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[IPk] The Times article

You have to register with The Times to read this, and the system seems very 
poor (I've been waiting nearly 2 hours for my new password to arrive). So 
I've copied the text, but bear in mind this is copyright material so don't 
redistribute it.
A needle match
By Jane Feinmann
A pump that releases insulin has been dubbed the closest thing to a healthy 
pancreas, yet diabetics are divided over it

MEDICAL ADVANCES are typically greeted with much fanfare  so why has the 
news that the NHS is to provide diabetics with a new tool to control this 
difficult and potentially dangerous disorder been met instead with uneasy 

Diabetes is characterised by swings in blood sugar caused by problems in 
the production of insulin. Although the disorder is relatively rare  three 
in a hundred people in Britain are affected  diabetes care accounts for up 
to 10 per cent of the NHS budget, largely as a result of complications, 
including stroke, heart disease, blindness and kidney failure, caused by 
failure to control the condition. These complications can affect anyone 
with diabetes. However, the impact is disproportionately high for those 
with early-onset diabetes, whose daily lives are tested by having to match 
insulin injections to food and activity levels.

But thanks to a recent decision by the National Institute for Clinical 
Excellence (NICE), their lives could become more flexible and "normal". 
NICE has just announced that an insulin "pump" is to be available on the 
NHS for those with early-onset diabetes.

The pump delivers a continuous dose of fast-acting insulin, which means 
that the user no longer has to self-administer insulin by injection several 
times a day. It has been described by one advocate as "the closest we can 
get to mimicking a healthy pancreas" in terms of insulin release, and is 
already used widely in Europe and America (half of American doctors with 
diabetes use the device).

Here, however, the uptake of the pump is expected to be low. NICE has 
predicted that between 1 and 2 per cent of sufferers will use the pump. 
This is partly for financial reasons: at around #2,000 a year, the pump 
costs up to three times as much as the most expensive injectable insulin. 
But money is not the only problem, as the experiences of two sisters, both 
diabetic, demonstrate.

Kate Clapham, a graphic designer and mother of three, was first given the 
pump four years ago, when she was six weeks pregnant with her third child.

"The first two pregnancies were horrendously difficult, with my diabetes 
constantly seesawing out of control," she says. "I suffered nocturnal fits 
with the first child and had to stop driving with the second, and both 
babies started life in intensive care."

When Clapham became pregnant again her specialist suggested that she use a 
pump to help to control her fluctuating hormone and blood sugar levels. 
"The pump isn't something you put on and forget about," she says  she has 
to measure her carbohydrate intake for every meal and carry out frequent 
blood tests. "But despite the extra work, the pump has been a liberation, 
enabling me for the first time to eat only when I'm hungry and take 
exercise without having to plan it beforehand. I feel physically healthier, 
happier and more confident."

But Clapham's sister, Liz Moore, a GP and mother of two, has not been 
persuaded to follow her example. "My control of my diabetes has always been 
reasonable, and I'm now using an improved delivery system, with better 
insulin, which means that it's getting better all the time," she says. 
Moore is currently on a four-injection a day regime, and says that she can 
easily adjust the amount of insulin according to how hectic her life is, or 
what she is eating.

"I prefer injections to having a needle permanently inserted under my 
skin," Moore says. "For a start, you have to hang the pump on something, 
and that is difficult when you're swimming or going to the gym."

These differences in view echo divisions in the world of diabetes care. 
Diabetes UK, a patient support group, for instance, has welcomed the NICE 
ruling, but it is also concerned that provision will be patchy, depending 
on the view taken by local clinicians  many of whom see pump therapy as 
complicated and potentially risky in untrained hands, and think that it 
will mean extra work for staff. Specialists are also concerned about 
working with unfamiliar technology.

"We should avoid being coerced into dabbling in pump therapy by patients or 
pressure groups," Dr Graham Knight, a GP in Rotherham, South Yorkshire, 
wrote recently in the British Medical Journal.

There are other developments that may make pumps less attractive, according 
to Stephanie Amiel, a professor of diabetic medicine at King's College 
Hospital in London. While pumps have their place, insulin glargine  the 
type that Liz Moore uses  provides many of the same benefits.

"In the 20 years that other countries have started to increase their use of 
pumps, we have continued to develop better drugs and systems of delivery," 
Amiel says. "Insulin glargine provides peakless, background insulin to 
which short, sharp doses of insulin boosts can be added to cope with meals 
and activity."

It is likely that, in the short term at least, the fitting of pumps will be 
concentrated at certain centres, such as Harrogate District Hospital, where 
Clapham is one of more than a hundred people who have chosen this option.

"We are all pump evangelists here," admits Sandra Dudley, the hospital's 
diabetes specialist nurse. "The first time you see someone's life being 
changed when they get the pump, you think it's a fluke. When it happens 
every time you realise that this is something special."

Dr Peter Hammond, a Harrogate diabetes specialist, believes that specialist 
opinion will change as further evidence of the benefits of pump use emerges.

"There is no doubt that fewer blood sugar highs and lows mean fewer 
complications  and the pump makes that happen by delivering a constantly 
varying amount of insulin instead of a flat-rate dose, which the patient 
has to manipulate by eating and exercising to order," he says.

He adds that new evidence from a fivecountry study of pump use  due to be 
published later this year  is set to confirm that pumps allow better 
control of diabetes, with fewer complications and a better quality of life.

"Both Kate and I would love to forget about insulin intake for ever," says 
Moore. "Until then however, we'll probably continue to disagree about the 
best form of therapy  though, of course, we're grateful that we have both 
found ways of living virtually normal lives despite our diabetes."

How it works

THE pump, about the size of a pager, is attached to the body via tubing 
with a needle at the end that is inserted into the skin. The usual site is 
the stomach, though the hips, thighs or buttocks are also suitable. The 
pump contains a reservoir of insulin, but instead of the normal combination 
of long and fast-acting insulin, only the fast-acting is used (administered 
at two rates to provide long-term background insulin cover, as well as 
short bursts for mealtimes). The wearer has to measure carbohydrate intake 
for every meal and do frequent blood tests, then adjust this constant flow 
of insulin. The pump can be carried in a pocket or attached to a belt (and 
can be used even when swimming or showering). Less insulin is needed to 
achieve better control.

Copyright 2003 Times Newspapers Ltd.
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