Budget impact analysis for three glucagon-like peptide-1 receptor agonist-based therapies for type 2 diabetes mellitus management in Saudi Arabia

Figures & data

Table 1. Basic model parameters.

Parameter	Value
Total diabetes population size	53,717
Prevalence of T2DM	95%
Diabetes attributable mortality	1.0%
Patients currently using GLP-1 RA	4%
BMI range (kg/m²)	35

Total diabetes population size, proportion currently using GLP-1 and BMI values derived from Novo Nordisk market research²⁰. Prevalence of T2DM and diabetes attributable derived from Saudi Arabia diabetes data available elsewhere⁴⁰.

Table 2. Subpopulations.

Subpopulation	T2DM patients on treatment type	Uncontrolled patients	Patients intensifying with a GLP-1 RA
Oral patients	77%	28%	12%
Basal insulin patients	21%	28%	8%

All values from Novo Nordisk market research²⁰.

Table 3. Derivation of annual patient numbers receiving GLP-1 RA or GIP/GLP-1 agents.

	Year 1	Year 2	Year 3	Year 4	Year 5
Overall T2DM patients (multiplying total population size by the prevalence of T2DM among diabetes patients)	51,031	51,031	51,031	51,031	51,031
Patients intensifying with a GLP-1 RA from oral	1,320	1,320	1,320	1,320	1,320
Patients intensifying with a GLP-1 RA from basal	240	240	240	240	240
Total patients intensifying with a GLP-1 RA	1,560	1,560	1,560	1,560	1,560
Patients on GLP-1 RA	1,837	3,380	4,916	6,444	7,964
Total patients on GLP1-RA	3,397	4,941	6,476	8,004	9,525
Patient mortality	34	49	65	80	95
Patients receiving GLP-1 at the end of the year	3,363	4,891	6,412	7,924	9,429
Half-cycle corrected population	3,380	4,916	6,444	7,964	9,477

All values from Novo Nordisk market research²⁰. Abbreviations. GLP-1 RA, Glucagon-like peptide-1 receptor agonists; GIP/GLP-1, Glucose-dependent/insulinotropic polypeptide/glucagon-like peptide-1.

Table 4. HbA1c results.

Comparator	HbA1C < 7.0% (26 weeks)	HbA1C < 7.0% (52 weeks)
Semaglutide 1.0 mg	79.8%	95.9%
Dulaglutide 1.5 mg	64.7%	87.5%
Tirzepatide 15 mg	86.6%	98.2%
Odds ratio: tirzepatide 15 mg vs. semaglutide 1 mg	1.63

HbA1c results at 26 weeks for semaglutide and dulaglutide were derived from Hansen et al.⁴¹, while odds ratios from Frías et al.²² were used to derive the proportion of tirzepatide patients achieving HbA1c < 7.0% at 26 weeks. The probability of achieving HbA1c < 7.0% at 26 weeks was converted into a rate and subsequently used to calculate probability at 52 weeks⁴².

Table 5. Cardiovascular event rates and treatment-specific risk reductions.

	CV death	Non-fatal stroke	Non-fatal MI
Base rate per patient-year	0.02	0.01	0.01
Semaglutide 1.0 mg	0.98	0.61	0.74
Dulaglutide 1.5 mg	0.91	0.76	0.96
Tirzepatide 15 mg	0.90	0.80	0.76

All values are reported as hazard ratios relative to the study-specific comparator. Base rates of CV death, non-fatal stroke, and non-fatal MI were derived from selected cohort studies^43–45. Hazard ratios were obtained from relevant trials for semaglutide and dulaglutide^60,61 and from a meta-analysis of SURPASS trials for tirzepatide²⁶.

Table 6. Comorbidity prevalence and weight loss relative risk reductions.

	Prevalence	Source	RRR for 7% weight loss (semaglutide)	RRR for 3% weight loss (dulaglutide)	RRR for 13% weight loss (tirzepatide)
Chronic kidney disease	24%	^3	3.39%	1.69%	5.1%
Heart failure	2%	^3	3.45%	0.00%	3.45%
Hypertension	41%	^62	2.70%	1.04%	5.2%
Dyslipidemia	67%	^63	1.73%	0.58%	3.5%

Abbreviations. RRR, Relative Risk Reduction.

Values for RRRs linking weight loss to reduction of comorbidities are informed by Alqahtani et al.⁴⁷.

Table 7. Annual non-medication costs per patient.

	HbA1c < 7%	HbA1c 7–9%	HbA1c > 9%
Laboratory test costs	174.5	199.5	302.0
Hospitalization costs	249.4	399.2	680.2
Outpatient visit costs	154.7	156.0	158.5
Medical specialist costs	154.7	158.1	152.6
Dietary education costs	14.7	10.8	30.7
Other costs	93.9	192.8	423.6
Total costs	1,018.8	1,341.0	2,114.6

All costs derived from Almutairi and Alkharfy⁴⁸.

All prices in 2023 USD. Note, costs from Almutairi and Alkharfy⁴⁸ were in 2011 Saudi Riyal, while total costs were inflated to 2022 Saudi Riyal and subsequently transformed to USD, accounting for discrepancies between line items and their sum.

Table 8. Event unit costs.

Event	Source	Cost (USD)
Cardiovascular death	^23	6,372.60
Non-fatal stroke	^23	31,412.66
Acute stroke rehabilitation	^23	15,535.33
Non-fatal MI 1st year	^23	17,758.31
Non-fatal MI 2nd + year	^23	1,252.50
CKD	^47	4,787.03
Heart failure	^47	7,175.87
Hypertension	^47	2,250.66
Dyslipidemia	^47	4,240.43

Abbreviations. MI, myocardial infarction; CKD, chronic kidney disease.

Table 9. Drug acquisition and administration costs.

Drug	Pack price (USD)	# Days/pack	Daily cost (USD)
Semaglutide 1.0 mg	79.49	28	2.84
Dulaglutide 1.5 mg	79.89	28	2.85
Tirzepatide 15 mg	278.09	28	9.93

Abbreviation. USD, United States Dollar.

All pack prices obtained from NUPCO and converted to USD⁴⁹.

Table 10. Total budget impact.

Period	Semaglutide	Tirzepatide	Dulaglutide
Year 1	8,366,997	16,988,393	9,109,066
Year 2	12,599,267	25,260,344	13,786,528
Year 3	17,008,519	33,745,700	18,688,391
Year 4	21,593,870	42,443,396	23,813,534
Year 5	26,354,439	51,352,369	29,160,841
Total	85,923,092	169,790,202	94,558,360

All outcomes in 2023 USD.

Table 11. Disaggregated budget impact by cost category in years 1, 5, and total.

Cost category	Semaglutide	Tirzepatide	Dulaglutide
Medication costs (Year 1, Year 5, Total)	3,503,077	12,254,648	3,520,758
	9,820,791	34,355,609	9,870,359
	33,349,253	116,664,120	33,517,578
Diabetes management (Year 1, Year 5, Total)	3,541,660	3,487,168	3,742,527
	9,928,958	9,776,190	10,492,083
	33,716,563	33,197,800	35,628,815
CV complications (Year 1, Year 5, Total)	1,718,130	1,949,902	2,051,139
	7,714,500	9,192,324	9,374,112
	22,625,947	26,623,928	27,366,964
Weight reduction savings (Year 1, Year 5, Total)	395,869	703,325	152,410
	1,109,810	1,971,755	427,278
	3,768,672	6,695,646	1,450,942

All outcomes in 2023 USD.

Figure 1. HbA1c outcomes – current scenario (semaglutide) and new scenario (tirzepatide).

Figure 2. Number of CV events – current scenario (semaglutide) and new scenario (tirzepatide).

Table 12. Sensitivity analysis – price parity between semaglutide and tirzepatide years 1, 5, and total.

Price parity sensitivity analysis	Semaglutide	New scenario
Price parity: semaglutide and tirzepatide	3,503,077	3,503,077
	9,820,791	9,820,791
	33,349,253	33,349,253
Diabetes management	3,541,660	3,487,168
	9,928,958	9,776,190
	33,716,563	33,197,800
CV complications	1,718,130	1,949,902
	7,714,500	9,192,324
	22,625,947	26,623,928
Weight reduction savings	395,869	703,325
	1,109,810	1,971,755
	3,768,672	6,695,646
Total	8,366,997	8,236,822
	26,354,439	26,817,551
	85,923,091	86,475,336

All outcomes in 2023 USD.

Figure 4. Probabilistic sensitivity analysis.

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