Migrants in Denmark with type 2 diabetes receive intensive treatment less often

Treatment for people with type 2 diabetes has advanced to a point where they often receive two, three or more drugs to regulate their blood glucose. In addition to lowering blood glucose, combination treatment also reduces the risk of developing various complications of type 2 diabetes, including kidney disease and cardiovascular disease.

However, a new study in Denmark shows that fewer migrants than native Danes with type 2 diabetes are treated with a combination of diabetes drugs.

Fewer migrants receive GLP-1 receptor agonists, and this is worrying since they provide many health benefits, including protecting the kidneys and heart and being associated with considerable weight loss.

“Treatment with a GLP-1 receptor agonist, along with SGLT2 inhibitors, is the most effective drug treatment for type 2 diabetes and its risk factors. We are therefore also concerned that many fewer migrants receive this type of medicine, and we need to find out why this is the case,” explains a researcher involved in the study, Anders Isaksen, Clinical Researcher, Steno Diabetes Center Aarhus and Aarhus University.

The research has been published in Diabetes, Obesity and Metabolism.

Data for more than 250,000 people

The researchers used various databases to examine the medicine taken by 253,364 people with type 2 diabetes in Denmark.

The researchers divided the study population into nine groups: native Danes and first-generation migrants from the Middle East, Europe, Turkey, the former Yugoslavia, Pakistan, Sri Lanka, Somalia and Vietnam.

They then examined the drugs these people received while adjusting the relative risk for various factors that could influence treatment, including sex, age, duration of diabetes, complications, blood glucose levels, income and employment.

The researchers compared the proportions receiving two drugs or three or more drugs in the groups.

“This provides insight into how intensively the groups of migrants in Denmark are treated for diabetes. Great differences might give rise to concern that some groups are not being treated as effectively as others and that this might lead to more complications and straining the resources of the health system in the future. Identifying any differences is also important to determine the reasons so that we can change the situation,” says Anders Isaksen.

Fewest migrants from Somalia receive optimal treatment

The results show very considerable differences in the adjusted relative risk that the various groups are receiving two or three or more drugs for type 2 diabetes.

34.7% of native Danes received two or more drugs. Most of the migrant groups had a higher adjusted relative risk of not receiving two or more drugs, with migrants from Somalia having a 23% lower probability of receiving two or more drugs (adjusted relative risk of 0.77).

9.1% of migrants from Somalia received three or more drugs versus 12.9% for native Danes, with the adjusted probability being 0.56 for migrants from Somalia.

Migrants from Pakistan, Sri Lanka and Vietnam also had a lower probability of receiving two or three or more drugs than native Danes although not as low as migrants from Somalia.

Migrants from the Middle East, Europe and the former Yugoslavia did not differ appreciably from native Danes in the probability of receiving two or more drugs for type 2 diabetes.

“We cannot say why the groups differ, but the reasons are probably based on the doctors, the patients and the reimbursement system for medicine,” explains Anders Isaksen.

Fewer receiving GLP-1 receptor agonists in particular

The study also shows that the most common drug native Danes received was metformin, at 62.1%, followed by DPP-4 inhibitors (13.3%), SGLT2 inhibitors (11.9%) and sulfonylureas (5.2%). 18.7% of native Danes used insulin during the study period, and 13.3% used GLP-1 receptor agonists.

The adjusted probability of migrants using metformin, DPP-4 inhibitors, SGLT2 inhibitors and sulfonylureas was the same as or higher than that for native Danes but lower for insulin and GLP-1 receptor agonists.

According to Anders Isaksen, there may be clear reasons why migrants have lower adjusted probabilities of receiving insulin and GLP-1 receptor agonists.

“They require injections, and migrant communities may think that injecting drugs is more stigmatising than taking tablets. In addition, GLP-1 receptor agonists also cost more than metformin in the first months of treatment until the public system begins to subsidise the cost. People who are not as well versed in Denmark’s subsidy system for medicine may have difficulty in determining the out-of-pocket cost, and this may be why many choose not to take it,” he says.

Anders Isaksen also thinks that language barriers could hinder doctors in prescribing more complex treatments.

“These are all guesses, but language barriers might make doctors more reluctant to prescribe some types of drugs if they are not sure that their patients fully understand how to take them,” he adds.

Education is key

Anders Isaksen thinks that the study paves the way for more investigations of the barriers to migrants receiving the same treatment as native Danes for type 2 diabetes.

This type of research should aim to eliminate the challenges, to reduce the future strain on the resources of the healthcare system that could arise because of undertreating type 2 diabetes with suboptimal regulation for many years.

In addition, migrants are more likely to develop type 2 diabetes and be diagnosed earlier in life.

“We probably need to focus on education to ensure that everyone with type 2 diabetes in Denmark is aware of why they should take various drugs and how the public subsidy system for medicine works. This task becomes even more important as more new drugs come on the market and because of the need to treat not only type 2 diabetes but also all its comorbidities,” concludes Anders Isaksen.