E3   cadth 2013 dm talk - klarenbach - salon f
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    E3   cadth 2013 dm talk - klarenbach - salon f E3 cadth 2013 dm talk - klarenbach - salon f Presentation Transcript

    • Type II DM andAntidiabetes AgentsCosts
    • Cost of Anti-diabetesAgents• Dramatic variation in daily costs• Recent introduction of newer agents (more costly)ODBF 2012 - lowest cost generic; no dispensing fee
    • Drug Expenditure OralAnti-Diabetes Agents• From 1998 to 2009• Private: $7 to $123 M• Public (RAMQ) $13 to $55 M• 4 to 17 x increase in expenditureWhat are the drivers of growth?
    • Drug Expenditure Oral Anti-DiabetesAgentsPrivate Drug Plans 1998-2009
    • Drug Expenditure Oral Anti-DiabetesAgentsQuebec public drug plan 1998-2009
    • Drug Expenditure OralAnti-Diabetes AgentsClassTotal Days Supply(2009)Total Cost (2009)MetforminSulphonylureasTZDsDPP-4 Inhibitors59% 33%23% 10%11% 38%4% 15%1 patient treated with TZD or DPP-4 inhibitor = 8-12 patients treated with sulphonylurea
    • Summary ofRecommendations
    • ToolsCOMPUS
    • Type II DM andAntidiabetes AgentsSystematic Review ofEffectiveness & Harms
    • Systematic Review & Mixed Treatment ComparisonChange in A1cAll classes: meaningful reduction in A1c
    • Systematic Review & Mixed Treatment ComparisonOdds of ≥1 hypoglycemic eventNote: severe hypoglycemia rarely observed
    • Systematic Review & Mixed Treatment ComparisonChange from baseline in body weight
    • Benefits & HarmsClinical evidence / inputs• Lack of long term RCTs adequately powered forclinically meaningful outcomes• A1c → little differences between agents• Hypoglycemia → differences (low absolute risk)• Weight change → differences (clinical relevance)• Side effects → CHF, Fractures, GI symptoms, etcCosts• treatment → drug ± test strips• side effects• diabetes related complications
    • SynthesisEffectiveness (A1c)• Little difference between agentsWhy doesn’t hypoglycemia play more of a role?• Baseline risk of hypoglycemia low• 2nd line: mild-moderate 0.86% / severe 0.05% annually*• 3rd line: mild-moderate 2.3 events per patient year/ severe242/100,000 patient years**• Agents that cause less hypogylcemia may be more attractive inpatients at much higher risk of this eventWhy doesn’t weight gain play more of a role?• unclear what impact few kg difference to health• unclear if there is a significant difference in quality of life*Home Lancet 2009; Leese Diab Care 2003**Holman NEJM 2007; Bodmer Diab Care 2008
    • Bariatric SurgeryandType II Diabetes
    • Bariatric Surgery for Severe Obesity• Epidemic of obesity and severe obesity• Obesity related comorbid conditions(diabetes, sleep apnea, hypertension,etc.)• Increased mortality• Reduced quality of life• Few effective treatment strategies (diet,medication)• Increasing demand for bariatric surgery in CanadaPadwal,Tonelli, Klarenbach (under Review)
    • Bariatric Surgery for Severe ObesityPadwal,Tonelli, Klarenbach (under Review)
    • Bariatric Surgery for Severe ObesityEffectiveness• Compared to standard care• Clinically important, sustained weightlossPadwal,Tonelli, Klarenbach (under Review)
    • Bariatric Surgery for Severe ObesityCost-effectivenessPadwal,Tonelli, Klarenbach (under Review)
    • Bariatric Surgery for Severe ObesityCost-effectivenessPadwal,Tonelli, Klarenbach (under Review)
    • Bariatric Surgery for Severe ObesityCost-effectivenessPadwal,Tonelli, Klarenbach (under Review)
    • Bariatric Surgery for Severe ObesityCost-effectivenessPadwal,Tonelli, Klarenbach (under Review)
    • Bariatric Surgery for Severe Obesity• Eligible population estimated 1.5 million• Agree to surgery : 1-2%• Current provision: 1500 surgeries (<0.1%)• Not feasible to provide to all eligible patients• Need additional criteria to triage• clinical, humanistic and cost-effectivenessdata to inform optimal triage strategyPadwal,Tonelli, Klarenbach (under Review)
    • Bariatric Surgery for Severe Obesity• Effective and cost-effective• dominant in some patient groups• Require additional analyses (includingcost-effectiveness analysis) to identifyoptimal triage criteriaPadwal,Tonelli, Klarenbach (under Review)