The disclosure of proven cardiorenal benefits with certain antidiabetic agents was supposed to herald a new era in the management of type 2 diabetes (T2D), especially for the many patients with T2D who are at high risk for cardiovascular and renal events. However, as the evidence in favour of various sodium–glucose transporter-2 inhibitor (SGLT2i) and glucagon-like peptide-1 receptor agonists (GLP-1 RA) accumulates, prescriptions of these agents continue to stagnate, even among eligible, at-risk patients. By contrast, dipeptidyl peptidase-4 inhibitors (DPP-4i) DPP-4i remain more widely used than SGLT2i and GLP-1 RA in these patients, despite a similar cost to SGLT2i and a large body of evidence showing no clear benefit on cardiorenal outcomes. We are a group of diabetologists united by a shared concern that clinical inertia is preventing these patients from receiving life-saving treatments, as well as placing them at greater risk of hospitalisation for heart failure and progression of renal disease. We propose a manifesto for change, in order to increase uptake of SGLT2i and GLP-1 RA in appropriate patients as a matter of urgency, especially those who could be readily switched from an agent without proven cardiorenal benefit. Central to our manifesto is a shift from linear treatment algorithms based on HbA1c target setting to parallel, independent considerations of atherosclerotic cardiovascular disease, heart failure and renal risks, in accordance with newly updated guidelines. Finally, we call upon all colleagues to play their part in implementing our manifesto at a local level, ensuring that patients do not pay a heavy price for continued clinical inertia in T2D.

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BackgroundCurrently there is no diabetes-specific quality of life (QOL) instrument available in Lithuanian language. We aimed to develop a Lithuanian version of a widely-used individualised instrument - the Audit of Diabetes Dependent Quality of Life questionnaire (ADDQOL-19) and assess the validity and reliability in patients with type 1 and type 2 diabetes mellitus (DM).MethodsThis study was conducted at the Primary Care and Endocrinology Outpatient Clinics in Vilnius. The ADDQOL was translated from the original English (UK) into Lithuanian using a standardized methodology of forward and back translation. After cognitive “debriefing” the validity and reliability of LT-ADDQOL questionnaire were assessed in a sample of 138 diabetes patients. Cronbach’s alpha coefficient, factor analysis, independent t tests and ANOVA were used.ResultsThere were 106 participants with type 2 and 32 with type 1 DM included in the study with a mean age of 55.5 years (± 14.5) and 56.2% women. The Cronbach’s alpha coefficient was 0.908 and most of items loading values onto one single factor were larger than 0.40 (varied from 0.41 to 0.77), indicating good internal consistency and reliability of instrument.ConclusionsWe developed the Lithuanian version of ADDQOL-19 which is a valid and reliable instrument to measure impact of diabetes on QOL. It could be further used by clinicians and researchers for comprehensive assessment of QOL in adults with diabetes.

ObjectiveTo investigate the predictive value of different biomarkers for the incidence of type 2 diabetes mellitus (T2DM) in subjects with metabolic syndrome.MethodsA prospective study of 525 non-diabetic, middle-aged Lithuanian men and women with metabolic syndrome but without overt atherosclerotic diseases during a follow-up period of two to four years. We used logistic regression to develop predictive models for incident cases and to investigate the association between various markers and the onset of T2DM.ResultsFasting plasma glucose (FPG), body mass index (BMI), and glycosylated haemoglobin can be used to predict diabetes onset with a high level of accuracy and each was shown to have a cumulative predictive value. The estimated area under the receiver-operating characteristic curve (AUC) for this combination was 0.92. The oral glucose tolerance test (OGTT) did not show cumulative predictive value. Additionally, progression to diabetes was associated with high values of aortic pulse-wave velocity (aPWV).ConclusionT2DM onset in middle-aged metabolic syndrome subjects can be predicted with remarkable accuracy using the combination of FPG, BMI, and HbA1c, and is related to elevated aPWV measurements.

Background. Patients with multimorbidity account for ever-increasing healthcare resource usage and are often summarised as big spenders. Comprehensive analysis of health care resource usage in different age groups in patients with at least two non-communicable diseases is still scarce, limiting the quality of health care management decisions, which are often backed by limited, small-scale database analysis. The health care system in Lithuania is based on mandatory social health insurance and is covered by the National Health Insurance Fund. Based on a national Health Insurance database. The study aimed to explore the distribution, change, and interrelationships of health care costs across the age groups of patients with multimorbidity, suggesting different priorities at different age groups. Method. The study identified all adults with at least one chronic disease when any health care services were used over a three-year period between 2012 and 2014. Further data analysis excluded patients with single chronic conditions and further analysed patients with multimorbidity, accounting for increasing resource usage. The costs of primary, outpatient health care services; hospitalizations; reimbursed and paid out-of-pocket medications were analysed in eight age groups starting at 18 and up to 85 years and over. Results. The study identified a total of 428,430 adults in Lithuania with at least two different chronic diseases from the 32 chronic disease list. Out of the total expenditure within the group, 51.54% of the expenses were consumed for inpatient treatment, 30.90% for reimbursed medications. Across different age groups of patients with multimorbidity in Lithuania, 60% of the total cost is attributed to the age group of 65–84 years. The share in the total spending was the highest in the 75–84 years age group amounting to 29.53% of the overall expenditure, with an increase in hospitalization and a decrease in outpatient services. A decrease in health care expenses per capita in patients with multimorbidity after 85 years of age was observed. Conclusions. The highest proportion of health care expenses in patients with multimorbidity relates to hospitalization and reimbursed medications, increasing with age, but varies through different services. The study identifies the need to personalise the care of patients with multimorbidity in the primary-outpatient setting, aiming to reduce hospitalizations with proactive disease management.

Various comorbidities and multimorbidity frequently occur in chronic obstructive pulmonary disease (COPD), leading to the overload of health care systems and increased mortality. We aimed to assess the impact of COPD on the probability and clustering of comorbidities. The cross-sectional analysis of the nationwide Lithuanian database was performed based on the entries of the codes of chronic diseases. COPD was defined on the code J44.8 entry and six-month consumption of bronchodilators. Descriptive statistics and odds ratios (ORs) for associations and agglomerative hierarchical clustering were carried out. 321,297 patients aged 40–79 years were included; 4834 of them had COPD. A significantly higher prevalence of cardiovascular diseases (CVD), lung cancer, kidney diseases, and the association of COPD with six-fold higher odds of lung cancer (OR 6.66; p < 0.0001), a two-fold of heart failure (OR 2.61; p < 0.0001), and CVD (OR 1.83; p < 0.0001) was found. Six clusters in COPD males and five in females were pointed out, in patients without COPD—five and four clusters accordingly. The most prevalent cardiovascular cluster had no significant difference according to sex or COPD presence, but a different linkage of dyslipidemia was found. The study raises the need to elaborate adjusted multimorbidity case management and screening tools enabling better outcomes.

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