The Institute for Clinical and Economic Review (ICER) in the US has published its revised Evidence Report assessing the comparative clinical effectiveness and value of subcutaneous semaglutide (Wegovy, Novo Nordisk), liraglutide (Saxenda, Novo Nordisk), phentermine/topiramate (Qsymia, Vivus Pharmaceuticals), and bupropion/naltrexone (Contrave, Currax Pharma) for the treatment of obesity.
The report has found that greater weight loss was seen with semaglutide and with phentermine/topiramate. Less weight loss was seen with liraglutide and with bupropion/naltrexone. However, the value of semaglutide used for weight loss would achieve common thresholds for cost-effectiveness if priced between US$7,500-US$9,800 per year; phentermine/topiramate and bupropion/naltrexone already meet common thresholds for cost-effectiveness.
At the September 16 virtual public meeting, ICER’s independent appraisal committee reviewed the evidence, heard further testimony from stakeholders, and deliberated over these treatments’ comparative clinical effectiveness, other potential benefits, and long-term value for money.
“The vast majority of people with obesity cannot achieve sustained weight loss through diet and exercise alone,” said Dr David RindICER’s Chief Medical Officer. “As such, obesity, and its resulting physical health, mental health, and social burdens is not a choice or failing, but a medical condition. The development of safe and effective medications for the treatment of obesity has long been a goal of medical research that now appears to be coming to fruition. With a condition affecting more than 40% of adults in the US, the focus should be on assuring that these medications are priced in alignment with their benefits so that they are accessible and affordable across US society.”
A draft version of this report was previously open for a four-week public comment period. The updated Evidence Report and voting questions reflect changes made based on comments received from patient groups, clinicians, drug manufacturers, and other stakeholders.
Semaglutide and liraglutide also improved blood sugar and blood pressure compared to usual care, but how they compare to phentermine/topiramate and bupropion/naltrexone is less certain. In addition, none of these drugs have assessed long-term outcomes in adults without pre-existing diabetes mellitus, and thus there is uncertainty around long-term benefits such as cardiovascular morbidity and mortality.
Phentermine/topiramate and bupropion/naltrexone both meet commonly accepted cost-effectiveness thresholds vs. lifestyle modification alone; both of these combination therapies are cost-saving when prescribed generically. When used for weight loss among patients with obesity (and not treatment of diabetes), semaglutide does not meet typical cost-effectiveness thresholds at its current estimated net price (Table 1), but it is more effective, less burdensome, and more cost effective than liraglutide.
Table 1: Key cost-effectiveness findings
Annual Net Price (US$) ICER Health-Benefit Price Benchmark (HBPB)
Semaglutide $13,618 $7,500-$9,800
Liraglutide $11,760 $3,800-$4,800
Phentermine/Topiramate $1,465 $3,600-$4,800
Bupropion/Naltrexone $2,094 $1,800-$2,400
ICER’s HBPB is a price range suggesting the highest US price a manufacturer should charge for a treatment, based on the amount of improvement in overall health patients receive from that treatment, when a higher price would cause disproportionately greater losses in health among other patients in the health system due to rising overall costs of health care and health insurance. In short, it is the top price range at which a health system can reward innovation and better health for patients without doing more harm than good.
The Institute for Clinical and Economic Review (ICER) is an independent non-profit research institute that produces reports analyzing the evidence on the effectiveness and value of drugs and other medical services. ICER’s reports include evidence-based calculations of prices for new drugs that accurately reflect the degree of improvement expected in long-term patient outcomes, while also highlighting price levels that might contribute to unaffordable short-term cost growth for the overall health care system.