Cost Effectiveness of Sodium-Glucose Cotransporter 2 Inhibitors Compared with Mineralocorticoid Receptor Antagonists among Patients with Heart Failure and a Reduced Ejection Fraction

Objective: Sodium-glucose cotransporter 2 inhibitors (SGLT2i) are approved for heart failure with reduced ejection fraction (HFrEF). However, their cost-effectiveness remains unknown. We aimed to compare the cost-effectiveness of SGLT2i versus mineralocorticoid antagonists (MRAs). Methods: Data from the RALES, EPHESUS, EMPHASIS, DAPA-HF, and EMPEROR-Reduced trials were included. We calculated the risk-ratio (RR) for a composite of cardiovascular death or heart failure hospitalization (CV death-HHF), all-cause mortality, and heart failure hospitalization (HHF) between MRAs and SGLT2i. A Markov model was developed to simulate the progression of HFrEF over 5 years. The primary outcome was incremental cost-effectiveness ratio (ICER), measured by cost per quality-adjusted life-year (QALY) gained. Results: We observed a similar benefit in CV death-HHF (RR 1.04; 95% CI 0.82-1.31), all-cause mortality (RR 0.91; 95% CI 0.78-1.06), and HHF (RR 1.05; 95% CI 0.84-1.31) between MRAs and SGLT2i. In a 5-year model, no difference in survival was observed between treatments. MRAs were associated with lower cost ($63,135.52 vs. $80,365.31) and more QALYs gained per patient (2.53 versus 2.49) than SGLT2i. The ICER for SGLT2i versus MRAs was $-172,014.25/QALY, in favor of MRAs. Conclusion: MRAs and SGLT2i provided similar benefits; however, MRAs were a more cost-effective treatment than SGLT2i.