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Re: [IPk] NICE Guidelines


I am very wary of setting criteria to define when existing pump user should 
switch back to MDI for a trial period. How long should that trial period be 

I would argue very strongly that for existing pump users that previous 
HbA1c's and medical history should be used and that should include quality 
of life issues.

Presumably for most pump users who are currently funded by their Trust 
there was a "clinical" case for the PCT/Trust to fund them. Hopefully with 
the FAD in its current form they would continue to receive funding, as the 
clinical case had previously been made.

For those of use who are self funded, I would hope that our previous 
history would be sufficient to demonstrate that it would be extremely 
difficult to achieve an HBA1c of less than 7.5 on MDI without disabling 
hypos occurring.

The difficult area would be for those people who switched to a pump through 
personal choice but previously had HBA1c's of less than 7.5 when they were 
on MDI.

The way I am reading it at the moment is that people would be recommended 
for CSII where MDI has failed ie people cannot maintain an HBA1c of less 
than 7.5% without disabling hypos occurring. MDI would be any combination 
of short/medium/long acting insulins.

One query regarding the treatment of disabling hypos by third parties, is 
does third parties include anybody capable of treating a person with a hypo 
ie family, friends, work colleagues, passers by etc or would be restricted 
to medically qualified people?

Kind regards


> >I don't believe glargine would be aywhere near as bad as ultratard due 
> to the
> >fact that it is supposed to be predictable , but I would not expect success
> >with it unless basals are fairly constant and you do not often need to set a
> >temporary reduction
>And this is one message which we need to get to all the formal
>consultees: return to mdi / trial of glargine should _only_ be
>considered for those who's optimised pump use (and 'optimisation' should
>be 'after a year of use') entails a pretty level basal rate (varying no
>more that 10% over 24 hrs) and, even if a level basal rate is used, does
>not entail regular (more than once a month) adjustment to the basal rate
>for a temporary period (e.g. increase of basals by 20% at menstruation,
>or reduction of basals by 30% for 4 hrs after exercising).
>If NICE do not believe that use of non-level basals, or varying basals,
>is a very safe predictor of the benefit of pump use over glargine, they
>need to commission some research, and keep on pumps those who want to be
>kept on pumps, in the interim.
>Best wishes to all,
>Pat Reynolds
>email @ redacted
>    "It might look a bit messy now, but just you come back in 500 years time"
>    (T. Pratchett)
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