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Weighing the costs vs. benefits of SGLT2 inhibitors and GLP-1 receptor agonists


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3 minutes

Sodium-glucose cotransporter 2 (SGLT2) inhibitors and glucagon-like peptide-1 (GLP-1) receptor agonists have transformed diabetes care, particularly for individuals who also have cardiovascular disease (CVD) or have multiple risk factors for CVD. But both classes of agents come with significant costs.

Hui Shao, MD, PhD
Hui Shao, MD, PhD

“If you think about the choice between SGLT2 inhibitors versus older drugs like the sulfonylureas, the differences are huge, in both effectiveness and cost—$5,000 to $10,000 per patient per year,” said Hui Shao, MD, PhD, Assistant Professor of Pharmaceutical Outcomes and Policy at the University of Florida College of Pharmacy. “And although there is a high level of consensus that for heart failure prevention you should use an SGLT2 inhibitor, there is little consensus over which class you should use for other cardiovascular benefits.”

Dr. Shao will discuss the financial burden that SGLT2 inhibitors and GLP-1 receptor agonists have brought to the health care system during the symposium STLG2is and GLP1-RAs—Are They Worth It? The two-hour session will begin at 4:15 p.m. ET on Friday, June 25.

Also during the session, Jason Alexander, MD, Assistant Professor of Medicine at the University of Chicago, will explore the growing list of cardiovascular and renal benefits associated with the two classes. And Aaron Winn, PhD, Assistant Professor of Pharmacy Administration at the Medical College of Wisconsin, will weigh the issues of equity and value inherent in using these newer, more broadly potent agents versus older agents that can effectively control blood glucose levels but have few other clinical benefits.

“The reality is growing evidence backing the superiority of SGLT2 inhibitors over all the other competitors in the prevention of heart failure,” Dr. Shao said. “The evidence is so strong, the ADA updated treatment guidelines in 2020 to recommend SGLT2s as the preferred agent in diabetes management among patients with a history of heart failure or heart conditions that might have a high risk of heart failure.”

GLP-1 receptor agonists present patients and clinicians with a similar cost vs. benefit conundrum. The 2020 Standards of Medical Care in Diabetes noted that both SGLT2 and GLP-1 inhibitors “should be considered for patients with atherosclerotic cardiovascular disease (ASCVD), heart failure, or chronic kidney disease predominates independent of A1C.”

The problem is that while type 2 diabetes patients, their caregivers, and their clinicians all want the most effective treatment available, not everyone with diabetes is an appropriate candidate for every treatment.

“Currently, the combined number of patients using SGLT2 inhibitors and GLP-1 receptor agonists exceeds half of all patients with diabetes under second-line, glucose-lowering treatment,” Dr. Shao noted. “Are all of them really at high risk for ASCVD or heart failure? That’s not likely. Using these agents for patients at lower risk is not precisely a waste of health care resources, but it’s not an efficient way to design a health care system.”

As list prices rise, so do patient costs, making these highly effective agents less accessible to patients who are most likely to benefit.

“Ideally, you want patients who could really benefit from these agents to pay less, not more, to encourage their use and reduce the risk of a major event,” Dr. Shao said. “The biggest challenge in designing health plans is basing patient costs on the individualized value of the treatment, which is determined by patients’ individual health conditions and the potential benefits one can receive.”


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