Cost effectiveness of empagliflozin in adult patients with chronic kidney disease in the Netherlands

Abstract

Aim: The recent EMPA-KIDNEY trial showed evidence for preventing disease progression in adult patients with chronic kidney disease (CKD) treated with empagliflozin. It is however yet unknown if use of empagliflozin is cost effective in the Netherlands. We aimed to evaluate the cost effectiveness of empagliflozin in adult patients with CKD in the Netherlands.

Methods: A cost-effectiveness analysis was conducted using a Markov state microsimulation model, simulating kidney progression of CKD patients with eGFR <90 ml/min per 1.73 m2 comparing empagliflozin plus standard of care (SoC) and SoC alone. KDIGO classification was used to describe the risk of CKD progression. The input data were taken from the EMPA-KIDNEY trial (baseline characteristics, treatment effect, and utilities), and published data and national sources were used for general population mortality, treatment and event costs. The analyses were performed from a societal perspective with applying a lifetime horizon. Discounting was done according to the Dutch pharmacoeconomic guidelines. The incremental cost-effectiveness ratio (ICER) was compared to a willingness-to-pay threshold of €50,000/QALY. Deterministic and probabilistic sensitivity analyses were performed to explore the impact of uncertainty around the input parameters.

Results: The base-case results showed total discounted costs for empagliflozin plus SoC and SoC alone of €200,193 and €234,574 respectively, indicating total savings of €34,380. Empagliflozin plus SoC was associated with higher total discounted health benefits of 11.06 life years (LYs) and 9.01 quality-adjusted life years (QALYs), compared with 9.74 LYs and 7.79 QALYs for SoC alone, resulting in an additional 1.31 LYs and 1.22 QALYs for empagliflozin plus SoC. Empagliflozin plus SoC is a dominant alternative compared to SoC alone. Sensitivity analyses confirmed the robustness of the findings and conclusion.

Conclusion: Using empagliflozin in addition to SoC in adult patients with CKD is likely to be cost saving compared to the current SoC in the Netherlands, irrespective of diabetes status and albuminuria.

Fig 1. Health states, complications and events included in the CKD disease progression model.

Abbreviations: A = KDIGO uACR category (in mg/g), AV = arteriovenous, BMD = bone and mineral disease, BMI = body mass index, BSI = blood stream infection, CKD = chronic kidney disease, CVD = cardiovascular disease, eGFR = estimated glomerular filtration rate, ESKD = end-stage kidney disease, G = KDIGO eGFR category (in mL/min/1.73²), HD = hemodialysis, HF = heart failure, HTN = hypertension, HS = health state, KDIGO = Kidney Disease: Improving Global Outcomes, MI = myocardial infarction, PAD = peripheral arterial disease, PD = peritoneal dialysis, RT = renal transplantation, TIA = transient ischemic attack, uACR = urine albumin-creatinine ratio. *Even though this is not considered as CKD according to KDIGO criteria, an assumption has been made to include this in the model to model the disease progression, however, treatment effects were not considered in this group.

Fig 2. Tornado diagram representing the results of the one-way sensitivity analysis.

Abbreviations: A = KDIGO uACR category (A1-A3), eGFR = estimated glomerular filtration rate, HD = hemodialysis, ESKD = end-stage kidney disease, G = KDIGO eGFR category, KDIGO = Kidney Disease: Improving Global Outcomes, NMB = net monetary benefit, RFP = risk factor progression, SoC = standard of care, uACR = urine albumin-creatinine ratio, EMPA = empagliflozin.

Fig 3. Cost-effectiveness plane scatterplot showing the results of the probabilistic sensitivity analysis.

Abbreviations: QALY = quality-adjusted life year, 95% = 95% confidence interval, BC = base case, PSA = probabilistic sensitivity analysis.