In the Journals

Second-line sulfonylureas lower cost option for type 2 diabetes

In patients with type 2 diabetes, the use of a sulfonylurea drug as a second-line agent appears to yield glycemic control and quality-adjusted life years similar to those provided by similar agents, but at a lower cost, according to recent findings.

In the study, the researchers created a population-based, glycemic control Markov model to mimic natural variations in HbA1c progression. Through this model, they evaluated the following four second-line intensification regimens: metformin, sulfonylurea and insulin (T1); metformin with a DPP-IV inhibitor and insulin (T2); metformin with a glucagon-like peptide-1 receptor agonist and insulin (T3); and metformin and insulin (T4). In each treatment regimen, metformin monotherapy was initiated when HbA1c reached a pre-planned glycemic control target, and in T1, T2 and T3, a second-line agent was used to intensify the treatment. If or when HbA1c again surpassed the glycemic control target, insulin replaced the second-line agent as a third-line agent combined with metformin. In the T4 treatment regimen, treatment was intensified by direct addition of insulin once HbA1c surpassed the glycemic control target.

In all treatments, no changes were made once insulin was added. The Markov model was formulated using a US dataset of individuals diagnosed with type 2 diabetes, and the four treatment approaches were assessed using the Markov model by backward induction.

The study’s outcome measures were life-years, quality-adjusted life-years (QALYs), mean time to insulin dependence and anticipated costs of medication per QALY from diagnosis onset of diabetes complication or death.

Based on the Markov model, the researchers found that all treatment regimens yielded comparable life-years and QALYs, regardless of glycemic control target. However, the regimen in which sulfonylurea was the second-line treatment accrued significantly lower cost per QALY and had the longest time to insulin dependence. For all treatment approaches, an HbA1c goal of 7% resulted in higher QALYs vs. a goal of 8%.

According to the researchers, the study took into account concerns regarding severe hypoglycemia in association with sulfonylurea use.

“Our model, which considers the side effect of severe hypoglycemia, suggests that for a glycemic control goal of 6.5% or 7%, sulfonylureas provide higher value than incretin,” the researchers wrote. “Indeed, use of incretins as second-line agents resulted in significantly higher cost but slightly less clinical benefit as measured by [life-years] and QALYs to first incident diabetes-related complication or death.”

Disclosure: The researchers report no relevant financial disclosures.