Building an Evidence Matrix for SGLT2 Inhibitor Formulary Decisions

In "Building an Evidence Matrix for SGLT2 Inhibitor Formulary Decisions," Dr. Haumschild closes the series with a forward-looking framework for formulary decision-making.

Dr. Haumschild closes by pushing P&T committees to think ahead rather than react to each new trial. He warns against two extremes when evaluating a class as broad as SGLT2 inhibitors. One extreme treats every agent in the class as fully interchangeable without exception. The other extreme treats every trial difference as proof the products are fundamentally distinct. He argues the right answer sits somewhere in the middle of those positions. His recommended approach is evaluating the totality of evidence by indication, systematically and consistently. That starts with building a formal evidence matrix across every relevant clinical outcome. The matrix should cover type 2 diabetes and cardiovascular outcomes as a starting point. It should also track chronic kidney disease progression and outcomes in heart failure with reduced ejection fraction. Cardiovascular mortality, hospitalization rates, and EGFR thresholds all belong in that same matrix. So do outcomes for patients without diabetes and the current guideline recommendations for each indication. Building this matrix, he says, is how a committee does its homework properly. From there, committees can ask whether differences are clinically meaningful enough to justify a formulary preference. They can also ask whether the evidence supports a preference based on net cost alone. Dr. Haumschild is clear about what he would not support in this process. He would not let rebate economics override the clinical narrative that the evidence actually supports. Nor would he support a rebate-driven narrative that outpaces what the data shows. The clinical determination has to come first, before procurement or economics enter the conversation. Once that clinical foundation is set, cost considerations can responsibly round out the recommendation. That order, he says, protects the integrity of the formulary process while stewarding limited resources.

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