Objective  To evaluate the economic value of using glucagon-like peptide-1 receptor agonist (GLP-1RA) in combination with metformin for the treatment of type 2 diabetes mellitus (T2DM).

Methods  Based on 7 randomized controlled clinical trials (RCTs), Markov model was built to simulate the dynamic changes of metformin alone or combined with GLP-1RA in the treatment of T2DM patients without or with complications and death from the perspective of China's health system. Quality-adjusted life years (QALYs) was used as a health output indicator and 3 times China's per capita gross domestic product (GDP) in 2023 was set as the willingness-to-pay (WTP) threshold. The cycle was at the rate of 1 year and a total of 20 years cohort simulation in Markov model was applied to obtain long-term cost and effect of each treatment strategy. The incremental cost-utility ratio (ICUR) was analyzed as the primary evaluation indicator and the sensitivity of cost, utility and discount was performed to test the stability of the results.

Results  Compared with metformin alone, the ICUR of GLP-1RA including liraglutide, dulaglutide, exenatide, loxenatide, semaglutide combined with metformin were all below the WTP threshold, and the increased cost was acceptable. Extending the simulation time to 30 years or 50 years had no effect on results. The results of probability sensitivity analysis showed that the cost effect of semaglutide 0.5 mg combined with metformin had the highest probability of a cost-utility advantage of 99.7% among all the treatment strategies when WTP threshold was 3 times China's per capita GDP in 2023 (268  074 yuan).

Conclusion  GLP-1RA, including liraglutide, dulaglutide, exenatide, lixisenatide, and semaglutide, at the regular recommended dose combined with metformin, would present higher cost-utility compared to metformin monotherapy.

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