGLT2 inhibitors—dapagliflozin, empagliflozin, and canagliflozin—to the standard of care (SoC) compared to SoC alone for T2D-HF patients in Thailand. The economic model factored in both direct medical costs (outpatient visits, inpatient care, drug prescriptions) and direct non-medical costs (accommodation, supplements, informal care, medical equipment, and home renovation) from a societal perspective.
Methodology and Findings
The study employed a Markov model with three health states: stable heart failure (SHF), heart failure hospitalization (HFH), and all-cause death. Data from 120,861 T2D-HF patients were analyzed to estimate transitional probabilities between these states. A systematic review and network meta-analysis (SRNMA) was conducted to assess the efficacy of individual SGLT2 inhibitors on HFH and all-cause mortality.
The SRNMA indicated that SGLT2 inhibitors, as a class, significantly reduced the risk of HFH (relative risk [RR] 0.74, 95% CI 0.67–0.81) and all-cause mortality (RR 0.91, 95% CI 0.84–0.98). However, the cost-utility analysis revealed that none of the SGLT2 inhibitors were cost-effective at the national ceiling threshold of US$4,564 per quality-adjusted life year (QALY) gained.
Price Reduction Scenarios
The analysis indicated that price reductions of 2.3% for canagliflozin, 38.2% for dapagliflozin, 90.2% for empagliflozin, and 55.6% for the overall SGLT2i group would be necessary to achieve cost-effectiveness within the established threshold.
Comparison with Previous Studies
Previous economic evaluations of SGLT2 inhibitors have yielded inconsistent results. Some studies suggested that dapagliflozin and empagliflozin were cost-effective, but these analyses were often conducted from a governmental perspective, excluding direct non-medical costs. Additionally, earlier studies primarily focused on patients with heart failure with reduced left ventricular ejection fraction (LVEF), whereas the current study considered a broader patient population.
Limitations and Future Directions
The authors acknowledged several limitations, including the lack of clinical efficacy data specific to Thai T2D-HF patients and the reliance on utility data from a single tertiary hospital. The clinical efficacy of canagliflozin was mainly derived from a single cardiovascular outcome trial with a small sample size. Further studies investigating the cardiovascular benefits of canagliflozin in T2D-HF patients are necessary to confidently benchmark its clinical efficacy.
Despite these limitations, the study provides valuable insights for policymakers in Thailand and other low- to middle-income countries (LMICs) facing similar healthcare challenges. The findings underscore the importance of considering both clinical efficacy and economic factors when making decisions about drug reimbursement and inclusion in national essential medicine lists.
The study highlights the need for further research to assess the cost-effectiveness of SGLT2 inhibitors in diverse patient populations and healthcare settings. Additionally, strategies to reduce the price of these drugs may be necessary to improve access and affordability in LMICs.
