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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)