The good news is that a few diabetes drugs now show valid cardioprotective benefits; the bad news is the drugs are unaffordable for many.
Jardiance and Victoza improve hard outcomes, but at a hefty cost
With the availability of new treatment options for type 2 diabetes, new questions are being asked about cost and effectiveness.
Following last week's announcement that liraglutide (Victoza) was associated with a reduction of major cardiovascular events and all-cause mortality, physicians now have another option -- along with empagliflozin (Jardiance), the only other drug to show cardiovascular superiority in a postmarketing trial -- to help patients mitigate the cardiovascular risks that come with diabetes, with an agent mainly targeted at diabetic processes. Even some cardiologists are considering prescribing diabetes drugs as well.
But an analysis of the fine print reveals that there is a relatively high number needed to treat for the drugs, both of which aren't cheap. According to GoodRx, which collects pricing data from pharmacies for consumer use, the cost of empagliflozin is $405 for 30 25-mg tablets, while the cost of liraglutide is $702 for a single carton of three pens (each pen can deliver 10-30 daily doses).
A spokesperson for GoodRx said these figures come from taking the lowest price available at each U.S. pharmacy -- a total of about 75,000 prices -- and from that they take the 25th percentile to calculate their "fair price," or what consumers should be capable of getting if they're conscientious about pricing. This method, repeated every 2 weeks, excludes online and membership prices (from programs at CVS or Rite Aid, for example).
The number of patients who would need to be treated with liraglutide, a glucagon-like peptide 1 (GLP-1) receptor agonist, to prevent one coronary event over a 3-year period was found to be 66, while the number to treat to prevent one death was 98. Empagliflozin, a sodium glucose cotransporter 2 (SGLT-2) inhibitor, fared better on this front: to prevent one case of a coronary event over a 3-year period, 63 patients need to be treated, and to prevent one death, 38 patients need to be treated.
"It's a challenge to push these drugs in the absence of adequate insurance coverage," Robert Eckel, MD, of the University of Colorado School of Medicine, told MedPage Today. "I am not going to make somebody broke by giving them an agent that has a number to treat of 1 in 60."
Insurance companies sometimes cover these drugs in part or in full in the U.S., but Irl Hirsch, MD, at the University of Washington in Seattle, who has written before on costs of diabetes drugs, said that, in reality, many people pay the full cost of the drugs themselves, including those in the Medicare Part D "doughnut hole" and those with high deductibles.
"And don't forget the 9.5% still without insurance despite the Affordable Care Act," he added in an email to MedPage Today. "So in actuality there are many who pay the list prices."
He added that physicians should be aware that many Americans might not pay for a drug if it is too expensive, and cited evidence that about half of people in the country couldn't pay an unexpected $400 bill without having to sell something or borrow money.
"At the end of the day, I guess the question we need to answer ('we' being society, not physicians) is how much are we willing to pay for a drug that either lowers glucose, lowers weight, lowers blood pressure, etc?" he asked. "And what should we be willing to pay for a drug that gives us a number needed to treat of 38, or 98?"
He also said there are still questions about whether the effects that the drugs have are class effects, and could thus be seen with treatment from other SGLT-2 and GLP-1 drugs. France, Germany, Canada, and Great Britain "refuse these high costs" so the overall cost to society is less, he added, even though "the number needed to treat for a Brit is no different than an American."
Joel Zonszein, MD, at the Albert Einstein College of Medicine in New York, wrote in an email that because older medications like sulfonylureas weren't particularly effective and can be unsafe, the new treatment options are a "game-changer." But he added that price is something that clinicians should always have on their mind.
"Our patients pay very high prices for their medical insurance, and diabetes is not a rare disease," he wrote. He added that it's useful to differentiate cost from cost-effectiveness, since insurance companies often pay for expensive procedures like dialysis but refuse to pay for the medications that might help to prevent those complications.
He added that liraglutide and empagliflozin have other benefits, including weight loss, that can help patients, so it might make sense to favor those drugs over older ones. "But being unable to treat a common disease because of price in the United States of America is pathetic," he wrote.
This article was first published on MedPage Today and reprinted with permission from UBM Medica. Free registration is required.