Cost-effectiveness of sodium–glucose cotransporter 2 inhibitors and glucagon-like peptide-1 receptor agonists for patients with high cardiovascular risk and type 2 diabetes in Canada

BACKGROUND: Diabetes Canada and the Canadian Cardiovascular Society recommend that patients with type 2 diabetes and cardiovascular disease, renal disease, or multiple cardiovascular risk factors begin glucagon-like peptide-1 receptor agonists (GLP-1 RA) or sodium-glucose cotransporter 2 inhibitors (SGLT2i). We assessed cost-effectiveness in patients meeting these criteria in Canada. METHODS: Our patient-level simulation estimated lifetime costs, clinical events, and quality-adjusted life-years (QALYs) for patients initiating SGLT2i or GLP-1 RA or remaining on "baseline treatment"; i.e., other standard-of-care medications. We based initial laboratory values and characteristics on 216 patients from a Quebec clinic focused on initiating guideline-directed diabetes therapies from 2022 to 2025. We calibrated risk equations and treatment effects to end points from placebo-controlled cardiovascular outcome trials. We estimated cost-effectiveness over a patient lifetime horizon from a Canadian health care payer perspective using a 1.5% annual discount rate. We performed probabilistic sensitivity analysis. RESULTS: Compared with baseline treatment, SGLT2i and GLP-1 RA reduced lifetime rates of cardiovascular and renal events and produced higher net present QALYs (+0.24 SGLT2i; +0.23 GLP-1 RA ), but at a higher net present cost (+$5000 SGLT2i; +$27 000 GLP-1 RA [2023 Canadian $]). Sodium-glucose cotransporter 2 inhibitors cost $21 400 per QALY gained and were consistently cost-effective in sensitivity analyses. In 62% of probabilistic sensitivity analysis iterations, GLP-1 RA were dominated, producing fewer QALYs at a higher cost than SGLT2i. INTERPRETATION: Sodium-glucose cotransporter 2 inhibitors provided more QALYs at a lower price than GLP-1 RA and were cost-effective at current prices. Glucagon-like peptide-1 RA cost-effectiveness may improve if outcomes beyond typical diabetes complications are considered and if generic GLP-1 RA become available.