OBJECTIVES : Type 2 diabetes (T2DM) management remains poor in China, although there are multiple antidiabetic drugs. With the increasing health expenditure related to T2DM, it’s important to choose cost-effective drugs to reduce costs and optimize for efficacy and safety. Besides Chinese clinical guideline recommends a stepwise-escalation treatment strategy in T2DM care which consists of three therapy lines. Many patients use monotherapy in each therapy line in clinical practice. Thus this study aims to develop several alternative pharmacological monotherapy strategies, and estimate and compare the cost-effectiveness of each strategy.

METHODS : Referring to Chinese guideline, three-lines eight-classes of antidiabetic drugs were included: 1^st-line-drug (metformin=MET), 2^nd-line-drug (α-glycosidase-inhibitor=AGI, sulfonylurea=SU, glinide=NIDE, DPP-4-inhibitor=DPP-4I, thiazolidinedione=TZD), 3^rd-line-drug (insulin=INS, GLP-1-receptor-agonist=GLP-1RA); and 10 (=1*5*2) pharmacological monotherapy strategies were developed: using MET as 1^st-therapy-line, one of the five 2^nd-line-drugs as 2^nd-therapy-line, and one of the two 3^rd-line-drugs as 3^rd-therapy-line. From societal perspective, Cardiff T2DM model was used to estimate the cost-effectiveness of 10 pharmacological monotherapy strategies vs. nonpharmacological treatment. Clinical data on Chinese T2DM patients were obtained from systematic literature review combined with meta-analysis of 46 studies. Costs were collected from claims database study of 1164 patients combined with hospital information system. Utilities were obtained from EuroQol-5D survey of 868 patients. Simulation time was 40-years. Discount rate was 3%. Several sensitivity analyses were conducted.

RESULTS : Compared with nonpharmacological treatment, 70% of the pharmacological monotherapy strategies were cost-saving (increasing QALYs while saving costs), and 30% were cost-effective (the ICERs within 1-3 times GDP/capita). Ranking the strategies by considering incremental QALYs and costs, strategy-5a(MET, NIDE, INS) was optimal, followed by strategy-9a(MET, TZD, INS), strategy-1a(MET, AGI, INS), strategy-7a(MET, DPP-4I, INS), strategy-6a(MET, NIDE, GLP-1RA), strategy-10a(MET, TZD, GLP-1RA), strategy-2a(MET, AGI, GLP-1RA), strategy-8a(MET, DPP-4I, GLP-1RA), strategy-3a(MET, SU, INS), and strategy-4a(MET, SU, GLP-1RA).

CONCLUSIONS : Strategy-5a is worthy of clinical application among monotherapy strategies. This study provides evidence-based references for diabetes care.