Cost-Effectiveness of Dapagliflozin as a Treatment for Chronic Kidney Disease: A Health-Economic Analysis of DAPA-CKD

Abstract

Background and objectives: CKD imposes a significant burden on patients and health care providers, particularly upon reaching kidney failure when patients may require KRT. The Dapagliflozin and Prevention of Adverse Outcomes in CKD (DAPA-CKD) trial demonstrated that dapagliflozin, with standard therapy, reduced CKD progression and KRT requirement. The study objective was to estimate the cost-effectiveness of dapagliflozin for the treatment of CKD from payer perspectives in the United Kingdom, Germany, and Spain.

Design, setting, participants, & measurements: We constructed a lifetime Markov model to characterize outcomes in patients with CKD on the basis of the DAPA-CKD trial. Health states were defined by eGFR level and KRT type. Direct health care costs and utility values were sourced from published literature and the DAPA-CKD trial, respectively. Costs and benefits were discounted at 3.5% per annum in the United Kingdom and 3% in Germany and Spain.

Results: In patients eligible for the DAPA-CKD trial, treatment with dapagliflozin was predicted to reduce rates of CKD progression, with patients predicted to spend 1.7 (95% credibility interval, 0.8 to 2.4) more years in the eGFR range 15-89 ml/min per 1.73 m² versus standard therapy alone (12.1; 95% credibility interval, 8.9 to 14.1 versus 10.4; 95% credibility interval, 7.7 to 12.4 years). Life expectancy (undiscounted) was correspondingly predicted to increase by 1.7 (95% credibility interval, 0.7 to 2.5) years (15.5; 95% credibility interval, 11.1 to 18.2 versus 13.8; 95% credibility interval, 9.9 to 16.5 years). This in addition to reduced incidence of adverse clinical outcomes, including hospitalization for heart failure, resulted in modeled quality-adjusted life year (discounted) gains between 0.82 (95% credibility interval, 0.38 to 1.18) and 1.00 (95% credibility interval, 0.46 to 1.41). These gains translated to incremental cost-effectiveness ratios of $8280, $17,623, and $11,687 in the United Kingdom, Germany, and Spain, respectively, indicating cost-effectiveness at willingness-to-pay thresholds (United Kingdom: $27,510 per quality-adjusted life year; Germany and Spain: $35,503 per quality-adjusted life year).

Conclusions: In patients meeting the eligibility requirements for the DAPA-CKD trial, dapagliflozin is likely to be a cost-effective treatment within the UK, German, and Spanish health care systems.

Clinical trial registry name and registration number: Dapagliflozin and Prevention of Adverse Outcomes in CKD (DAPA-CKD), NCT03036150.

Keywords: SGLT2 inhibitor; chronic kidney disease; cost-effectiveness; dapagliflozin.

Graphical abstract

Figure 1.

Markov model schematic diagram. Patients can move between any eGFR-defined health state prior to kidney failure; once patients suffer kidney failure, they enter irreversibly into KRT-defined health states. Patients can suffer transient events, incurring associated costs and disutilities in the cycle of incidence. Death is an absorbing health state calculated by survival models on the basis of the all-cause mortality end point.

Figure 2.

Subgroup analysis: change relative to the base case incremental cost-effectiveness ratio (ICER; discounted) in patient subgroups dichotomously stratified by baseline type 2 diabetes status, eGFR level, or urine albumin-creatinine ratio (UACR). The degree to which the ICER of the subgroup of interest increases or decreases relative to the ICER relating to the base case population receiving dapagliflozin with standard therapy versus standard therapy alone. QALY, quality-adjusted life year.

Figure 3.

ICER (US dollars per QALY) evolution over time in the United Kingdom, Germany, and Spain. Negative ICERs represent scenarios where dapagliflozin is considered the dominant treatment option (i.e., a lower cost and higher QALYs compared with placebo).

Figure 4.

Cost-effectiveness acceptability curves for the United Kingdom, Germany, and Spain. The probability of dapagliflozin with standard therapy being cost effective at a given willingness-to-pay threshold versus standard therapy alone. The established willingness-to-pay threshold for each country is indicated by a vertical line from the y axis.