title: Evaluation of the cost effectiveness of exenatide versus insulin glargine in patients with sub-optimally controlled type 2 diabetes in the United Kingdom.
abstract: OBJECTIVE
  Exenatide belongs to a new therapeutic class in the treatment of diabetes (incretin mimetics), allowing glucose-dependent glycaemic control in type 2 diabetes. Randomised controlled trial data suggest that exenatide is as effective as insulin glargine at reducing HbA1c in combination therapy with metformin and sulphonylureas; with reduced weight but higher incidence of adverse gastrointestinal events. The objective of this study is to evaluate the cost effectiveness of exenatide versus insulin glargine using RCT data and a previously published model of type 2 diabetes disease progression that is based on the United Kingdom Prospective Diabetes Study; the perspective of the health-payer of the United Kingdom National Health Service.
  
  
  METHODS
  The study used a discrete event simulation model designed to forecast the costs and health outcome of a cohort of 1,000 subjects aged over 40 years with sub-optimally-controlled type 2 diabetes, following initiation of either exenatide, or insulin glargine, in addition to oral hypoglycaemic agents. Sensitivity analysis for a higher treatment discontinuation rate in exenatide patients was applied to the cohort in three different scenarios; (1) either ignored or (2) exenatide-failures excluded or (3) exenatide-failures switched to insulin glargine. Analyses were undertaken to evaluate the price sensitivity of exenatide in terms of relative cost effectiveness. Baseline cohort profiles and effectiveness data were taken from a published randomised controlled trial.
  
  
  RESULTS
  The relative cost-effectiveness of exenatide and insulin glargine was tested under a variety of conditions, in which insulin glargine was dominant in all cases. Using the most conservative of assumptions, the cost-effectiveness ratio of exenatide vs. insulin glargine at the current UK NHS price was -29,149 pounds/QALY (insulin glargine dominant) and thus exenatide is not cost-effective when compared with insulin glargine, at the current UK NHS price.
  
  
  CONCLUSIONS
  This study evaluated the relative cost effectiveness of insulin glargine versus exenatide in the management of type 2 diabetes using a published model. Given no significant difference in glycaemic control and applying the additional effectiveness of exenatide over insulin glargine, with respect to weight loss, and using the current UK NHS prices, insulin glargine was found to be dominant over exenatide in all modelled scenarios. With current clinical evidence, exenatide does not appear to represent a cost-effective treatment option for patients with type 2 diabetes when compared to insulin glargine.
authors.affiliation: School of Mathematics, Cardiff University, Cardiff, UK. woehla@cardiff.ac.uk
authors.forename: Anette
authors.initials: A
authors.lastname: Woehl
authors.forename: Mark
authors.initials: M
authors.lastname: Evans
authors.forename: Anthony P
authors.initials: AP
authors.lastname: Tetlow
authors.forename: Philip
authors.initials: P
authors.lastname: McEwan
mesh_terms: D003198:Computer Simulation; D003362:Cost-Benefit Analysis; D003924:Diabetes Mellitus, Type 2 / Q000188:drug therapy / Q000191:economics*; D016527:Drug Costs; D000077270:Exenatide; D005260:Female; D006801:Humans; D007004:Hypoglycemic Agents / Q000191:economics* / Q000627:therapeutic use; D007328:Insulin / Q000031:analogs & derivatives* / Q000191:economics / Q000627:therapeutic use; D000069036:Insulin Glargine; D049528:Insulin, Long-Acting; D008297:Male; D008875:Middle Aged; D018803:Models, Economic; D009313:National Health Programs / Q000191:economics; D010455:Peptides / Q000191:economics* / Q000627:therapeutic use; D011446:Prospective Studies; D019057:Quality-Adjusted Life Years; D016032:Randomized Controlled Trials as Topic; D016896:Treatment Outcome; D006113:United Kingdom; D014688:Venoms / Q000191:economics* / Q000627:therapeutic use
chemical_list: D007004:Hypoglycemic Agents; D007328:Insulin; D049528:Insulin, Long-Acting; D010455:Peptides; D014688:Venoms; D000069036:Insulin Glargine; D000077270:Exenatide