NICE Prescribes Greater Role For Insulin Pumps On The NHS, Thousands More Type 1 Diabetics To Benefit From New Guidance, UK

Main Category: Diabetes
Article Date: 24 Jul 2008 - 1:00 PDT

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Thousands more children and adults with type 1 diabetes could benefit from 'life-changing' insulin pumps, following new National Institute for Health and Clinical Excellence (NICE) guidance issued on Wednesday 23rd July 2008.[i] The new guidance recommends insulin pumps for children younger than 12 years with type 1 diabetes when doctors believe conventional insulin injections are impractical or inappropriate.1

Latest estimates are that up to 16,000 children aged 16 years or under in the UK are living with type 1 diabetes2,3 and numbers are increasing, particularly in the those under five years.4 New figures released by Diabetes UK this month stated that last year there were more than 3000 hospital admissions for children with type 1 diabetes. Despite having the fourth highest incidence of type 1 diabetes in children across Europe, the UK has the lowest number of children attaining good diabetes control.5

Insulin pump therapy is now also recommended in adults or children aged 12 years or older with type 1 diabetes, if trials of conventional multiple daily injections (MDIs) have failed to control blood sugar levels (HbA1C levels have remained at 8.5% or above).1

The new guidance also takes account of the fear people with diabetes of all ages can experience from severe hypoglycaemic (dangerously low blood sugar) attacks, which can lead to coma and death. NICE now recommends the use of an insulin pump in patients who suffer repeated and often unpredictable hypoglycaemic attacks, or where the patient is so worried that the fear has a negative impact on their life.

Research has indicated that insulin pumps help patients control their diabetes more effectively, which can reduce the harmful long-term effects of poor blood sugar control such as blindness, kidney failure and heart disease, and preventing hospital admissions due to hypoglycaemia.6,7

Dr Fiona Campbell, Consultant Paediatric Diabetologist at Leeds Teaching Hospitals and a clinical expert advising NICE commented, "Using an insulin pump has made good control considerably easier to achieve. Insulin pump therapy should be considered a safe and effective alternative to multiple injections of insulin and can be started even as early as the point of diagnosis if this is clinically indicated. The publication of the new NICE Guidelines will greatly support clinicians in their decisions to use insulin pumps to help patients manage their diabetes and we should expect to see insulin pump use in paediatric routine care to increase dramatically."

Dr Campbell continued, "It is essential that the best possible control of blood glucose levels is achieved as early as possible in children who have diabetes to help prevent later complications of having diabetes. This often means that the child must have several injections of insulin each day. Achieving good control in this way, without increasing the incidence of the child experiencing too low blood glucose levels at times, is extremely challenging, especially in toddlers and pre school children."

Previous guidance issued in 2003 recommended use of insulin pumps where multiple daily injections have failed. However, it did not account for patients where the use of injections has caused significant difficulties as a treatment method in everyday life, which is particularly the case in children who struggle to self-inject.8

Despite this earlier positive guidance, many PCTs have struggled to provide funding and a report by the Insulin Pumps Working Group published in March 2007 confirmed that there was still unacceptable variation in access to pumps across the UK.9 Even today, uptake of insulin pump therapy in the UK remains very low at no more than 1% of type 1 diabetes cases, compared to many countries such as US, Israel and Germany where 15-20% of people with type 1 diabetes use an insulin pump.10 These figures demonstrate the poor uptake of this form of treatment compared to other countries of comparable economic standing and healthcare provision level.10

Impact of type 1 diabetes

Type 1 diabetes develops if the body is unable to produce any insulin. This type of diabetes usually appears before the age of 40. Type 1 diabetes is the least common of the two main types and accounts for between 5 - 15% of all people with diabetes.11 Type 1 diabetes is the most common chronic disease in children in developed countries.12

Type 1 diabetes patients need insulin daily to manage their condition. Insulin can be delivered by injection or via an insulin pump. Most people with type 1 diabetes currently manage their blood glucose by finger prick tests and regular injections of insulin. This method is also restrictive in terms of day-to-day living, limiting the times that patients can eat and also dictating the types of food they are able to include in their diet. Therefore, some people and particularly children have difficulties in managing their diabetes in this way, potentially endangering their health. Insulin pumps can offer a valuable alternative to this, helping such patients to manage their diabetes more effectively.

Poor management of type 1 diabetes can have severe consequences due to difficulties with blood glucose control. This can lead to:

• Hypoglycemia (low blood glucose), with serious complications including loss of consciousness and eventually coma or death if unmanaged
  
  
• Hyperglycemia (high blood glucose), which contributes to long-term complications, such as blindness, kidney failure, cardiovascular disease and limb amputation if untreated.
  
  
• Diabetic ketoacidosis (DKA), inadequate insulin levels resulting in high blood glucose and accumulation of organic acids and ketones in the blood. This is the leading cause of morbidity and mortality in children with type 1 diabetes.13

Insulin pump therapy

An insulin pump, also known as continuous subcutaneous insulin infusion (CSII), is a pager-size device that delivers insulin around the clock, much like a healthy pancreas. An insulin pump automatically delivers a constant rate of insulin - called a 'basal rate' - to keep glucose levels in the desired range. At the touch of a few buttons, patients can deliver extra insulin - called a 'bolus' - to prevent excessive rises in glucose levels.

References

1. NICE, TA57 Diabetes (type 1) - Insulin pump therapy - guidance, July 2008

2. 2001 Census (.xls) . (Accessed 11th June 2008)

3. Making Every Young Person with Diabetes Matter. Report of the Children and Young People with Diabetes Working Group. April 2007

4. Gardner SG, Bingley PJ, Sawtell PA, Weeks S, Gale EAM, EURODIAB and Barts Oxford Study Group (1997) Rising incidence of insulin dependent diabetes in children aged under 5 years in the Oxford region: time trend analysis. British Medical Journal (BMJ), 315: 713-17

5. Diabetes.org.uk - More than 3000 hospital admissions for children with diabetes

6. E.A. Boland, M. Grey, A. Oesterle, L. Fredrickson, W.V. Tamborlane Continuous subcutaneous insulin infusion. A new way to lower risk of severe hypoglycemia, improve metabolic control, and enhance coping in adolescents with Type 1 diabetes. Diabetes Care 22(11): 1779-84, 1999.

7. K. Dahl-Jorgensen et al. Effect of near normoglycemia for two years on progression of early diabetic retinopathy, nephropathy and neuropathy: the Oslo study. BMJ 293: 1195-1201, 1986.

8. NICE, TA57 Diabetes (type 1) - Insulin pump therapy - guidance, February 2003

9. Report of the Insulin Pumps Working Group, published March 2007. (Last accessed 11th June 2008)

10. Diabetes UK, Insulin Pump Services - Report of the Insulin Pumps Working Group, March 2007

11. Diabetes.org.uk - What is diabetes(Accessed 11th June 2008)

12. LaPorte R, Matsushima M, Chang Y. Prevalence and incidence of insulin-dependent diabetes. In Diabetes in America, second edition, ed. NDDG NIH 1995:37-46

13. Dunger DB, Sperling MA, Acerini CL, et al., European Society for Paediatric Endocrinology/Lawson Wilkins Pediatric Endocrine Society Consensus Statement on Diabetic Ketoacidosis in Children and Adolescents, Pediatrics Vol. 113 No. 2 February 2004

For further information please go to:
National Institute for Health and Clinical Excellence