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[IPk] NICE Guidelines
The NICE guidelines state that CSII should be available to those for whom MDI
has failed and that:
"People for whom MDI therapy has failed are considered to be those for whom it
has been impossible to maintain a haemoglobin A1c level no greater than 7.5%.
without disabling hypoglycaemia occurring despite a high level of self care of
Which I understand to mean MDI has failed if 1)achieving an A1c of <7.5% is
only possible with the repeated occurrence of severe hypoglycaemia, or 2) if
it is impossible to maintain an A1c <7.5% full stop. (That then makes the
following section on the description of what constitutes disabling
hypoglycaemia irrelevant.) As far as I can see, there is nothing that
explicitly states that hypos must occur - only that they must occur if the A1c
is below 7.5%.
"'Disabling hypoglycaemia'. means the repeated and unpredictable occurrence of
hypoglycaemia requiring third-party assistance that results in continuing
anxiety about recurrence and is associated with significant adverse effects on
quality of life"
I wouldn't particularly have a problem with this statement if it included the
word 'or' a couple of times. i.e. 'Disabling hypoglycaemia'. means the
repeated and unpredictable occurrence of hypoglycaemia requiring third-party
assistance OR that results in continuing anxiety about recurrence OR THAT is
associated with significant adverse effects on quality of life". I don't see
why all these elements must occur together, as is currently implied, when any
single one is bad enough. And it is quite possible to suffer anxiety about
having hypos without them being very frequent - as anyone who has ever had a
hypo knows! QoL should, in my opinion take precedence anyway.
I have a bit of a problem with the "third-party assistance part" in that I
could easily decide, as others I think have already said, to start dialling
999 every time I have a hypo, or wait for assistance, particularly if it was
going to help me get funding! I guess it doesn't really mean anything - who
can decide if someone is truly incapable or not? It's impossible to define,
because no one ever knows how someone else is feeling when having a hypo. Like
I said, QoL is much more important!
With regard to this issue of pumpers switching back to MDI, section 1.7 states
"Established users of CSII therapy should have their insulin management
reviewed by their specialist team so that a decision can be made about whether
a trial of a switch to MDI incorporating insulin glargine would be
Any consultant with any sense should be able to see that glargine will not be
appropriate for any pumper using more than one basal rate, and therefore that
a trial would be inappropriate. (Should being the operative word there -
perhaps the guidelines need to be more specific!) I would like to think that
if such a trial is deemed inappropriate, that would mean by definition that
the person in question would be entitled to funding - what other option can
there be if it is decided that MDI/glargine won't work for a person then
surely that means a pump must be necessary and so funding available?
I would also like to think that previous history could be used to decide
whether the criteria for funding can be met. For many people, their pre-pump
medical records will show that the criteria are met, but there is no provision
for this within the appraisal document. So presumably such people might be
expected to switch back to MDI to prove a point for which there is already
ample evidence. I accept that it is less unreasonable to expect someone whose
pre-pump records were good to have to try to explicitly demonstrate fulfilment
of the criteria by switching back to MDI.
The only mention of how long a trial of MDI needs to be is "sufficiently
long", which isn't particularly helpful either!
I think we should all be pleased that the lack of understanding amongst health
professionals is acknowledged and is given as one reason for the lack of use
of pumps. All we need now is for that to change!!
(Currently re-establishing that MDI doesn't work for me, and desperate to get
back on my pump!)
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