Abstract
Background and objective
Intensive insulin therapy improves glycosylated haemoglobin (HbA1C) levels and delays the onset of long-term diabetes-related complications. Current treatment guidelines recommend maintaining a glycosylated haemoglobin (HbA1C) of ≤7% in patients with type 1 and 2 diabetes mellitus. However, the risk of hypoglycaemia increases with lower HbA1C levels. As such, patients often choose to settle for suboptimal glucose control in order to prevent hypoglycaemic events. At a given HbA1C level, treatment with insulin glargine results in a lower risk of hypoglycaemia in type 1 and 2 diabetes compared with NPH insulin. It has been proposed that the lower hypoglycaemic risk will allow more patients to achieve target HbA1C levels with insulin glargine compared with NPH insulin. The objective of this study was to assess the cost effectiveness of insulin glargine compared with NPH insulin in patients with type 1 or 2 diabetes who had inadequate glycaemic control.
Methods
A long-term, state-transition model was developed to simulate the natural history of type 1 and 2 diabetes. Risks of diabetes-related macro- and microvascular complications and mortality by HbA1C levels were estimated based on the UKPDS (United Kingdom Prospective Diabetes Study). Outcome measures included complication rates and associated costs, insulin costs, life years (LYs) and QALYs. The baseline analysis was conducted for patients with type 1 and 2 diabetes (aged 27 and 53 years, respectively) with HbA1C levels >7%, using a 36-year time horizon and a Canadian public payer perspective. Costs and effects were discounted at 5% per annum. Univariate sensitivity analyses were performed on key model inputs. All costs were reported in $Can (2005 values).
Results
The NPH insulin group had lower total costs than the insulin glargine group for patients with inadequately controlled diabetes (HbA1C >7%; lifetime difference $Can1398 and $Can1992, respectively, in type 1 and 2 diabetes). However, patients treated with insulin glargine had greater total and quality-adjusted life expectancy than those who received NPH insulin (incremental LY = 0.08 and QALYs = 0.07 in type 1 diabetes and incremental LY = 0.25 and QALYs = 0.23 in type 2 diabetes). The weighted incremental cost per LY gained and QALY gained were $Can18 661 and $Can20 799, respectively, in type 1 diabetes and $Can8041 and $Can8618, respectively, in type 2 diabetes (discounted results).
Conclusions
The cost-effectiveness ratios for insulin glargine use for type 1 and 2 diabetes provide evidence for its adoption from a Canadian healthcare payer perspective.
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Acknowledgements
Funding for this study and preparation of this paper was provided by sanofi-aventis Canada. The general choice of the study design was determined by the consultants, and the design of the model, selection of data to populate the model, conduct of the health economic analysis and writing of this paper were the responsibility of the consultants with input provided by sanofi-aventis. The authors wish to thank the project advisor, Dr Bernard Zinman (Endocrinologist, Toronto General Research Institute, Toronto, ON, Canada) for his contribution to the model design. Luc Sauriol was an employee of sanofi-aventis at the time the study was conducted. Luc Sauriol owns stock options in sanofi-aventis.
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Grima, D.T., Thompson, M.F. & Sauriol, L. Modelling Cost Effectiveness of Insulin Glargine for the Treatment of Type 1 and 2 Diabetes in Canada. Pharmacoeconomics 25, 253–266 (2007). https://doi.org/10.2165/00019053-200725030-00007
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DOI: https://doi.org/10.2165/00019053-200725030-00007