Baltic Statistics

on Medicines
2016–2018

Vilnius 2019
Edited by:
Lithuanian State Medicines Control Agency
Linas Savaikis

Latvian State Agency of Medicines

Andis Seilis, Elma Gailīte

Estonian State Agency of Medicines

Ott Laius

Published by:
State Medicines Control Agency of Lithuania
139A Zirmunu str.
LT-09120 Vilnius
Lithuania
[email protected]
www.vvkt.lt

When using or quoting the data included in this issue, please indicate the source.

ISBN 978-609-462-139-0
Contents

Preface .......................................................................................................... 5
1. Facts about the Baltic countries .............................................................. 7
2. Medicinal products regulation and pharmaceutical
services in the Baltic countries ................................................................ 8
2.1 Procedures of marketing authorisation of medicinal
products in Baltic States ...................................................................... 8
2.2 Marketing authorisation licences ........................................................ 9
2.3 Non-authorised medicinal products .................................................... 9
2.4 Medicinal products mark-up . ............................................................ 10
2.5 Generics market . ............................................................................... 14
2.6 Retail and hospital pharmacies and wholesalers................................ 15
3. Drug reimbursement systems in the Baltic countries.............................. 18
3.1 Description of the reimbursement systems........................................ 18
3.2 Changes in the reimbursement systems
(during the period of 2016–2018)...................................................... 22
3.3 Reference price systems .................................................................... 23
4. Materials and methods used for the Baltic Statistics
on Medicines......................................................................................... 26
4.1 Data collection in the Baltic States .................................................... 26
4.2 ATC/DDD methodology and interpretation of
drug sales statistics............................................................................. 27
4.3 Factors affecting the interpretation of drug utilization data . ............ 28
5. Cost of drugs as a share of total health care expenditure
in the Baltic countries ........................................................................... 29
5.1 The medicinal products market ......................................................... 28
5.2 Sale of drugs according to the ATC main groups
(DDD/1000 inhabitants/day) ............................................................. 31
5.3 Sale of drugs according to the ATC main groups (turnover) .............. 32
6. Sales statistics 2016–2018 ..................................................................... 35
Expert comments on Consumption of anti-diabetic medications............... 52
Expert comments on Consumption of antibacterials for systemic
use medicines in Lithuania........................................................................ 106
Expert comments on Consumption of non-steroidal anti-inflammatory
and antirheumatic medicines in Latvia in 2016-2018................................ 127
Expert comments on Consumption of psycholeptics in Lithuania............. 147
Expert comments on Consumption of medications for treatment
of chronic obstructive disease (COPD) in Latvia in 2016-2018.................. 161
7. Top 15 of prescription-only medicines in 2018 ......................................175
8. Top 15 of over-the-counter medicines in 2018 ......................................176
9. Top 15 most used ATC 3rd level groups in 2018 ......................................177
10. Contacts ...............................................................................................178
11. References ...........................................................................................179
 Preface 5

Preface

Kristin Raudsepp Svens Henkuzens Gytis Andrulionis

Director General Director Director
State Agency of State Agency of State Medicines
Medicines Medicines Control Agency
Estonia Latvia Lithuania

This book is the 3rd edition on the consumption of medicines in three Baltic States
over a three-year period. This consumption analysis enables evaluation of habits
of medicines use, also changes and trends in this particular region. The first edition
of „Baltic Statistics on Medicines 2010-2012“ was published in 2013 by Estonia.
The second edition of „Baltic Statistics on Medicines 2013-2015“ was published in
2016 by Latvia. In 2019 Lithuania took responsibility to publish the third edition
that includes statistical data from 2016 to 2018.
It is worth to mention, that all three Baltic countries regularly assembles national
statistics on consumption of medicines. Medicines in this publication are classified
in accordance with the Anatomic Therapeutic Chemical (ATC) classification system
and consumption is expressed as defined daily doses per 1000 inhabitants per day
(DDD). It is a recommendation from World Health Organisation.
All three countries had very similar development during last three decades, af-
ter these countries become independent. Countries have built very stable health
care systems. All Baltic States have joined the European Union (EU). Lithuanian,
Latvian and Estonian medicines agencies have been operating in compliance with
EU and national legal acts, have been participating in various joint-actions and
collaborations not even at the EU level, but also worldwide.
6 Preface

Consumption data of Lithuania, Latvia, and Estonia were analysed in various aspects.
What is new in this edition – that there were included conclusions and remarks of
experts, doctors on consumption changes in concrete ATC groups during 2010 -2018
period in connection with reimbursement changes and changes in treatment guide-
lines. You can find remarks of experts on consumption changes of drugs used in
diabetes (ATC group A10), antibacterials for systemic use (J01), anti-inflammatory
and antirheumatic products (M01), psycholeptics (N05) and drugs for obstructive
airway diseases (R03).
The book also contains a short description of the pharmaceutical market, regulatory
requirements, medicinal product reimbursement systems in all three countries. In
this book we can find many similarities and also several important differences in
consumption of medicines in the countries. Data show that in all countries we can
see the increase of consumption of medicines.
All three Baltic countries were also compared by other aspects: statistics of various
licences, wholesalers, financial aspect (turnovers) and many other aspects, which
you will find while reading this book.
In order to ensure that the resulst are comparable and representative, specialists
from the medicines agencies in Lithuania, Latvia, and Estonia were in a very close
collaboration with each other.
 Facts about the Baltic countries 7

1. Facts about the Baltic countries

Estonia Latvia Lithuania

Population (01.01.2019) 1 323 824 1 920 100 2 790 322

Total health expenditure (2017, 1 003 mln 3 009 mln 2 385 mln
euro)

Total health expenditure per capita 1 006 1 543 837

(2017, euro)

GDP per capita (2017, euro) 19 450 15 263 14 900

Total health expenditure as a % of 6.5% 6.3% 5.7%

GDP (2017)

Medicinal products turnover (2018, 325 mln 365 mln 635 mln
wholesale, VAT excluded, euro)

Number of general pharmacies per 37 41 47

100 000 inhabitants (01.01.2019)

Number of physicians per 100 000 345 337 492

inhabitants (01.01.2019)

Total number of reimbursed 8.6 mln 6.8 mln 10.3 mln

prescriptions (2018)
8 Medicinal products regulation and pharmaceutical services in the Baltic countries

2. Medicinal products regulation and

pharmaceutical services in the Baltic
countries
2.1 Procedures of marketing authorisation of medicinal products in
Baltic States
The procedure of the marketing authorisation of the medicinal products in the
Baltic States is following the European Union law as well as the EU and international
guidelines. The procedures are similar in all EU member states. An application for
a marketing authorisation for a medicinal product may be filled under the mutual
recognition, decentralised, centralised or national procedure.
The National Procedure may be used when an application for the marketing
authorisation of a product is filled for the first time in the European Union. This
procedure may also be applied to the ’extensions of marketing authorisations’,
wherein an application is filled, for example, for a new strength or pharmaceutical
form of a product already approved nationally. After the evaluation of the application
the product may be granted a marketing authorisation nationally.
The Mutual Recognition Procedure (MRP) makes use of a marketing authorisation
already granted for the medicinal product by an EU Member State (or by Norway,
Iceland or Liechtenstein). The Member State whose evaluation statement
(assessment report) is used as grounds for recognising the marketing authorisation
is known as the Reference Member State (RMS), while the member state recognising
the authorisation is known as the Concerned Member State (CMS).
The Decentralised Procedure (DCP) may be applied for products that do not
have a marketing authorisation in any Member State. This procedure will allow
concomitant application for authorisations in both the RMS and the CMS. The
process is conducted by the RMS while the CMSs participate in the evaluation of
the application prior to the granting of the marketing authorisation in any of the
Member States taking part in the process.
In the event that a marketing authorisation is recognised, the product will be
granted a national marketing authorisation as soon as the national translations of
its summary of product characteristics (SmPC), package information leaflet (PIL)
and labelling confirming the product information mutually agreed in the Mutual
Recognition or Decentralised Procedure are ready and approved.
The Centralised Procedure is used when a marketing authorisation is applied
within the entire EU area for the new biotechnological and other innovative
medicinal products. Such marketing authorisation applications are filled with the
European Medicines Agency (EMA). Applications for the marketing authorisation
concerning the medicinal products for human use are evaluated by the Committee
for Medicinal Products for Human Use (CHMP) and those for veterinary use by
the Committee for Medicinal Products for Veterinary Use (CVMP). Each Member
State has nominated one regular member and one alternate member to each of
Medicinal products regulation and pharmaceutical services in the Baltic countries 9

these committees. Furthermore, five auxiliary members have been elected to each
committee based on their scientific competence.
For each application the Committees will elect a rapporteur and a co-rapporteur
from among their members to carry out the evaluation of the application with the
aid of the resources made available by the medicines agencies of the Member States.
Based on the reviews obtained, the committees will issue a scientific statement to
be submitted to the EU Commission for the actual decision-making process. The
marketing authorisation granted by the Commission is valid in every Member State
as well as in the European Economic Area (EEA) countries Iceland, Liechtenstein and
Norway.

2.2 Marketing authorisation licences

Table 1. Marketing authorisations in January 2019

Estonia Latvia Lithuania Centrally

Authorised
Products
(CAP) in EU
Number of trade names 2569 2643 2680 1085
Number of INN 837 1306 879 696
Number of products 3746 4423 4501 2731
INN - International Non-proprietary Name

2.3 Non-authorised medicinal products

As a general rule, the medicines used in all three Baltic States must have a valid
marketing authorisation. Considering the relatively small size of the pharmaceutical
market in all three countries, non-authorised medicines may be used exceptionally
if there is no suitable authorised medicine in the register or if the authorised
medicine is not available.
n ESTONIA
The use of the non-authorised medicines is permitted on the basis of applications
from doctors (for ambulatory use per patient or for in-hospital use per medical
institution for a maximum of 1 year) or from professional organisations (for a
cohort of patients). The Agency assesses whether there are grounds for using a
particular medicine and in justified cases may issue a permission for the use of a
non-authorised medicine.

n LATVIA
In exceptional cases the State Agency of Medicines issues a permit to wholesalers
for the distribution of the medicines authorised in other countries. The medicines
wholesaler bases its request for the distribution of the non-authorised medicines
on a request from a pharmacy or from a healthcare institution.
10 Medicinal products regulation and pharmaceutical services in the Baltic countries

n LITHUANIA
To ensure the availability of all the necessary medicines for the patients the use of
the non-authorised medicines is permitted under exceptional circumstances. The
non-authorised medicines may be used in the ambulatory care and at the hospital
on the basis of a special application from a doctor with signed informed consent of
the patient. The treating physician is responsible for prescribing, information and
safe use of the non-authorised medicines.

2.4 Medicinal products mark-up

All Baltic States regulate the maximum value that wholesalers and pharmacies are
allowed to add to their purchasing price (PP).

n ESTONIA
The level of maximum limits is required by law to allow the weighted average mark-
up of 7-10% in wholesale and 21-25% in retail sale of pharmaceuticals and should
be adjusted accordingly based on an annual market analysis by the Ministry of
Social Affairs. In practice the applied mark-up may be lower than this maximum,
which is frequent for the over-the-counter (OTC) pharmaceuticals. This is one of
the commercial possibilities for the wholesalers and pharmacies to attract clients.

Table 2. Wholesale mark-up scheme in Estonia

Ex-factory price in € Maximum mark-up

(% of ex-factory price)
up to 1.60 20
1.61–2.88 15
2.89–6.39 10
6.40–12.78 5
over 12.78 3
Medicinal products regulation and pharmaceutical services in the Baltic countries 11

Table 3. Pharmacy mark-up scheme in Estonia

Pharmacy purchasing price Pharmacy mark-up Fixed pharmacy mark-up

in € coefficient (% ) in €
up to 0.64 - 0.38
0.65–1.28 40 0.38
1.29–1.92 35 -
1.93–2.56 30 -
2.57–3.20 25 -
3.21–6.39 20 -
6.40–44.74 15 -
over 44.74 - 5.11

A value-added tax (VAT) of 9% is applied for all pharmaceuticals and nutritional

mixtures used for medicinal purposes. A standard value-added tax (VAT) of 20% is
applied for other goods in Estonia.

n LATVIA
The principles for the determination of the price of the medicinal products are
described in the legislation.
The maximum wholesale mark-up is determined by the following formula:
Maximum wholesaler’s price = manufacturer’s price x correction factor + correction
sum in currency + VAT. The correction factor and correction sum shall be determined
on the basis of the manufacturer’s price (see Table 4).

Table 4. Wholesale mark-up scheme in Latvia

Manufacturer’s price in € Correction factor Correction sum in €
up to 4.26 1.18 -
4.27-14.22 1.15 0.13
14.23 and more 1.10 0.84

The maximum retail mark-up is determined by the following formula:

Maximum pharmacy price = procurement price x correction factor + correction sum
in currency + VAT. The correction factor and correction sum shall be determined on
the basis of the procurement price (see Table 5).
12 Medicinal products regulation and pharmaceutical services in the Baltic countries

Table 5. Pharmacy mark-up scheme in Latvia

Procurement price € Correction factor Correction sum €
up to 1.41 1.40 -
1.42–2.84 1.35 0.07
2.85–4.26 1.30 0.21
4.27–7.10 1.25 0.43
7.11–14.22 1.20 0.78
14.23–28.45 1.15 1.49
28.46 and more 1.10 2.92

The manufacturer’s prices are declared to the State Agency of Medicines by

the manufacturers twice a year and every time the prices are changed or a new
product is placed on the market. The maximum retail prices are then calculated
and published on the Agency’s website for consumers and other interested parties.
The standard rate of value added tax (VAT) in Latvia is 21%. The reduced rate of 12%
is applied to the medicinal products. The VAT for medicines in Latvia was increased
twofold from 5% to 10% in 2010 and then to 12% in 2011.
n LITHUANIA
Wholesalers and pharmacy maximum mark-ups of pharmaceuticals is regulated by
law and a combination of fixed and regressive schemes is used. Since 2018 fixed
mark – ups for reimbursed pharmaceuticals is used. In practice for non – reimbursed
pharmaceuticals the applied mark-up may be lower than this maximum. This is one
of the commercial possibilities for the wholesalers and pharmacies to attract clients.
In Lithuania standard rate of VAT consists of 21%.The VAT for reimbursed and non
- reimbursed pharmaceuticals with prescription is 5 % and 21% for not reimbursed
over-the-counter pharmaceuticals.
Table 6. Wholesale mark-up scheme in Lithuania for non – reimbursed
pharmaceuticals

Ex-Factory Price Maximum wholesale Maximum wholesale

in € mark-up in % mark-up in €
up to 1.86 18% -
1.87 – 2.89 16% -
2.90 – 5.63 9% -
5.64 – 7.24 8% -
7.25 – 15.51 7% -
15.52 – 19.74 6% -
19.75 – 263.29 5% -
263.30 and more - 14.48
Medicinal products regulation and pharmaceutical services in the Baltic countries 13

Table 7. Wholesale mark-up scheme in Lithuania for reimbursed pharmaceuticals

Ex-Factory Price Wholesale mark-up in €
in €
up to 49,99 0,51
50 – 263,29 2,45
263.30 and more 5,79

Table 8. Pharmacy mark-up scheme in Lithuania for non – reimbursed

pharmaceuticals

Pharmacy purchase price Maximum pharmacy Maximum pharmacy

(PPP) in € mark-up in % mark-up in €
up to 2.37 30% -
2.38 – 2.89 25% -
2.90 – 4.42 23% -
4.43 – 7.24 22% -
7.25 – 7.90 19% -
7.91 – 21.72 17% -
21.73 – 144.81 15% -
144.82 and more - 17.38

Table 9. Pharmacy mark-up scheme in Lithuania for reimbursed pharmaceuticals

Pharmacy purchase price Maximum pharmacy

(PPP) in € mark-up in %
up to 47,46 1,00
47,47 – 144,80 5,10
144.81 and more 14,48
14 Medicinal products regulation and pharmaceutical services in the Baltic countries

2.5 Generics market

n ESTONIA
Although there is no explicit regulation on the (mandatory) use of generics in Estonia
(i.e. generic substitution), there are some regulative measures in place, directing
doctors and patients towards the wider use of generics where these are available.
Doctors have to prescribe pharmaceuticals by their International Non-proprietary
Name (INN) as the default option; if prescribing by the trade name, they have to
document this in the medical record of the patient providing the justification and to
mark “not to substitute” on the prescription.
If the pharmaceutical has been prescribed by the INN, the pharmacist has to offer
different preparations to the patient, including the cheapest alternative for the
patient. In discussion with the patient the most appropriate preparation is to be
chosen.
The prevailing reference price system, establishing the reference price of a
pharmaceutical as the basis for the reimbursed amount, is a strong incentive to
accept substitution, as patients would have to pay the price difference between the
reference price and the reimbursed amount on top of their statutory out-of-pocket
payments.

n LATVIA
According to the Latvian legislation a physician may prescribe the medicinal product
by the trade name and the pharmacist is allowed to substitute it with an analogue if
the doctor has not forbidden this possibility on the prescription.
However, in case of the first prescription of a reimbursed medicinal product the
INN name of the medicinal product should be indicated on the prescription and the
pharmacist has to offer different preparations to the patient, including the cheapest
alternative for the patient.

n LITHUANIA
Several measures have been introduced in order to stimulate the use of generic
medicines.
According to the Lithuanian legislation the medicines should be prescribed by
the INN. The prescribing by the trade name is only allowed for the biological
pharmaceuticals. Some medicines with narrow therapeutic window may be
prescribed by the trade name after the decision of the specialists’ commission. All
pharmacies are obliged to provide data on prices to the patients on the screen and
are obliged to have the cheapest product in the store.
Medicinal products regulation and pharmaceutical services in the Baltic countries 15

2.6 Retail and hospital pharmacies and wholesalers

Table 10. Pharmacies and wholesalers in the Baltic States as of 1st Jan 2019

Estonia Latvia Lithuania

Retail pharmacies 494 (including 144 871+ (including 1317
structural units) 80 structural
units)
Hospital pharmacies 24 (including 1 31 (no structural 44
structural units) units)
Human medicines
wholesalers (incl.
64 84 166
human and veterinary
medicines distribution)
Veterinary medicines
wholesalers (only 3 26 41
veterinary medicines)
Structural unit is a separate pharmacy acting under the same activity licence as the main pharmacy.

n ESTONIA
In January 2019 there were 64 medicines wholesalers in Estonia and 3 of them
were specialised only in veterinary medicines. 18 wholesalers had both, human and
veterinary products wholesale licences.
In 2018, 29 wholesalers sold human medicines to general or hospital pharmacies
or to other institutions. Three major wholesalers covered 77% of human medicinal
products market: Magnum Medical (28%), Tamro Estonia (27%) and Apteekide
Koostöö Hulgimüük (21%). Followed by Roche Estonia (5%), Baltfarma (5%) and
Estonian Health Board (5%). The total market share of the other wholesalers
remained under 10%.
Table 11. Wholesalers of the medicinal products in Estonia

2015 2016 2017 2018 2019

Wholesalers (human and
51 54 58 62 61
veterinary medicines)
Wholesalers (only veterinary
6 6 6 5 3
medicines)

Together 57 60 64 67 64

At the beginning of 2019 there were 494 general pharmacies (including 163
structural units), 24 hospital pharmacies (including 1 structural unit) and 4
veterinary pharmacies in Estonia.
16 Medicinal products regulation and pharmaceutical services in the Baltic countries

Table 12. Pharmacies in Estonia

2015 2016 2017 2018 2019

Retail pharmacies 476 493 490 495 494

Hospital pharmacies 24 24 24 24 24

Veterinary pharmacies 4 4 4 4 4

n LATVIA
In January 2019 there were 84 authorised human medicines wholesalers in Latvia.
10 of them had wholesale licences with special activity type that allows to distrib-
ute veterinary medicines as well.
Since January 1st 2011 the licences for the distribution of veterinary medicines are
being issued by the Food and Veterinary Service. Before that from 2008 till 2011
veterinary medicines wholesalers were licenced by the State Agency of Medicines.
In 2018, 50 wholesalers of human medicines distributed medicines to the pharma-
cies, health care institutions, medical practitioners and other recipients. Over 94%
of medicinal products market was covered by the eight major wholesalers: Recipe
Plus (33%), Tamro (18%), Magnum Medical (18%), Euroaptieka (13%), Olainfarm
(5%), Oribalt Rīga (previously Oriola Rīga) (3%), Vita-Farm (Baltfarma) (2%) and Uni-
farma (2%).

Table 13. Wholesalers of the medicinal products in Latvia

2014 2015 2016 2017 2018

Human medicines wholesalers

65 63 74 85 84
(incl. human and veterinary
(6) (6) (4) (7) (10)
medicines distribution)

Veterinary medicines
wholesalers (only veterinary 23 23 24 30 28
medicines)

Total 88 86 98 115 112

In the beginning of 2019 there were 840 retail pharmacies (including 80 structural
units) and 31 hospital pharmacies in Latvia. 55% of all retail pharmacies are located
in the 9 largest cities of Latvia - 34% in Riga, 5% in Daugavpils, 4% in Liepaja, 3%
in each Jelgava and Jurmala, 2% in each Rezekne and Ventspils and 1% in each
Jekabpils and Valmiera.
Medicinal products regulation and pharmaceutical services in the Baltic countries 17

Table 14. Pharmacies in Latvia

2014 2015 2016 2017 2018

Retail pharmacies (including 874 867 871 842 840

structural units) (95) (95) (95) (81) (80)

Hospital pharmacies 34 33 33 32 31

Veterinary pharmacies 92 97 122 138 138

n LITHUANIA
In 2018, 40 out of 125 wholesalers sold medicines to the general or hospital phar-
macies or to other institutions. The following 6 wholesalers cover 94% of the me-
dicinal product market: UAB “EVD” (32%), UAB „LIMEDIKA“ (26%), UAB „Nemuno
vaistinė“ (20%), UAB „Tamro” (8%), UAB „ARMILA“ (5%) and UAB „Medikona“ (3%).
The market share of the other wholesalers made up 6% of the total market.

Table 15. Wholesalers of the medicinal products in Lithuania

2015 2016 2017 2018 2019

Human medicines wholesalers 123 126 117 124 125

(incl. suspended licences)

Veterinary medicines
wholesalers (only veterinary 40 45 42 42 41
medicines)

Total 163 171 159 166 166

Hospital pharmacies are funded by the hospitals and do not dispense medicines
to outpatients. Not every hospital has a hospital pharmacy for inpatients; however
the majority of health care providers have ordinary community pharmacies on the
premises.

Table 16. Pharmacies in Lithuania

2015 2016 2017 2018 2019

Retail pharmacies 1380 1387 1311 1299 1317

Hospital pharmacies 47 47 44 44 44

Veterinary pharmacies 158 167 311 321 332

18 Drug reimbursement systems in the Baltic countries

3. Drug reimbursement systems in the

Baltic countries

3.1 Description of the reimbursement systems

The structure of the reimbursement systems has similarities in Baltic states:
• Medicinal products are compensated for on the basis of the diagnosis.
• Reimbursement rates are divided according to the severity of the disease.
There are Positive Lists of the products.
• For certain patient groups additional discounts are provided, for example
children and the elderly.
• Medicinal products are compensated for according to the reference prices
in case it exists.
Details of the systems are described below.
n ESTONIA
The Estonian health insurance relies on the principle of solidarity. The Estonian
Health Insurance Fund (EHIF) covers the costs of health services required by a
person in case of an illness regardless of the amount of the social tax paid for the
person concerned. The Fund uses the social tax paid for the working population
also for covering the cost of the health services provided to the persons who have
no income with regard to work activities. The employers are required by law to
pay social tax for all persons employed, the rate of this tax is 33% of the taxable
amount, 20% of which is allocated for the pension insurance and 13% for the health
insurance.
The purpose of the health insurance in Estonia is to cover the costs of the health
services provided to the insured persons to prevent and cure diseases, finance the
purchase of the medicinal products and medical devices, and provide the benefits
for the temporary incapacity for work and other benefits.
Only the medicinal products included in the EHIF’s list of medicinal products and
authorised in Estonia are compensated for. Special reimbursement mechanism
is available for the products not having a marketing authorisation in Estonia.
Medicinal products are compensated for according to the reference prices and
price agreements in case these exist; in other cases the refund is based on the
product’s retail price. At the manufacturing level there is statutory pricing (after
the negotiations) for reimbursable pharmaceuticals. The process of pricing is
incorporated into the procedure of reimbursement decision making. Medicinal
products are compensated for on the basis of the diagnosis. Medicinal products
intended for hospital use are compensated to health care providers if their cost is
included in service fee.
 Drug reimbursement systems in the Baltic countries 19

Reimbursement rates for medicinal products for out-patient use:

100% reimbursement – Pharmaceuticals for the treatment of choice of serious,
life-threatening or epidemic diseases.
Patient shall make an own contribution of 2.5 EUR and in case there is a reference
price or a price agreement, pay the sum that exceeds that price. Health Insurance
Fund will cover 100% of the sum that exceeds 2.5 EUR and is within the reference
price or price agreement.
75% reimbursement - Pharmaceuticals for the treatment of choice of chronic
diseases, threatening the quality of life.
The patient makes an own contribution of 2.5 EUR per prescription, pays 25% of
the sum remaining between 2.5 EUR and the reference price/price agreement and
everything exceeding the reference price/price agreement. The Health Insurance
Fund shall pay 75% of the amount between 2.5 EUR and the reference price/price
agreement.
50% reimbursement - all other pharmaceuticals in the Positive List.
The patient shall make an own contribution of 2.5 EUR, pay 50% of the sum between
2.5 EUR and the reference price/price agreement and everything exceeding the
reference price/price agreement. The Health Insurance Fund shall pay 50% of the
amount exceeding 2.5 EUR.
A compensation rate of 90% applies to medicinal products with a discount rate of
75% in case of the following patient groups:
• children aged 4 to 16 years;
• insured persons over 63 years of age, in addition, all persons who have
been granted pension under the State Pension Insurance Act.
For children under 4 years old, compensation rate of 100% is applied on all medicinal
products included in the EHIF list of medicinal products.

n LATVIA
The general principles of the reimbursement system of pharmaceuticals are set in
the legislation. The reimbursement of pharmaceuticals shall be provided according
to the character and severity of the disease. The following categories are applied:
100% reimbursement - for chronic, life threatening diseases or diseases causing
irreversible disability, where the use of pharmaceuticals ensures and maintains the
patient’s life functions,
75% reimbursement - for chronic diseases, for which the maintenance of the
patient’s life functions are aggravated without the use of pharmaceuticals,
50% reimbursement – for diseases where pharmaceuticals maintain or improve the
patient’s health and for vaccines.
20 Drug reimbursement systems in the Baltic countries

All drugs for the same indication are reimbursed at the same rate. For the
pharmaceuticals for which the reference price is calculated the reimbursement rate
is applied to the reference price.
The pharmaceuticals eligible for the reimbursement are listed in the Positive List
elaborated by the National Health Service (NHS) of Latvia.
The Positive List consists of three parts – List A, List B and List C according to the
following basic principles:
• List A includes pharmaceuticals, which have several preparations of
the same therapeutic effectiveness within the scope of the INN or the
pharmaco-therapeutic group and medical devices of the same type;
• List B includes pharmaceuticals and medical devices, without an authorised
alternative;
• List C includes pharmaceuticals, costs of which exceed 4270 € per patient
per year and special medical restrictions cannot be applied to reduce the
expenditure.

Reimbursable pharmaceuticals are prescribed by family doctors and certain

specialists who have an agreement with the NHS of Latvia.
Reimbursement is provided through pharmacies on the basis of a special
reimbursable prescription, patients have to pay the co-payment in the case of the
75% or 50% reimbursement levels, or € 0.71 at the 100% reimbursement level.
When more expensive, not the reference (cheapest) product is prescribed, patient
pays also the difference between the reimbursement sum and the price of the
product.
A pharmaceutical to be included in the Positive List is to:
• be authorised by the national medicines agency or by the European
Commission, or parallel imported according to the regulations;
• be classified as a “prescription only” (over-the-counter (OTC) products are
not reimbursable);
• have an approved indication relevant to the diseases listed in Appendix of
the Regulation of Cabinet of Ministers.
In Latvia, there is statutory pricing (after the negotiations) for reimbursable
pharmaceuticals and free pricing for non-reimbursable pharmaceuticals at the
manufacturer level. The process of pricing is incorporated into the procedure of the
reimbursement decision making. During the price negotiations both external and
internal price referencing mechanisms are used.
The main therapeutic criteria for a pharmaceutical to be reimbursed are:
- therapeutic value of a pharmaceutical based on the evidence level from
published clinical trials;
 Drug reimbursement systems in the Baltic countries 21

- relevance to the treatment schemes and international guidelines for the

treatment of the disease;
- place in the treatment scheme of the disease (e.g. first/second-line
treatment, specific patient group);
- relevance of the dosage, pharmaceutical form and pack size to the
treatment course.
The main economic criteria for a pharmaceutical to be reimbursed are:
- justified price, based on comparison with other available treatments and
prices in reference countries;
- cost-effectiveness data; relevance of pharmaceutical expenditure with
expected therapeutic effectiveness;
- budget impact.
Prescription-only medicines that are not included in the Positive List, are reimbursed
for children up to 24 months of age (reimbursement rate 50%) and for pregnant
women and women within 42 days of postnatal period (reimbursement rate 25%)
(List M).

n LITHUANIA
The state health care system is intended to serve the entire population, and the
Health Insurance Law requires all permanent residents to participate in the
compulsory health insurance scheme without an option to opt-out. Compulsory
health insurance covers almost all inhabitants. Compulsory health insurance
provides a standard benefits package for all beneficiaries. There is no positive list
of health services provided in the state-financed health care facilities. Emergency
care is rendered free of charge to all permanent residents irrespective of their
insurance status. Drugs prescribed by a physician are reimbursed according to the
reimbursement lists. Expensive hospital medicines are centrally purchased by the
National Health Insurance Fund.
There are two reimbursement lists, A and B.
List A covers pharmaceuticals for specific diseases in three reimbursement
categories:
100% reimbursement: Covers the most serious and expensive diseases, including
oncology, diabetes, haemophilia, schizophrenia, asthma etc.
At 90% and 50% reimbursement level are reimbursed only a few diseases.
Reimbursement from the disease-based list A accounts to approximately 95% of
the country`s total pharmaceutical reimbursement.
22 Drug reimbursement systems in the Baltic countries

List B is a list of 56 active substances or combinations reimbursed for certain social

groups, including children under 18 years old, the disabled and pensioners with two
reimbursement rates:

• 100% is granted to children and the severely disabled,

• 50% is given for other disabled patients and pensioners.

3.2 Changes in the reimbursement systems

(during the period of 2016–2018)

n ESTONIA
The decision making of active substances to be added to the positive list was moved
from the Ministry of Social Affairs to the Health Insurance Fund in the beginning
of 2018. The procedure itself remained practically unchanged. There were no
major changes in the reimbursement system during this period in Estonia. New
active substances are still added to the list of reimbursed medicines quarterly. The
prescription fee was unified for all the reimbursement categories. Before it was
1.27€ for 100% and 75% reimbursed medicines and 3.19€ for 50% reimbursed
medicines, now it is 2.5€ for all reimbursement classes.

n LATVIA
Since August of 2018 the Positive list is updated monthly.
Until 1st September 2018 the prices of the interchangeable medicines whose price
was more than 100% higher than the price of the cheapest medicine within INN had
to be reduced to 100% price difference threshold or by 20%.

n LITHUANIA
From 2015 to 2018 the expenditure on pharmaceuticals and medical devices
covered by the NHIF has increased from 213 to 248 million Euros (average annual
growth 4,1 %). The patients co-payments decreased during this period from 54 to
40 millions Euros.
Seeking to reduce the level of out of pocket payment and improve the accessibility and
affordability of medicines, the Minister of Health has approved the Pharmaceutical
Policy Guidelines in August of 2017. The main goals of Pharmaceutical Policy
Guidelines are:
1. to improve an access to innovative medicines having high therapeutic value for
people suffering from severe diseases;
 Drug reimbursement systems in the Baltic countries 23

2. to implement the measures promoting rational use of medicines;

3. to introduce the measures to lower pharmaceutical prices.

Implemented measures:
• The uniform 5% VAT rate for all prescribed medicines has been
established since 1st January 2018 (previously 5% VAT tariff was applicable
for reimbursed pharmaceuticals and 21% VAT tariff for non-reimbursable
medicines). The reduced VAT rate resulted in decreased patient’s
expenditure on medicines. During the 1st quarter of 2018 patients
expenditure for the prescribed non-reimbursable medicines decline by
3.2 million EUR.
• The pricing methodology of subsidized medicines has been changed as
well in 2018. Tightened conditions for the inclusion of medicines into the
positive list played the significant role on the decline of the co-payments
since encouraged manufacturers and suppliers to offer cheaper medicines.
• More medicines started to be compensated by 90 or 100 percent. The
reimbursement level of medicines previously compensated by 80 %, was
increased to 100 % (except pharmaceuticals for cardiovascular diseases)
and the level of medicines for cardiovascular diseases by 90% in 2018.
Regulation of patient co-payment by setting the maximum possible co-
payment for package.
• The amendments of the pricelists are performed 4 times per year (instead
of former one);
• During 2018 the inter-institutional working group analysed the legal
framework and provided proposals concerning measures for reduction of
the OOP on medicines, odonatological services for low income people. The
amendments of the Law on Health Insurance concerning the exemption of
low incomes population from paying co-payments for subsidised medicines
and medical aids is presented to the Lithuanian Parliament.

3.3 Reference price systems

n ESTONIA
The reference price is based on the internal price referencing, where the
pharmaceuticals are grouped on the basis of active ingredients (Anatomic
Therapeutic Chemical classification ATC-5 level), route of administration and
pharmaceutical form. Parallel traded pharmaceuticals have been incorporated into
the reference price system as well.
The procedures for setting manufacturer prices differ depending on whether the
pharmaceutical in questions is an innovative or a generic product.
24 Drug reimbursement systems in the Baltic countries

There are specific criteria for reimbursement of the parallelly traded pharmaceuticals:
the price for these has to be 10% lower than the price of the primary authorised
product on the market.
Statutory pricing – in combination with price negotiations – is applied to the
innovative and in-patent reimbursable pharmaceuticals in Estonia. The statutory
price levels are set according to the prices of the product in the reference countries
(Latvia, Lithuania, Hungary, Portugal, France and the country of origin). If applicable,
and similarity is proven, the prices of pharmaceuticals of similar effect are also
compared.
The Estonian Health Insurance Fund is the main authority involved in the pricing
decisions, receiving advice from the Pharmaceutical Committee.
If the price of the pharmaceutical is according to the opinion of the Pharmaceutical
Committee set too high, price negotiations with the manufacturer are started.
Negotiations are possible for the same pharmaceuticals and on the basis of the
same legal framework/procedure as statutory pricing.
n LATVIA
The reference price system is used in Latvia. The products are grouped into clusters:
• within the INN or
• within the pharmacotherapeutic group if there are no clinically relevant
differences in the effectiveness and side-effects for the same indication
and drugs are intended for the same patient group.

Products are clustered according to the pharmaceutical form and dosage. Then the
reference product for each cluster is identified (the cheapest pharmaceutical) and
on the basis of the price of the reference product the reimbursement price for each
pharmaceutical in the cluster is calculated.

n LITHUANIA
There have been a number of changes to the reference price system in Lithuania
in the recent years. The system is based on both external and internal reference
pricing measures. Previously, maximum reimbursement prices, or reference
prices, were set taking into account the lowest price on the Lithuanian market
and ex-manufacturers’ prices were negotiated taking into account prices in the
neighbouring markets, including Latvia and Estonia. With effect from 2002, phased
changes were introduced, to take into account the pricing of products relative to
that in other EU states. In 2004, a temporary external reference pricing mechanism
was based on a review of pricing in the then 15 EU member states (prior to the EU
accession of Lithuania and other countries included in this report). This identified
the lowest price in these states, to which 5% was added for Lithuanian pricing.
 Drug reimbursement systems in the Baltic countries 25

From 2005, six countries deemed to have similar per capita income to Lithuania:
Latvia, Estonia, Poland, Czech Republic, Slovakia and Hungary are used to detect
reference price level. Under the revised approach, the declared manufacturer
price is compared with a level which is 95% of the average of that found in the
reference countries. In cases where the product is not on the market in some of
these countries, the average is taken from the markets in which it is present. In
cases where the product is not on the market in any of the reference countries, the
price of the product in the country of manufacture is used. From 2009 onwards,
Romania and Bulgaria were added to the list of reference countries.
Since July 2018, only patent-protected and off-patent medicines supplied by only
one producer are covered by the reference price system:
• Patent-protected drugs: the maximum reimbursement price (reference
price) for each INN and strength is determined with a reference to the
average of three lowest prices in EU.

For the purposes of determining the reference price, products are grouped by
the active ingredient and strength, with separate clusters drawn up for the same
route of administration and pharmaceutical form. Separate clusters are formed for
products for paediatric use. Given the nature of the system, patented products are
at the moment protected from the impact of internal price referencing, which in
effect results in reimbursement pricing at the level of the cheapest product in the
group.
For patent non protected medicinal products which are supplied by two or more
suppliers only internal reference system is used. Such products are clustered
by the active ingredient, with separate clusters drawn up for the same route of
administration and pharmaceutical form. Different strength products are clustered in
one cluster. There is introduced highest margin of patient co-payment and products
which exceed the highest co-payment aren’t included to the reimbursement system.
26 Materials and methods used for the Baltic Statistics on Medicines

4. Materials and methods used for the Baltic

Statistics on Medicines
4.1 Data collection in the Baltic States

n ESTONIA
Estonian State Agency of Medicines (SAM) is collecting and analysing drug utilization
data in Estonia.
According to the Medicinal Product Act and Decree of the Minister of Social Affairs
all wholesalers of medicinal products have to report their sales data quarterly to
SAM. The reports include the following data for each product: package ID, ATC
code, active substance(s), trade name, pharmaceutical form, strength, package size
and the manufacturer. The sales data are presented in monetary value and by unit
of volume (number of packages).
From these reports only the sale to end-consumers (retail and hospital pharmacies,
nursing homes etc) are used for calculating the medicines consumption.
Estonian SAM has been collecting and analysing the data since 1994. Statistics on
medicines are annually published at the Agency’s website (www.ravimiamet.ee).

n LATVIA
Statistical data regarding consumption of human medicines in Latvia is collected
and processed by the State Agency of Medicines (SAM). In accordance with the
Pharmaceutical Law and Regulations of the Cabinet of Ministers all wholesalers
of medicines are submitting their sales data (including data regarding parallel
imported and parallel distributed medicines) on a monthly basis by uploading to
the Agency’s database. The reports include the following information: medicinal
product identification code in accordance with medicinal product register; trade
name; price per package; number of packages sold for the particular price and
consumer group to which the product was sold.
Only the sales data of medicines sold to the final recipients (pharmacies, healthcare
institutions, medical practitioners and other recipients) are used for calculating
medicines consumption statistics. Latvian SAM has been collecting and analysing
the data since 2001. The national report on statistics on medicines consumption is
annually published on the Agency’s website (www.zva.gov.lv).

n LITHUANIA
Lithuanian State Medicines Control Agency (SMCA) is responsible for collection and
analysis of drug utilization data in Lithuania.
According to the Pharmaceutical Law and Order of the Head of State Medicines
Control Agency all wholesalers of medicinal products have to report their sales data
monthly to SMCA. The reports include the following data: a number of wholesaler’s
licence, package ID of medicinal product, and the number of packages sold. The
 Materials and methods used for the Baltic Statistics on Medicines 27

sales data are presented in volume (number of packages).

From these reports only the sale to end-consumers are used to calculate the
medicines consumption.
The Lithuanian SMCA has been collecting and analysing the data since 2009.
Since 2010 statistics on medicines are annually published at the Agency’s website
(www.vvkt.lt.)

4.2 ATC/DDD methodology and interpretation of drug sales statistics

The Anatomical Therapeutic Chemical (ATC) classification system and the Defined
Daily Dose (DDD) as a measuring unit have become the gold standard for international
drug utilization research. The ATC/DDD system is developed and maintained by the
WHO Collaborating Centre for Drug Statistics Methodology situated in Oslo (www.
whocc.no).
The purpose of the ATC/DDD system is to serve as a tool for drug utilization research in
order to improve quality of drug use. One component of this is the presentation and
comparison of the drug consumption statistics at international and national levels.
In the Anatomical Therapeutic Chemical (ATC) classification system, the active
substances are divided into different groups according to the organ or system on
which they act and their therapeutic, pharmacological and chemical properties.
Drugs are classified in groups at five different levels. The drugs are divided into
fourteen main groups (1st level), with pharmacological/therapeutic subgroups (2nd
level). The 3rd and 4th levels are chemical/pharmacological/therapeutic subgroups
and the 5th level is the chemical substance. The 2nd, 3rd and 4th levels are often used
to identify pharmacological subgroups when that is considered more appropriate
than therapeutic or chemical subgroups.
The complete classification of metformin illustrates the structure of the code:
A Alimentary tract and metabolism (1st level, anatomical main group)
A10 Drugs used in diabetes (2nd level, therapeutic subgroup)
A10B Blood glucose lowering drugs, excl. insulins (3rd level, pharmacologi-
cal subgroup)
A10BA Biguanides (4th level, chemical subgroup)
A10BA02 metformin (5th level, chemical substance)

Thus, in the ATC system all plain metformin preparations are given the code A10BA02.
Medicinal products are classified according to the main therapeutic use of their main
active ingredient, on the basic principle of assigning only one ATC code for each
pharmaceutical formulation (i.e. similar ingredients, strength and pharmaceutical
form). A medicinal product can be given more than one ATC code if it is available in
two or more strengths or formulations with clearly different therapeutic uses.
The Defined Daily Dose (DDD) is the assumed average maintenance dose per day for
a drug used for its main indication in adults.
28 Materials and methods used for the Baltic Statistics on Medicines

A DDD will only be assigned for drugs that already have an ATC code. DDDs are not
established for topical products (e.g. dermatologicals), sera, vaccines, antineoplastic
agents, allergen extracts, general and local anaesthetics and contrast media.
It should be emphasised that the defined daily dose is a unit of measurement and
does not necessarily reflect the recommended or Prescribed Daily Dose (PDD).
Doses for individual patients and patient groups will often differ from the DDD and
will necessarily have to be based on individual characteristics (e.g. age and weight)
and pharmacokinetic considerations.
Drug consumption data presented in DDDs only give a rough estimate of
consumption and not an exact picture of actual use. The DDD provide a fixed unit of
measurement independent of price and dosage form (e.g. tablet strength) enabling
the researcher to assess trends in drug consumption and to perform comparisons
between population groups.
Drug consumption figures are usually presented as numbers of DDDs/1000
inhabitants/day. Sales data presented in DDD/1000 inhabitants/day provides a rough
estimate of the proportion of the population within a defined area treated daily with
certain drugs. For example, the figure 10 DDDs/1000 inhabitants/day indicates that
1% of the population on average gets a certain treatment daily.
The use of a drug expressed as DDD/1000 inhabitants/day is derived by calculating
the overall amount of a drug being used over a specified period of time (e.g. a year)
and dividing this by the DDD multiplied by the population and the number of days
in the period. Amount used in 1 year*1000
DDD/1000 inhabitants/day =
DDD* population* 365(days)
Collecting and publishing drug utilization statistics are critical elements in the process
of improving the prescription and dispensing of medicines. For drug utilization
statistics to have the best possible impact on drug use, the statistics need to be used
in a focused and active manner.
All figures presented in this publication are based on the ATC/DDD version valid from
January 2016.
More detailed information can be found at www.whocc.no.

4.3 Factors affecting the interpretation of drug utilization data

Classification of the medicinal products in the Baltic States
The classification of medicinal products may vary between countries. Consequently,
data on drug use in different countries may not be directly comparable in all of the
drug classes. For example some products may be classified as food supplements
or natural remedies in one country and as a medicine in another country. For this
reason the ATC groups A11 (vitamins) and A12 (mineral supplements) have been
excluded from this publication.
Cost of drugs as a share of total health care expenditure in the Baltic countries 29

5. Cost of drugs as a share of total health

care expenditure in the Baltic countries
5.1 The medicinal products market

n ESTONIA
As shown below, the Estonian human medicines market showed a steady increase
from 2014 to 2018 reaching 325 mln euros (excl. VAT).

n LATVIA
Medicines sales over the last 5 years has increased in Latvia by 30% reaching 366
million euros (excl. VAT) in 2018.
30 Cost of drugs as a share of total health care expenditure in the Baltic countries

n LITHUANIA
In 2016 the human medicinal products market reached 595 mln euros (excl. VAT)
and had +18.5% increase. In 2018 market increased by 6.7% comparing to 2016,
reaching 635 mln euros (excl VAT).
Cost of drugs as a share of total health care expenditure in the Baltic countries 31

5.2 Sale of drugs according to the ATC main groups

(DDD/1000 inhabitants/day)
When analyzing consumption of medicines using ATC/DDD methodology it is
evident that the volumes of DIDs consumed by each Baltic country are quite similar
and thereby readily comparable. The most widely used in all three Baltic countries
is the group of cardiovascular drugs consumption of which exceeds more then
threefold the consumption of second most widely used ATC goups in each country.
The second most widely used group of medicines was an alimentary tract and
metabolism drugs in Latvia and Estonia and the nervous system drugs in Lithuania.

Estonia had the biggest consumption of medicines in 2018, which was 1148.72 DDD,
Lithuania consumpted 1106.11 DDD and Latvia – 953.92 DDD. Total consumption in
Estonia increased by 8%, in Lithuania by 8 % and in Latvia by 4%, when comparing
to 2015. Consumption of alimentary tract and metabolism drugs increased the
most in Lithuania (increase of 30.63 DDD) and in Estonia (16.99 DDD). However in
Latvia the most increase was in cardiovascular drugs – 31.76 DDD). What is more
only in Latvia we can see decrease of consumption in respiratory system drugs (-
7.79 DDD), genito urinary system and sex hormones (-5.2 DDD), antiinfectives for
systematic use (-1.12 DDD).
32 Cost of drugs as a share of total health care expenditure in the Baltic countries

When comparing consumption by different ATC groups, we can see that Estonia is
leading by consumption in all ATC groups, except for Cardiovascular drugs, Nervous
system drugs, Hormones and insulins and antiinfectives for systematic use where
Lithuania is leading.

5.3 Sale of drugs according to the ATC main groups (turnover)

n ESTONIA
In 2018, 4292 different medicinal preparation packages and 1347 active
substances were marketed in Estonia. Based on ATC classification antineoplastic
and immunomodulating agents had the greatest market share (20%), followed
by antiinfectives for systemic use (14%) and alimentary tract and metabolism
medicines (12%).
Cost of drugs as a share of total health care expenditure in the Baltic countries 33

n LATVIA
3569 different medicines containing 1373 different active substances and
combinations of authorised medicines were distributed in Latvia in 2018. When
comparing turnover of the main ATC groups of medicines during 2016 to 2018 the
antiinfectives for systemic use made up the largest part i.e. 16% of the market in
Latvia. Previously the largest share of the market was accounted for medicines
intended for treatment of cardiovascular system diseases which now holds the
third largest market share. The change in top positions is related to the entry of
new expensive medicines into the market.
In 2017 the second and the third most sold groups of medicines switched
places. Since then the second most sold group is the group of antineoplastic and
immunomodulating agents with the market share of 15.5% and the third largest
group is made of medicines intended for treatment of cardiovascular system
diseases with almost 14% of total market share in 2018. The fourth and the fifth
most sold groups of medicines since 2016 are medicines for treatment of alimentary
tract and metabolism diseases (12.5%) and medicines for treatment of nervous
system diseases (9%). The rest of the ATC groups covered about one third (33%) of
medicinal products market in 2018.
34 Cost of drugs as a share of total health care expenditure in the Baltic countries

n LITHUANIA
Lithuanian expenditure data is based on the NHIF database and depicts expenditure
for medicines reimbursement and not wholesale turnover as the Estonian and
Latvian data. OTC medicines and non-reimbursed medicines are not included on
the figure.
 Sales statistics 2016–2018 35

6. Sales statistics 2016–2018

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Consumption of anti-diabetic medications

Prof. Vallo Volke, Estonian expert
Professor of Endocrine Physiology, University of Tartu
Teaching Physician, University Hospital of Tartu University, Internal Medicine Clinic
The statistics on the use of anti-diabetic medications in the Baltic countries tell us an
exciting story about the treatment and trends of the disease in three neighbouring
countries. I would assume that the prevalence and morbidity of type 2 diabetes
are very similar in our countries. Although IDF (International Diabetes Federation)
estimates the prevalence of diabetes in the adult population of different Baltic
countries to be at 5–7%, the realistic number is around 7%. As our physicians’
understanding of modern treatment for diabetes is also almost the same, a rather
similar level of overall use of medications can be expected and predicted.
When we look at the big picture, we can see that the use of medications in absolute
numbers, as well as changes in time are almost identical in Estonia, Latvia, and
Lithuania.

Use of insulins
Of the anti-diabetic medications, only insulins can be used to treat both type 1 and
type 2 diabetes. As type 1 diabetes is a much less common disease, therefore,
insulins are used mostly by patients with type 2 diabetes. When observing the use
of insulins, it should be first noted that the total use of insulins has not increased or
even decreased over the last five years. At the same time, the number of patients
is on the rise due to the increased incidence of disease and greater life expectancy.
Thus, the opposite trend of the use of insulins suggests that the introduction of the
newer medications for type 2 diabetes delays the addition of insulins to the regimen
and may also reduce insulin doses and/or injections in combined regimens.
In Latvia, the total use of insulins is 10–20% lower than in Estonia and Lithuania,
which, in my opinion, refers to some obstacle in terms of starting and/or carrying
out insulin treatment.
The use of mixed insulin is very different: In Estonia, the use of medium and short
term combined insulins is extremely modest, however, it is rather frequent in Latvia
and, in Lithuania, their use frequency is almost five times higher than in Estonia.

Use of other anti-diabetic medications

Traditional anti-diabetic medications metformin and sulphonylureas are the most
popular medications in all three countries. The use of metformin is constantly rising,
which corresponds well to the current treatment standard, where all patients who
do not have any contraindications should also use metformin in their regimen.
Sulphonylureas are the second most popular group of medicines, and their use has
been somewhat declining (Estonia), stable (Latvia) or slightly rising (Lithuania). As
these medications are effective, inexpensive, and also demonstrated cardiovascular
 Sales statistics 2016–2018 51

safety in the last study (glimepiride v linagliptin, CAROLINA, ADA 2019), their
widespread use is very reasonable.
With regard to the new medication groups (SGLT-2 inhibitors, GLP-1 agonists),
the Estonian Health Insurance Fund has been the fastest to make compensation
decisions and, therefore, these medications have become available in Estonia a
little earlier. Thus, the use of these medications is also slightly higher in Estonia,
followed by Latvia and Lithuania.
These are precisely the medications for which the fastest growth potential can be
predicted in the coming years. This is thanks to positive results in cardiovascular
safety studies, where both groups have surprisingly led to decrease in the
incidence of cardiovascular diseases. Therefore, their use by diabetic patients
with a cardiovascular disease and also by those who are at high risk of having a
cardiovascular disease is fully justified.
In summary, it can be said that there are only minor differences in the use of anti-
diabetic medications in the Baltic countries, and these are mainly due to different
medication compensation systems.
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Consumption of antibacterials for systemic use medicines in Lithuania

Eglė Karinauskė, Lithuanian expert,
Physician, clinical pharmacologist, Lithuanian University of Health Sciences Hospital Kaunas
Clinics
Assistant lecturer, Lithuanian University of Health Sciences
The consumption trends of antibiotics in Lithuania did not change that much during
the period of 2010-2018. In 2010, all antibacterials used systemically had 18.57
DDD/1000 people and in 2018 – 20.192 DDD/1000 people. The data also remained
the same since 2015.
There are not lots of guidelines, which can be used to treat infectious diseases in
Lithuania. The infectious diseases which are treated according to the guidelines in
Lithuania are community-acquired pneumonia for children and adults, gonococcal
infection, syphilis, pyelonephritis for children and adults, and the complications of
cystic fibrosis. Most of these guidelines are used for a longer time than 5 years, so
the consumption trends might not have an association with the use of guidelines
on infectious diseases.
The penicillins with extended spectrum remains to be mostly consumed group
of antibiotics since 2010 to 2018 (7.71 -> 8.03 DDD/1000 people). The most used
antibiotic from the earlier mentioned group in our country is amoxicillin (6.63 -> 7.76
DDD/1000 people) is prescribed and used to treat complications of viral infections
and quite often prescribed too soon because there is a problem that patients have
difficulty to believe that viral infections are only treated symptomatically and there
is no need of antibiotics.
Since 2015 the consumption of cephalosporins continues to expand (1.91 ->2.12
DDD/1000 people), the most consumed antibiotic from this group remains
cefuroxime, which had 0.62 DDD/1000 people in 2010, 1.2 DDD/1000 people in
2015 and 1.43 DDD/1000 people in 2018. It might be because second-generation
cephalosporins are one of the first choices when treating infections. Cefuroxime
is reimbursed to treat complications of cystic fibrosis, community-acquired
pneumonia, bronchiectasis, this reimbursement manner did not change in the last
3 years, so the consumption trend cannot be explained confidently.
The use of macrolides are also expanding, while the 1.91 DDD/1000 people was
used in 2010, the 2.23 DDD/1000 people was used in 2018. The most consumed
antibiotic from this group was clarithromycin with 1.43 DDD/1000 people in 2010
and 1.712 DDD/1000 people in 2018. Clarithromycin is reimbursed for cystic fibrosis,
community-acquired pneumonia, bronchiectasis, this reimbursement manner did
not change in the last 3 years, so the consumption trend cannot be explained.
Having in mind that azithromycin is also reimbursed for the same indications and it
is not as widely used as clarithromycin.
The consumption of aminoglycosides continues to decrease (0.3 -> 0,127 DDD/1000
people in 2010 and in 2018, respectively).
106 Sales statistics 2016–2018

Only tobramycin and gentamycin are in the reimbursement list but according to
most guidelines they are mainly used in children infections, such as pyelonephritis or
pneumonia. These antibiotics may be used in hospitals, so the real consumption of
aminoglycosides might not be seen. The decrease of consumption of metronidazole
is also seen since 2010 (1.03 -> 0.32 DDD/1000 people).
The existing guidelines and the antibiotics in the reimbursement list are those
which are consumed the most over the years in Lithuania.
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Consumption of non-steroidal anti-inflammatory and antirheumatic

medicines in Latvia in 2016-2018
Elita Poplavska, PhD Latvian expert
Assistant professor, Faculty of Pharmacy
Senior researcher, Institute of Public Health
Riga Stradins University
The Medicinal Product Register of Latvia includes almost 240 products belonging
to the M01A group. Just over 150 of these products are currently available on the
market. Approximately 30% of the available medicinal products are OTC medicines
containing ibuprofen, naproxen, diclofenac, dexketoprofen or glucosamine.
Non steroidal anti inflammatory and antirheumatic medicines are often the first
line treatment of acute and chronic pain, as well as inflammation.
The majority of NSAIDs inhibit COX-1 and COX-2 isoforms of the enzyme
cyclooxygenase involved not only in the process of inflammation and pain, but also in
the normal functioning of various organs. This explains both the therapeutic effects
and adverse reactions of these medicines. In contrast, selective NSAIDs inhibit
only the COX-2 isoform responsible specifically for the initiation of inflammatory
processes and pain.
Cardiovascular, gastrointestinal and renal complications are characteristic for all of
the medicines in the NSAID group. It has been pointed out that the widespread
use of NSAIDs may be considered as a significant public health issue due to the
adverse reactions of these medicines. It is known that depending on the specific
medicinal product NSAIDs may increase the risk of gastrointestinal disorders 3-5
times and the cardiovascular risk may increase by one third. ,1,21 All of the NSAIDs
have similar effectiveness, but different safety profiles, therefore, the choice of a
specific medicinal product largely depends on individual patient risk factors.
In addition to NSAIDs, the M01A group includes also glucosamine which has
approved indication for minimisation of symptoms of osteoarthritis and other joint
disorders.
Based on the data in Latvia, the overall consumption of medicinal products in the
M01A subgroup has remained unchanged over the last three years, with only minor
changes in the consumption of specific medicines.
Ibuprofen represents approximately one third of all of the M01A medications
consumed and is one of the most highly consumed medicines in Latvia in the last
few years. Its consumption continues to grow on average by 2-3% per year.

1
J. Castellsague, N. Riera-Guardia, B. Calingaert, C. Varas-Lorenzo, A.Fourrier-Reglat, F. Nicotra, et al. (2012). Individual
NSAIDs and upper gastrointestinal complications: a systematic review and meta-analysis of observational studies. Drug
Saf, 35, pp. 1127-1146
2
N. Bhala, J. Emberson, A. Merhi, S. Abramson, N. Arber, J.A. Baron, et al. (2013). Vascular and upper gastrointestinal
effects of non-steroidal anti-inflammatory drugs: meta-analyses of individual participant data from randomised trials.
Lancet, 382, pp. 769-779
126 Sales statistics 2016–2018

Its popularity may be explained by public awareness of these medicines and the wide
range of OTC products available. Ibuprofen is used to treat both short-term pain,
for example, headache, toothache, menstrual pain, muscle pain or postoperative
pain, and chronic pain, for example, pain related to rheumatoid arthritis and
osteoarthritis. The UK NICE guidelines recommend low-dose ibuprofen (up to 1200
mg per day) and naproxen (up to 1000 mg per day) as the first choice of NSAIDs.32
The data in Latvia indicates that naproxen is used rarely – 1.68 DDD/1000 inhabitants
per day (in comparison, ibuprofen consumption is 23.67 DDD/1000 inhabitants per
day), and its consumption shows a decreasing trend. Both of these medications
have similar effectiveness, but naproxen’s advantage is that it has a longer duration
of action and the lowest risk of cardiovascular adverse reactions among NSAIDs
therefore it might be a more appropriate choice for certain populations.
Similarly, medicines containing ketoprofen or a combination of naproxen and
esomeprazol had a low consumption in 2018 - 0.25 and 0.15 DDD/1000 inhabitants
per day, respectively. Over the last three years there has been a decreasing trend
in their consumption which may be explained by the availability and cost of these
medicines. In contrast, the consumption of dexketoprofen has increased by 30%
over the last three years. This may be due to the fact that in 2016 the first non
prescription dexketoprofen-containing medicines received marketing authorisation.
These medicines are characterised by rapid absorption and onset of action, and it is
hypothesized that dexketoprofen may have a lower risk of gastrointestinal adverse
reactions4.
Diclofenac is the second most popular product in the M01A subgroup in Latvia – in
2018 its consumption was 18.09 DDD/1000 inhabitants per day with some tendency
to decrease every year. Since 2013 when the European Medicines Agency added a
warning for diclofenac regarding increased risk of cardiovascular adverse events5 its
consumption in Latvia has decreased by roughly 13%.
Consumption of other products in this group, namely indometacin, ketorolac and
aceclofenac, practically has not changed over the last three years and remains
relatively low in 2018 at 0.16, 1.15 and 2.16 DDD/1000 inhabitants per day,
respectively. The lower popularity of these prescription medicines may be related
to their access and adverse reaction profile.
During this three-year period two COX-2 inhibitors or selective NSAIDs have been
consumed in Latvia – celecoxib and etoricoxib. These prescription medicines are
indicated for the symptomatic treatment of inflammation and pain caused by
arthritis and ankylosing spondylitis. The use of etoricoxib has increased from 2.19
in 2016 to 3.66 DDD/1000 inhabitants per day in 2018. Its consumption has tripled

3
https://www.nice.org.uk/advice/ktt13/chapter/evidence-context; Apskatīts: 30.05.2019
4
H. Gaskell, S. Derry, P.J. Wiffen, R. Moore (2017). Single dose oral ketoprofen or dexketoprofen for acute
postoperative pain in adults. Cochrane Database of Systematic Reviews, Issue 5. Art. No.: CD007355. DOI:
10.1002/14651858.CD007355.pub3
5
https://www.ema.europa.eu/en/documents/referral/diclofenac-article-31-referral-new-safety-advice-
diclofenac_lv.pdf; Apskatīts 30.05.2019
 Sales statistics 2016–2018 127

since 2013, and it may be related to the fact that several generic medicines entered
the market in 2016, making the medicines available at a lower cost. In 2018, this
was the third most popular M01A subgroup product. Advantage of COX-2 inhibitors
is their lower gastrointestinal adverse reactions63, but their overall consumption is
several times lower compared to other NSAIDs groups. However, their increased
risk for thrombosis makes them unfavourable choice for certain patient groups.
There is a steady decreasing trend in the consumption of glucosamine, nimesulide
and nabumetone and it remains relatively low at 1.7, 1.6 and 0.0041 DDD/1000
inhabitants per day, respectively. The actual consumption of glucosamine might be
higher because it is also available in nutritional supplements which consumption is
not tracked.
We cannot draw conclusions regarding patient demographics or doses to assess
safe and effective use of NSAIDs in Latvia, but such a high consumption of ibuprofen
and diclofenac compared to other choices may suggest that potentially there is
a room for improvement. Increasing consumption of OTC products may suggest
that there might be access barriers to health services. Studies conducted elsewhere
indicate number of problems associated with use of these medicines. For example,
coxibs, diclofenac and nimesulide are used much more widely by elderly people
than naproxen, which might be a safer option7 or patients tend to exceed the
recommended length of therapy8 thus exposing themselves to avoidable adverse
reactions. Taking into account the trends in consumption of these medicines, the
situation in Latvia could be similar and it might be useful to monitor use of these
medicines in more detail.

6
https://www.ema.europa.eu/en/news/european-medicines-agency-concludes-action-cox-2-inhibitors;
Apskatīts 30.05.2019.
7
Roberto, G., Bartolini, C., Rea, F., Onder, G., Vitale, C., Trifirò, G., … Italian Group for Appropriate Drug
prescription in the Elderly (I-GrADE) (2018). NSAIDs utilization for musculoskeletal indications in elderly
patients with cerebro/cardiovascular disease. European Journal of Clinical Pharmacology, 74(5), 637–643.
doi:10.1007/s00228-018-2411-y
8
K.A.J. Al Khaja, S. Veeramuthu, H.A. Isa, R.P. Sequeira (2017). Prescription audit of NSAIDs and
gastroprotective strategy in elderly in primary care. Int J Risk Saf Med. 29(1-2):57-68. doi: 10.3233/JRS-
170742.
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Consumption of psycholeptics in Lithuania

Skaistė Kasciuškevičiūtė, Lithuanian expert
Physician, clinical pharmacologist, Lithuanian University of Health Sciences Hospital Kaunas
Clinics
Assistant lecturer, Lithuanian University of Health Sciences
Psycholeptics comprise three large pharmacotherapeutic groups: antipsychotics,
anxiolytics and hypnotics/ sedatives. Total consumption of psycholeptics slightly
decreased during the period of 2010-2018 (60.27->58.98 DDDs/1000 inh./d.).
Trends in consumption of each pharmacotherapeutic group of psycholeptics and
possible causes of changes with regard to available guidelines and reimbursement
status are discussed separately below.

Antipsychotics (N05A)
18 antipsychotics are authorised in Lithuania and 13 of them (fluphenazine,
haloperidol, melperone, ziprasidone, flupentixol, clozapine, olanzapine, quetiapine,
tiapride, amisulpride, risperidone, aripiprazole, paliperidone) are fully reimbursed
for various psychiatric disorders. Reimbursed antipsychotics can only be prescribed
and subsequently continued by psychiatrist with an exception for tiapride which
can be continued by general practitioner. The majority of antipsychotics mentioned
above are reimbursed within licenced indications and only clozapine is restricted
for patients with resistant schizophrenia.
Over the 8 year period (2010-2018), the consumption of antipsychotics increased by
58% from 9.41 to 14.83 DDDs/1000 inhabitants daily. This change was mainly driven
by a constant increase in consumption of top 3 most commonly used antipsychotics
– quetiapine (1.46->3.30 DDDs/1000 inh. /d.), olanzapine (1.71-> 3.13 DDDs/1000
inh./d.) and haloperidol (1.81->2.30 DDDs /1000 inh./d.). During that period two
new drugs – aripiprazole and paliperidone – were included in the reimbursement
list and had some impact on increasing overall trend of antipsychotic consumption.
The use of other antipsychotics did not change significantly in 2010-2018. Not
reimbursed antipsychotics (levomepromazine, chlorprotixene, zuclopenthixol,
sulpiride, cariprazine) accounted for only 5% of the total consumption.
The treatment of schizophrenia spectrum disorders is guided by the guidelines
which were approved in 2012 by the Ministry of Health. However, these guidelines
describe treatment with reimbursed antipsychotics only, while national or nationally
approved international guidelines which would provide recommendations for the
treatment of schizophrenia spectrum disorders with any available antipsychotics
are lacking. According to the existing guidelines, the treatment can be initiated with
any of antipsychotic except clozapine or long acting injectable products. Haloperidol
is recommended to be used as the first line medication for children younger than 15
years old, and risperidone is preferred for 15 years and older children. Since there
are no preferred first line agent for total patient population and given there were
 Sales statistics 2016–2018 147

no updated versions, guidelines are considered to have minor to no impact on the

overall consumption trends.
There were no significant changes in reimbursement list regarding the antipsychotics;
no new or updated guidelines were developed in 2010-2018, therefore it can be
reasonably assumed that increased consumption is associated with other factors,
for example better diagnostics, lower stigmatization of patients with psychiatric
disorders, which might result in increased willingness for the treatment.

Anxiolytics (N05B)
Nine anxiolytics are available in Lithuania (diazepam, lorazepam, chlordiazepoxide,
medazepam, oxazepam, potassium clorazepate, bromazepam, clobazam,
alprazolam, buspirone), two of them – diazepam and lorazepam – are included
in reimbursement list. Diazepam and lorazepam are reimbursed within its
licenced indications but only for children, disabled or elderly patients, or those
with malignancies. In addition to that, diazepam is reimbursed for any patient
diagnosed with epilepsy or demyelinating diseases of the central nervous system.
The most consumed anxiolytics were lorazepam (13.70 DDDs/ 1000 inh. /d. in
2018), alprazolam (8.13 DDDs/ 1000 inh. /d. in 2018) and bromazepam (5.99 DDDs/
1000 inh. /d. in 2018) over the all analysed period. Thus, it can be concluded that
reimbursement has some impact on the choice which anxiolytic to prescribe.
Anxiolytics were the most consumed psycholeptics varying from 41.43 DDDs/ 1000
inh./d. in 2010 to 33.74 DDDs/ 1000 inh./d. in 2018. So, the total consumption
decreased by 19% with the most prominent drop observed in 2017 and 2018.
In 2017, Regional Health Insurance Fund conducted assessment of patterns of
anxiolytics prescriptions which aimed to assess compliance with the requirements
or relevant summary of product characteristics. This analysis showed that general
practitioners did not comply with the requirement to prescribe anxiolytics for
the shortest possible duration (not exceeding 4 weeks). After the publication of
results, Ministry of Health initiated discussions with the public and physicians to
inform about potential benzodiazepine harm with long-term use. Since there are
no restrictions to prescribe benzodiazepines in the reimbursement list or relevant
guidelines, information spreading is considered to have the major effect on
decreasing trends in anxiolytics use.

Hypnotics and sedatives (N05C)

Eight psycholeptics classified as hypnotics and sedatives are authorised in Lithuania
– nitrazepam, estazolam, triazolam, midazolam, zopiclone, zolpidem, melatonin
and dexmedetomidine. Only nitrazepam is reimbursed for the treatment of epilepsy
within its licenced indication. Also nitrazepam is included in the guidelines of the
treatment of epilepsy, where it is recommended as a second line treatment for the
West syndrome.
148 Sales statistics 2016–2018

On the whole, hypnotics and sedatives remained the least consumed psycholeptics
compared to the anxiolytics and antipsychotics during the 2010-2018 period,
however, its consumption has steadily increased by 51% from 6.90 DDDs/1000 inh.
/d. to 10.41 DDDs /1000 inh./ d in 2018. The most consumed hypnotics and sedatives
were zolpidem (5.22 DDDs /1000 inh./ d.) and triazolam (1.65 DDDs /1000 inh./
d.) until 2017, when zoplicone (2.11 DDDs /1000 inh./ d.) became more popular
than triazolam. Since nitrazepam is reimbursed only for very narrow indication, its
consumption is expectedly low representing 0.44 DDDs /1000 inh./ d. in 2018.
There are no therapeutic guidelines for the use of hypnotics and sedatives, only
nitrazepam is included in the reimbursement list, therefore the choice of particular
drugs is considered to be influenced by other factors.
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Consumption of medications for treatment of chronic obstructive

disease (COPD) in Latvia in 2016-2018
Dr. Ineta Grisle
Pneumonologist-allergologist
Head of Tuberculosis and Lung Disease Department, RAKUS, Centre of Tuberculosis and Lung
Disease
Board member of the Association of Physicians of Tuberculosis and Lung Disease
Consumption of medications for treatment of chronic obstructive pulmonary disease
(COPD) in Latvia shows a positive trend from 2016 and 2018. As recommended in
international guidelines, the number of patients with asthma or chronic obstructive
pumonary disease are being treated with a combination of medicines. In case
of asthma patients, the combination of an inhaled glucocorticosteroid and long-
acting β2 agonist is more effective than monotherapy and improves patient
compliance. In Latvia, there is increasing consumption of the combinations of
formoterol+budesonide and formoterol+beclometasone, which are recommended
in guidelines to be used as maintenance therapy and per necessity. The combination
of salmeterol+fluticasone is still the leader on the market in Latvia, which may be
explained by its historically earlier appearance on the market. The small decrease
in consumption of salmeterol+fluticasone in the previous year may be related
to the increasing prescription of the newer combination product containing
vilanterol+fluticasone. It is the only combination product that patients can use
once a day. Unfortunately, the β2 agonist salbutamol, which is used as a rescue
inhalator in case of an asthma attack, is still widely used in Latvia. This means there
is poor asthma control, and the most common reason for this is insufficient anti-
inflammatory therapy. There are no significant differences between the trends in
asthma treatment in the three Baltic states. Our neighbour countries also use a lot
of salbutamol, especially Lithuania.
Over the last couple of years, there have been significant changes in the treatment of
chronic obstructive pulmonary disease. International guidelines recommend timely
and regular bronchodilator therapy. In symptomatic patients with exacerbations,
preference should be given to combined dual therapy with a long acting β2 agonist
and a long-acting muscarinic antagonist. This is reflected also by the consumption
of medicines in Latvia. The consumption of long-acting muscarinic antagonist
monotherapy for treatment of COPD is decreasing, while the consumption of
combination therapy is increasing. This is reflected by the drop in the consumption
of tiotropium over the last couple of years. However, the increase in consumption
of medicines for treatment of COPD patients in Latvia is very slow. Due to economic
reasons, the combination of short-acting bronchodilators fenoterol+ipratropium
bromide is still widely prescribed. Similar trends in the consumption of certain
groups of medicines can be observed also in Lithuania and Estonia, but the overall
consumption of medicines is different. The consumption of medicines for treatment
of COPD in Latvia is not as high as in the neighbour countries.
162 Sales statistics 2016–2018

This can be clearly seen in the consumption of combination therapy products

which is 2-3 times lower than in Estonia. This may be explained by differences in
reimbursement policies, as patients in Latvia still have to cover 50% of the cost
of COPD medicines. From the comparison of the structure of medicinal product
consumption it can be concluded that the differences in treatment of obstructive
respiratory diseases are dictated not by variations in doctors’ opinion, but by
economic considerations.
years old, and risperidone is preferred for 15 years and older children. Since there
are no preferred first line agent for total patient population and given there were
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 Top 15 of prescription-only medicines in 2018 175

7. Top 15 of prescription-only medicines in 2018

176 Top 15 of over-the-counter medicines in 2018

8. Top 15 of over –the-counter medicines in 2018

 Top 15 of prescription-only medicines in 2018 177

9. Top 15 most used ATC 3rd level groups in 2018

178 Contacts

10. Contacts

n State Agency of Medicines

(Ravimiamet)
1 Nooruse Street
50411 Tartu
Estonia
[email protected]
www.ravimiamet.ee

n State Agency of Medicines

(Zāļu valsts aģentūra)
15 Jersikas Street
LV-1003 Riga
Latvia
[email protected]
www. zva.gov.lv

n State Medicines Control Agency

(Valstybinė vaistų kontrolės tarnyba)
139A Žirmūnų Street
09120 Vilnius
Lithuania
[email protected]
www.vvkt.lt
 References 179

11. References
1. WHO Collaborating Centre for Drug Statistics Methodology. ATC/DDD
methodology.
(http://www.whocc.no/atc_ddd_methodology/purpose_of_the_atc_ddd_system)
2. Pudersell, K., Vetka, A., Rootslane, L., Mathiesen, M., Vendla, K., Laasalu,
K.: PPRI Pharma Profile Estonia 2007. June; Pharmaceutical Pricing and
Reimbursement Information; Commissioned by the European Commission,
Directorate-General Health and Consumer Protection and Austrian Federal
Ministry of Health, Family and Youth.
(https://ppri.goeg.at/sites/ppri.goeg.at/files/inline-files/Estonia_PPRI_2007_4.
pdf)
3. Estonian Health Insurance. Health Insurance in Estonia.
(http://www.haigekassa.ee/eng/health-insurance-in-estonia)
4. Statistics Estonia. (http://www.stat.ee)
5. Estonian Statistics on Medicines.
(http://www.ravimiamet.ee/en/statistics-medicines)
6. Statistics on medicines consumption of Latvia
(http://www.zva.gov.lv/doc_upl/Zalu_paterina_statistika_2012-20130604.pdf)
7. Central Statistical Bureau of Latvia.
(http://data.csb.gov.lv/DATABASEEN/Iedz/databasetree.asp)
8. World Health Organization. Global Health Expenditure Database.
(http://apps.who.int/nha/database/PreDataExplorer.aspx?d=1)
9. The World Bank. Health expenditure per capita.
(http://data.worldbank.org/indicator/SH.XPD.PCAP/countries)
10. The Centre for Disease Prevention and Control of Latvia.
(http://www.spkc.gov.lv)
11. The National Health Service of Latvia.
(http://www.vmnvd.gov.lv)
12. Medicines consumption in Lithuania.
(http://www.vvkt.lt/Annual-Reports)
13. Statistics Lithuania (https://www.stat.gov.lt/)
14. National Health Insurance Fund (http://www.vlk.lt/sites/en)
15. Ministry of Health of the Republic of Lithuania (http://sam.lrv.lt/en/)