Dr. Rasa Verkauskiene, a key opinion leader in endocrinology in Lithuania, discusses the levels of diabetes in the country and how various stakeholders are working together to combat what is a serious issue, affecting the lives of more than 120,000 Lithuanians.

Could you please introduce yourself to our international audience?

I am currently heading the Department and Research Institute of Endocrinology at Lithuanian University of Health Sciences. The Department of Endocrinology in Kaunas covers both adult and pediatric populations with endocrine diseases. I am also the chair of Lithuanian Society for Pediatric Endocrinology, chair of Education and Training Committee of European Society for Pediatric Endocrinology, teaching faculty member in Postgraduate Courses of the European Association for the Study of Diabetes, and consultant for pediatric endocrinology at the Lithuanian Ministry of Health. My main research interests are fetal programming of long-term metabolic outcomes, children and adolescent obesity and metabolic syndrome, and the genetics of non-autoimmune diabetes.

Diabetes is one of Lithuania’s biggest health issues affecting the lives of more than 120,000 Lithuanians. On top of that, during the last decade, the number of people suffering from diabetes doubled in size. Can you expand on how diabetes prevalence has evolved in Lithuania in recent years?

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The prevalence of diabetes is growing globally, mostly due to three important causes: 1. Change in lifestyle/dietary habits, improved overall survival; 2. Improvement in diagnostic programs, and 3. Improved care of patients with diabetes, which leads to longer survival with a disease. The prevalence of diabetes in children and adults in Lithuania is steadily increasing as well. Despite the large emigration of the country’s population, both relative rates and absolute numbers of diabetes are increasing. Moreover, there is data showing that even with certain screening programs in place, significant numbers of patients are still undiagnosed and not treated.

What are the main reasons that support the worrying footprint of diabetes in the country?

The paradox with chronic diseases such as diabetes is that prevalence does not tell the whole story as the numbers are confounded by undiagnosed cases, as well as the fact that inadequate treatment results in premature death, which also reduce prevalence. Therefore, the disease burden is best assessed by the disability-adjusted life years (DALY) measure. We know that lifestyle and therapeutic interventions are effective only if applied early in the course of disease. Unfortunately, this is often overlooked because of the muted presentation of the disease and insufficient population screening programs. Another problem that is specific to Lithuania is that early intensive and individualized treatment is impossible due to severely outdated medication reimbursement guidelines that we as healthcare professionals have unsuccessfully worked to update over the past 4-5 years. The State regulators unfortunately have had a difficult time understanding that early targeted investment would result in significant long-term beneficial returns.

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Certainly, primary prevention – dietary, physical and behavioural intervention before the onset of the disease to prevent the development of the disease is an extremely important and severely underused tool.

When we met Mr Valatka on behalf of Novo Nordisk, he highlighted the low development of diabetes treatment in the country, with Lithuania positioned as the second worst country in the Euro Diabetes Index 2014. As an endocrinology key opinion leader, what are your conclusions on this front?

This is unfortunate and is reflective of a greater problem within the governing structure where great long-term results are all too eagerly substituted for quick but usually temporary gain. Another problem is a lack of understanding of pharmacoeconomic principles in managing chronic diseases, such as diabetes. The field is rapidly changing with new interventions opening new possibilities, and at the same time new data on already available treatments may change the landscape. All the outcome projections and calculations have to be done in light of current knowledge and it is admittedly not easy, however, we are there to help as soon as the regulators are ready to put these efforts to a good use.

What is your assessment of the treatment of diabetes in the country and more specifically the endocrinology patients’ access to the needed medicines?

It needs to be understood that the current paradigm of diabetes treatment focuses on timely treatment starts, intensification with various drugs combinations and strict goals early on. While after the latest additions in theory we have all novel medications available, the timing and conditions of when the treatment is actually available to the patient unfortunately are too little and too late. As for the off-patent medications, the drive towards generic medications may be laudable; however, removal of the more expensive options altogether may be seen as limiting the options for the patient.

What do you believe that the government, industry and healthcare professionals should do in order to revert this situation and advance towards a better level of care in this therapeutic area?

First, the government needs to understand that healthcare professionals are experts in the field and are to be trusted. Second, we need more transparency in the system. We need to be clear on what options are available, what the government is ready to pay for and provide an opportunity for the patient (or third parties) to pay for the gap between the two to get the best care available. This is not limited to pharmacological treatment. Success of interventional strategies in pilot studies in Lithuania and elsewhere has shown unequivocally that investment in diabetes early in the course of the disease leads to significant savings later on. That is, of course, if we value disability-free years as savings. We have had some help from pharmaceutical companies in carrying out certain interventions that would enable to prove this concept. Continued collaboration is very important in discussions with the government and in changing the view of the regulators that one needs to look further out into future that the four years they are likely to be in power.

From the industry perspective, how would you assess the role of pharmaceutical companies with valuable portfolio to target diabetes such as Novo Nordisk in enhancing the level of treating this burden disease in Lithuania?

Novo Nordisk is a company that has a full portfolio of diabetes medications, therefore their interest in driving the change is understandable but I am sure most companies share this outlook. We as professionals need to follow the best standards of treatment available globally; moreover, we need to develop novel combination interventional strategies consisting of medical, as well as non-pharmacological treatments; through their implementation we need to provide evidence on the effectiveness of such strategies. The support of pharmaceutical companies would be valuable in helping us to provide such evidence, as well as in discussion with the governmental institutions.

As members of the endocrinology physicians’ community, how well supported do you feel from the government and the industry to ensure high quality treatments to diabetes patients in Lithuania?

The government has been slow to adapt to the pace of the changing landscape of diabetes treatment and we need this to change for the sake of our patients. The industry has helped us by providing the access to the novel medications – albeit, of a limited sample, as well as supporting some of our scientific initiatives. I hope that the collaboration between all these parties will be more successful in close future.

Can you expand on the type of dialogues that the medical community is leading in collaboration with the government and industry to continue advancing on this front?

Constructive collaboration with the government has been lacking. There are currently multiple discussions and common workgroups open, which in itself is a positive process. However, despite of a lot of hours of professionals’ work, it does not seem to lead to any tangible outcomes: the new prescription and reimbursement strategy of antidiabetic drugs has been worked out and finalized in 2015, has not been approved until now, although it already needs to be updated in view of new medicines on the market. The workgroup for development of the Diabetes Program has been established in 2014, yet we have not developed a working strategy to this day. We are continuously working with the regulators trying to persuade them to adapt the basic long-term pharmacoeconomic variables. We need continued industry support as the third partner in this discussion, as well as development of further evidence that we could lean upon in future discussions.

As heads of endocrinology centers and from the human capital perspective, how would you assess the level of endocrinology professionals in the country?

As a head of the department of a University hospital I am happy to see the quality and expertise of our young specialists. My main concerns, however, are underappreciation of the healthcare specialists currently in the country that leads to emigration and potential burn out as many of them are constrained to work in multiple institutions. On the other hand, the fact that our specialists successfully find clinical positions abroad attests to their level as well as the quality of the training system.

What final message would you like to share with our international audience and any local stakeholders?

Lithuania is still a young country but has gone a long way, which is easy to forget while we are still going through these growing pains. Yet it must not be held as an excuse to avoid or delay change. We need more open mindedness, be more active in collaboration and make the best use of the potential that we have available in all sectors. As for healthcare professionals, we have been accepted as reliable partners in the scientific community and healthcare collaborative networks – we are pleased to work for the better future to our patients. We only hope that these benefits are available to as many of the patients as possible sooner rather than later.