Māori patients receive fewer prescriptions for common diabetes medication Metformin than non-Māori patients, and may
have worse health as a result, according to New Zealand research.
The researchers studied prescriptions from doctors, dispensing by pharmacies, and a marker of blood sugar levels over
time. The results from over 1,500 patients in the Waikato region revealed that Māori received fewer prescriptions than
non-Māori, and their blood sugar levels were worse on average.
The SMC asked experts to comment on the research.
Dr Rawiri Keenan (Te Atiawa/Taranaki), Senior Fellow, Medical Research Centre, National Institute of Demography and
Economic Analysis (NIDEA), University of Waikato, comments:
Note: Dr Keenan is co-author of this study.
“This study is really important in showing that, when given a prescription, Māori do pick it up. Previous reports have
shown that Māori receive less medication that non-Māori, but it is often explained as Māori not picking up scripts or
not wanting medication in the first place. Negative stereotypes and attitudes to Māori persist and are maintained by
deficit thinking in relation to Māori. This paper shows that gap is actually getting a prescription in the first place.
Māori were less likely to receive the five to seven prescriptions needed to maintain 100% medication cover. Importantly,
our study did show that if metformin was prescribed, Māori were just as likely as non-Māori to have the medication
dispensed.
“It is on us as a health system and providers to fix this. Many will try and explain this away as patients needing to
come in and take care and responsibility, but we too have a responsibility to ensure our practices and services are safe
and welcoming spaces. Removing barriers to medication is important if we are to tackle the growing burden of
uncontrolled diabetes; this affects Māori and Pacific people at much higher rates.
“Finally, later this year we will get new medication to control sugars and reduce complications (sodium glucose
co-transporter 2 (SGLT-2) inhibitors and glucagon-like peptide-1 receptor (GLP-1) agonists). However, despite pressure
from many places, especially Māori doctors and pharmacists, PHARMAC currently will only fund these if certain special
criteria are met, creating more barriers and most likely resulting poorer access to these medication by those most in
need.”
Conflict of interest statement: “Views are my own and not necessarily shared by any organisation I work for/am
contracted to.”
Dr Keenan is a GP and Māori Health Advisor, Public Health and Primary Care Transformation, Ministry of Health; Member of
RNZCGP Telehealth advisory group; Member of Te Ropu Whakakaupapa Uruta (unpaid); Member, Medical Council of New Zealand
Cultural Safety, Partnership and Health Equity committee (unpaid); Member, Health Quality and Safety Commission Patient
Experience of Care Governance Group; Trustee, New Zealand Institute of Rural Health (unpaid)
Professor Jim Mann, Professor of Medicine, Co-Director Edgar Diabetes and Obesity Research Centre, Director Healthier
Lives National Science Challenge, comments:
“Metformin was introduced as a medication for people with diabetes more than half a century ago. Despite the many newer
drugs which are now available for diabetes, it remains one of the most widely used tablet treatments for this condition
in New Zealand and worldwide. It is a cornerstone of treatment for the majority of people with type 2 diabetes even when
other treatments including insulin are needed.
“It is therefore of considerable concern to discover that there appears to be a reduction in metformin coverage in Māori
compared with New Zealand Europeans, given the appreciably higher rates of type 2 diabetes amongst Māori. Not only are
type 2 diabetes rates high among Māori, but there are ethnic disparities in terms of diabetes-related health outcomes.
“The authors present evidence to suggest that this is due principally to the fact that Māori are less likely to receive
as many prescriptions for the drug as do New Zealand Europeans and they reflect on possible reasons for this including
reduced access to health care. They also mention that ‘Māori may be less adherent to metformin because of other reasons
such as a higher rate of side effects.’ This statement concerns me because my own clinical experience suggests that,
while gastrointestinal side effects to metformin are indeed common, they can be greatly reduced and adherence improved
if patients are given simple advice such as gradually increasing to the full dose from a very small initial dose and
having the tablets with food.
“It is clearly important for these findings to be followed up in order to determine the reasons for reduced coverage of
this important drug amongst Māori and to ensure that they and, indeed all patients, are getting appropriate advice as to
avoid or at least greatly reduce risk of side effects.”
No conflict of interest
Jeremy Krebs, Professor, University of Otago, Wellington; Endocrinologist and Clinical Leader of Endocrinology and
Diabetes at Capital and Coast DHB; Researcher, Edgar Diabetes and Obesity Research Centre and the Healthier Lives
National Science Challenge, comments:
“It is well known that there are important disparities between ethnicities in New Zealand for rates of type 2 diabetes
and health outcomes related to this. Māori have higher rates compared with New Zealand Europeans, but lower than Pacific
people and South Asians.
“Metformin is the first line medication therapy for type 2 diabetes and should be prescribed for almost everyone unless
it has not been tolerated or is contraindicated.
“This paper explores the rates of adherence with Metformin in people with type 2 diabetes in Waikato. As a proxy of
actually being able to measure the drug in people, the authors have taken a sophisticated approach of extracting data on
dispensing rates of Metformin, but also prescriptions. This enables the differentiation of whether people are actually
picking up their prescriptions and a more nuanced analysis of where issues may lie in terms of use of Metformin.
“The main finding is that Māori are less likely to be prescribed metformin than non-Māori, but that when prescribed they
are equally likely to collect the prescriptions, and equally likely to get the benefit of that on glycaemic control.
“Having identified this, it raises the question of why they are not receiving prescriptions in the first place. That is
beyond the scope of the paper but focuses the attention on establishing this in order to improve outcomes for Māori and
improve equity.”
No conflict of interest