Quadruple therapy for heart failure cost-effective compared to previous standard of care
Adding a sodium-glucose cotransporter-2 inhibitor to standard care had intermediate cost-effectiveness, but replacing an angiotensin-converting enzyme inhibitor with an angiotensin receptor-neprilysin inhibitor was only borderline cost-effective, a modeling study found.
A new study assessed the cost-effectiveness of guideline-recommended quadruple therapy for heart failure with reduced ejection fraction.
The study notes that the latest guidance from the American Heart Association, American College of Cardiology, and Heart Failure Society of America recommends an angiotensin receptor-neprilysin inhibitor (ARNi), sodium-glucose cotransporter-2 (SGLT-2) inhibitor, mineralocorticoid receptor antagonist (MRA), and beta-blocker. Given that the ARNi and SGLT-2 inhibitor are newer additions to heart failure therapy, researchers compared the cost-effectiveness of sequentially adding these classes with the previous standard of care, an angiotensin-converting enzyme inhibitor plus MRA plus beta-blocker. Results were published by Circulation: Cardiovascular Quality and Outcomes on June 6.
The modeling study projected the expected lifetime discounted costs and quality-adjusted life years (QALYs) with each treatment, considering $50,000/QALY to be high value, $50,000 to $150,000/QALY to be intermediate value, and greater than $150,000/QALY to be low value.
Compared with the previous standard of care, adding an SGLT-2 inhibitor had an incremental cost-effectiveness ratio of $73,000/QALY. Adding an ARNi as well, to achieve quadruple therapy, offered 0.68 additional QALY at a cost of $66,700, resulting in an incremental cost-effectiveness ratio of $98,500/QALY.
The study authors noted that the analysis was “highly sensitive to drug pricing.” The incremental cost-effectiveness for quadruple therapy versus the old standard of care ranged from $73,500/QALY based on prices paid by the Department of Veterans Affairs to $110,000/QALY using drug list prices. They observed that prices have been changing, with the list wholesale price per unit rising 76% for dapagliflozin and 90% for empagliflozin from 2014 to 2022, while the price of a 30-day supply of an ARNi rose 70% from 2015 to 2022.
The authors concluded that quadruple therapy is only “borderline cost effective” compared with adding an SGLT-2 inhibitor alone to the previous standard of care. “ARNis and [SGLT-2 inhibitors] have trial-proven benefits for patients with [heart failure with reduced ejection fraction], but the substantial costs of these brand-only drugs with rising list prices may deserve additional scrutiny by payers and policymakers alike to ensure not only cost-effectiveness but also equitable access and affordability for patients,” they wrote.