e3 cadth 2013 dm talk - klarenbach - salon f

Type II DM and Antidiabetes Agents

Costs

Cost of Anti-diabetes Agents

• Dramatic variation in daily costs• Recent introduction of newer agents (more costly)

ODBF 2012 - lowest cost generic; no dispensing fee

Drug Expenditure Oral Anti-Diabetes Agents

• From 1998 to 2009

• Private: $7 to $123 M

• Public (RAMQ) $13 to $55 M

• 4 to 17 x increase in expenditure

What are the drivers of growth?

Drug Expenditure Oral Anti-Diabetes Agents

Private Drug Plans 1998-2009

Drug Expenditure Oral Anti-Diabetes Agents

Quebec public drug plan 1998-2009

Drug Expenditure Oral Anti-Diabetes Agents

Class Total Days Supply (2009)

Total Cost (2009)

Metformin

Sulphonylureas

TZDs

DPP-4 Inhibitors

59% 33%

23% 10%

11% 38%

4% 15%

1 patient treated with TZD or DPP-4 inhibitor = 8-12 patients treated with sulphonylurea

Summary of Recommendations

Tools

COMPUS

Type II DM and Antidiabetes Agents

Systematic Review of Effectiveness & Harms

Systematic Review & Mixed Treatment Comparison

Change in A1c

All classes: meaningful reduction in A1c

Systematic Review & Mixed Treatment Comparison

Odds of ≥1 hypoglycemic event

Note: severe hypoglycemia rarely observed

Systematic Review & Mixed Treatment Comparison

Change from baseline in body weight

Benefits & HarmsClinical evidence / inputs

• Lack of long term RCTs adequately powered for clinically meaningful outcomes

• A1c → little differences between agents

• Hypoglycemia → differences (low absolute risk)

• Weight change → differences (clinical relevance)

• Side effects → CHF, Fractures, GI symptoms, etc

Costs

• treatment → drug ± test strips

• side effects

• diabetes related complications

SynthesisEffectiveness (A1c)

• Little difference between agents

Why doesn’t hypoglycemia play more of a role?

• Baseline risk of hypoglycemia low

• 2nd line: mild-moderate 0.86% / severe 0.05% annually*

• 3rd line: mild-moderate 2.3 events per patient year/ severe 242/100,000 patient years**

• Agents that cause less hypogylcemia may be more attractive in patients at much higher risk of this event

Why doesn’t weight gain play more of a role?

• unclear what impact few kg difference to health

• unclear if there is a significant difference in quality of life

*Home Lancet 2009; Leese Diab Care 2003**Holman NEJM 2007; Bodmer Diab Care 2008

Bariatric Surgeryand

Type II Diabetes

Bariatric Surgery for Severe Obesity

• Epidemic of obesity and severe obesity

• Obesity related comorbid conditions (diabetes, sleep apnea, hypertension,etc.)

• Increased mortality

• Reduced quality of life

• Few effective treatment strategies (diet, medication)

• Increasing demand for bariatric surgery in Canada

Padwal, Tonelli, Klarenbach (under Review)

Bariatric Surgery for Severe Obesity

Padwal, Tonelli, Klarenbach (under Review)

Bariatric Surgery for Severe ObesityEffectiveness

• Compared to standard care

• Clinically important, sustained weight loss

Padwal, Tonelli, Klarenbach (under Review)

Bariatric Surgery for Severe ObesityCost-effectiveness

Padwal, Tonelli, Klarenbach (under Review)

Bariatric Surgery for Severe ObesityCost-effectiveness

Padwal, Tonelli, Klarenbach (under Review)

Bariatric Surgery for Severe ObesityCost-effectiveness

Padwal, Tonelli, Klarenbach (under Review)

Bariatric Surgery for Severe ObesityCost-effectiveness

Padwal, Tonelli, Klarenbach (under Review)

Bariatric Surgery for Severe Obesity

• Eligible population estimated 1.5 million

• Agree to surgery : 1-2%

• Current provision: 1500 surgeries (<0.1%)

• Not feasible to provide to all eligible patients

• Need additional criteria to triage

• clinical, humanistic and cost-effectiveness data to inform optimal triage strategy

Padwal, Tonelli, Klarenbach (under Review)

Bariatric Surgery for Severe Obesity

• Effective and cost-effective

• dominant in some patient groups

• Require additional analyses (including cost-effectiveness analysis) to identify optimal triage criteria

Padwal, Tonelli, Klarenbach (under Review)