OBJECTIVES: SGLT-2i’s and DPP-IVi's are recommended as preferred add-on OAD’s after metformin among T2DM patients with ASCVD, HF, CKD. They generally many folds costlier than other OAD’s. This is a simulatory analysis to assess the relative cost escalation and risk reduction with their hypothetical substitution / addition in prescriptions of high risk patients.

METHODS: A simple simulatory cost effectiveness analysis was performed using prescriptions of T2DM patients with established CV or renal disease or having high risk factors. SGLT-2i’s and DPP-IVi's with proven benefits / safety were substituted or added in place of other OADs. Increments in treatment costs were calculated, and anticipated decrease in hazards were extrapolated from CVOTs and real world studies. The ICERs (incremental cost effectiveness ratios) were calculated.

RESULTS: Prescriptions of 351 patients with mean age of 58.04 ± 8.67 years were analysed. Upon calculating the ICERs, additional cost to prevent one all cause death with dapagliflozin substitution is INR 37,33,220 - 1,43,58,538.5, INR Rs 22,23,326.09 with empagliflozin substitution, and INR 80,69,818.18 with canagliflozin substitution. The ICER for prevention of hospitalisation for HF (hHF) with dapagliflozin substitution is INR 74,66,440 – 81,15,695.65, INR 40,107,05.88 with empagliflozin, and INR 55,48,000 with canagliflozin. and INR 55,48,000 with canagliflozin. To prevent a 3P MACE event, INR 1,16,66,312.5 would be needed with dapagliflozin substitution, and INR 31,46,861.54 and INR 38,59, 478.26 with empagliflozin and canagliflozin respectively. Incremental costs for various outcomes were further higher with addition of SGLT-2i’s along with substitution with sitagliptin / linagliptin. The number needed to treat and patient years of treatment to prevent one event were calculated too. CONCLUSION: The incremental costs of prescribing SGLT-2i’s and DPP-IVi's per event reduction are very high for most outcomes considering Indian socioeconomic context; interpretations are subjective in terms of perceived value of an event prevention.