Background: For patients with type 2 diabetes in low-income and middle-income countries (LMICs), access to newer antidiabetic drugs (eg, sodium-glucose co-transporter-2 [SGLT2] inhibitors, glucagon-like peptide-1 [GLP-1] receptor agonists, and insulin analogues) could reduce the incidence of diabetes-related complications. We aimed to estimate price targets to pursue in negotiations for inclusion in national formularies given the addition of these novel agents to WHO's Essential Medicines List.

Methods: We incorporated individual-level, nationally representative survey data (2006-18) from 23 678 people with diabetes in 67 LMICs into a microsimulation of cardiovascular events, heart failure, end-stage renal disease, vision loss, pressure sensation loss, hypoglycaemia requiring medical attention, and drug-specific side-effects. We estimated price targets for incremental costs of switching to newer treatments to achieve cost-effectiveness (ie, <3-times gross domestic product per disability-adjusted life-year averted) or to achieve net cost-savings when including costs of averted complications. We compared switching to SGLT2 inhibitors or GLP-1 receptor agonists in place of sulfonylureas, or insulin analogues in place of human insulin, and also compared a glycaemia-agnostic pathways of adding SGLT2 inhibitors or GLP-1 receptor agonists to existing therapies for people with heart disease, heart failure, or kidney disease.

Findings: To achieve cost-effectiveness, SGLT2 inhibitors would need to have a median price of $224 per person per year (a 17·4% cost reduction; IQR $138-359, population-weighted across countries; mean price $257); GLP-1 receptor agonists $208 per person per year (98·3% reduction; $129-488; $240); and glargine insulin $20 per vial (31·0% reduction; $16-42; $28). To achieve net cost-savings, price targets would need to reduce by a further $9-10 to a median cost for SGLT2 inhibitors of $214 (21·4% reduction; $148-316; $245) and for GLP-1 receptor agonists to $199 per person per year (98·4% reduction; $138-294; $228); but insulin glargine remained around $20 per vial (32·4% reduction; $15-37; $26). Using SGLT2 inhibitors or GLP-1 receptor agonists in a glycaemia-agnostic pathway produced a 92% reduction (SGLT2 inhibitors) and 72% reduction (GLP-1 receptor agonists) in incremental cost-effectiveness ratios.

Interpretation: Among novel agents, SGLT2 inhibitors hold particular promise for reducing complications of diabetes and meeting common price targets, particularly when used among people with established cardiovascular or kidney disease. These findings are consistent with the choice to include SGLT2 inhibitors in the WHO Essential Medicines List.