They would not be cost-effective at current AUS prices.

Although most guidelines recommend metformin as the first-­line agent for patients with type 2 dia­betes (Diabetes Care 2018; 41: 2669­-2701), some experts now advocate starting with newer agents (e.g. sodium­-glucose cotransporter­-2 [SGLT­-2] inhibitors and glucagon­-like peptide­1 [GLP­-1] receptor agonists) as first­-line therapy. In a cost­ effectiveness analysis, researchers used randomised, controlled trials and large patient databases to estimate life expec­tancy and cost differences if patients with new diabetes used SGLT­-2 inhibitors or GLP­-1 receptor agonists as first­line agents instead of metformin.

First-line SGLT-2 inhibitors or GLP-­1 receptor agonists were associated with about 5% fewer macrovascular
complications (i.e. heart failure, ischaemic heart disease or stroke) compared with first­-line metformin; the newer agents increased life expectancy by only about three months. However, compared with metformin, SGLT­-2 inhibitors and oral GLP­-1 receptor agonists cost US$500,000 and US$800,000 more, respectively, per quality­adjusted life­-year (QALY) gained. (Note: Injectable GLP­-1 receptor agonists were considered to be less effective than metformin, primarily owing to lower quality of life related to injections.) 

Comment: SGLT­-2 inhibitors and GLP­-1 receptor agonists would require about 80% reduction in their current US prices to make them cost­-effective as first­-line agents for type 2 diabetes – at a willingness­-to­-pay threshold of US$150,000 per QALY gained. Until costs come down for these drugs, metformin should remain the first­-line agent for treating patients with new type 2 diabetes, unless coexisting heart failure is documented.

DANIEL D. DRESSLER, MD, MSc, MHM, FACP
Professor of Medicine, Emory University School of Medicine, Atlanta, USA.

Choi JG, et al. First-line therapy for type 2 diabetes with sodium–glucose cotransporter-2 inhibitors and glucagon-like peptide-1 receptor agonists: a cost-effectiveness study. Ann Intern Med 2022; 175: 1392-1400.

This summary is taken from the following Journal Watch title: Hospital Medicine