At 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.
Systematic Review (n=16)
Are SGLT2 inhibitors and ARNIs cost-effective compared to standard of care in patients with heart failure?
At negotiated prices resulting from the Inflation Reduction Act, SGLT2 inhibitors and ARNIs appear cost-effective in HFrEF, with cost-effectiveness in HFmrEF/HFpEF depending on price reductions.
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.
Alfie et al. (Tue,) 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 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.