Key result
CMS-negotiated prices make SGLT2 inhibitors and ARNIs cost-effective for heart failure at under ~$48,000/QALY.
Why the study?
SGLT2 inhibitors and ARNIs are heart failure therapies selected for price negotiations under the Inflation Reduction Act, motivating an evaluation of their cost-effectiveness by ejection fraction and drug price.
Does the use of SGLT2 inhibitors and ARNIs at CMS-negotiated prices improve cost-effectiveness compared to standard of care in patients with heart failure in the United States?
Systematic Review (n=16)
Does the use of SGLT2 inhibitors and ARNIs at CMS-negotiated prices improve cost-effectiveness compared to standard of care in patients with heart failure in the United States?
At CMS-negotiated prices under the Inflation Reduction Act, SGLT2 inhibitors and ARNIs are highly cost-effective for HFrEF and demonstrate intermediate economic value for HFmrEF and HFpEF.
Answers are grounded in this paper and cite their sources.
Supports adoption and coverage of SGLT2 inhibitors and ARNIs in HF at negotiated prices; extends cost-effectiveness data to post-IRA pricing.
BACKGROUND: Sodium-glucose co-transporter 2 (SGLT2) inhibitors and angiotensin receptor-neprilysin inhibitors (ARNI) are heart failure (HF) therapies selected for price negotiations under the Inflation Reduction Act. This study aimed to summarize the cost-effectiveness of SGLT2 inhibitors and ARNIs for HF, examine how cost-effectiveness varies by ejection fraction (EF) and drug price, and estimate the effect of negotiated prices on cost-effectiveness. METHODS: A systematic literature search identified cost-effectiveness analyses of SGLT2 inhibitors and ARNIs versus standard of care for the treatment of HF from a US perspective, published through 2025. Analyses were stratified by HF with reduced EF (<40%, HFrEF), moderately reduced EF (40% to 49%, HFmrEF), and preserved EF (≥50%, HFpEF). Incremental cost-effectiveness ratios were estimated at negotiated drug prices from base-case, threshold, and sensitivity analyses of drug pricing. Key drivers of cost-effectiveness were identified from the top 3 variables in 1-way sensitivity analyses. RESULTS: Of 821 studies identified, 16 were included: 11 HFrEF, 2 HFrEF/HFmrEF/HFpEF, and 3 HFmrEF/HFpEF. Across all EF categories, incremental cost-effectiveness ratios (2024 US dollars) versus standard of care ranged from $59 600 to $187 100/quality-adjusted life year (QALY) gained with SGLT2 inhibitors, $24 400 to $92 300 with ARNIs, and $69 300 to $91 500 with SGLT2 inhibitors + ARNIs. Incremental cost-effectiveness ratios in studies of HFrEF were <$120 000/QALY gained and all but 1 were ≥$120 000/QALY gained in studies of HFmrEF/HFpEF. At negotiated drug prices across all EF categories, the incremental cost-effectiveness ratio was estimated to be $47 800/QALY gained with SGLT2 inhibitors, $39 900/QALY gained with ARNIs, and $44 400/QALY gained with SGLT2 inhibitors+ARNIs. The key drivers of cost-effectiveness included drug price (17 studies), cardiovascular death risk with SGLT2 inhibitors and ARNIs (15 studies), and duration of intervention effectiveness (5 studies). CONCLUSIONS: At negotiated prices resulting from the Inflation Reduction Act, SGLT2 inhibitors and ARNIs seem cost-effective in HFrEF, with projected cost-effectiveness in HFmrEF/HFpEF dependent on price reductions and less certain treatment-effect estimates.
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Alfie et al. (2026) conducted a systematic review in Heart Failure (n=16). SGLT2 inhibitors and ARNIs vs. Standard of care was evaluated on Incremental cost-effectiveness ratio (ICER) per quality-adjusted life year (QALY) gained at CMS-negotiated prices (ICER $47,800/QALY gained with SGLT2 inhibitors and $39,900/QALY gained with ARNIs). At CMS-negotiated prices, SGLT2 inhibitors and ARNIs were estimated to be cost-effective for heart failure, with ICERs of $47,800 and $39,900 per QALY gained, respectively.
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