Cost Effectiveness of SGLT2 Inhibitors in Question for Patients With HFpEF

Volume 27, Issue 3

The SGLT2 inhibitors have emerged as a breakthrough drug class for patients with heart failure regardless of ejection fraction. This is particularly notable for patients with heart failure with preserved ejection fraction (HFpEF), as these patients have fewer available drug therapies which can slow disease progression and prevent mortality. 

The 2022 heart failure guidelines recently gave SGLT2 inhibitors a Class I, level of evidence B for use in patients with HFpEF. Given that another large, randomized clinical trial has been published since these guidelines were released, it stands to reason that this grade of evidence may soon be updated to level A. 

Despite these strong recommendations, cost effectiveness data are not available to support the use of SGLT2 inhibitors in patients with HFpEF. 

In this issue of Talking Therapeutics, we explore the findings from a paper evaluating the cost effectiveness of SGLT2 inhibitors in patients with HFpEF. 

Point 1: SGLT2 Inhibitors Provide Moderate-to-Low Cost Effectiveness

In this paper, the authors used a Markov model that simulated monthly outcomes based on results from the Empagliflozin in Heart Failure With a Preserved Ejection Fraction (EMPEROR-Preserved) and Dapagliflozin in Heart Failure With Mildly Reduced or Preserved Ejection Fraction (DELIVER) trials. 

This study showed SGLT2 inhibitor therapy increased survival by a meager 0.19 per quality adjusted life years (QALYs) at an increased cost of $26,300 compared with standard of care. The resulting cost-effectiveness ratio was $141,200 per QALY gained. If the morality benefit disappeared from the model, this increased the incremental cost-effectiveness ratio (ICER) to $373,400 per QALY gained. 

The American College of Cardiology and American Heart Association provide a value framework for interpreting the ICER. High value is defined at <$50,000, intermediate value ranges from $50,000 to <$150,000; and low value is ≥$150,000. Based on these thresholds, SGLT2 inhibitors in patients with HFpEF have moderate value at best, and low value at worst. 

Point 2: Drug Costs Likely Contribute

As with most models, the ICER was most sensitive to the cost of the medications. Reducing the per unit cost of the medication would likely expand access, which could be a win-win, as more patients would get an important drug therapy and manufacturers potentially could sell more units with a lower cost per unit.