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Background Info

Insulin Pump Therapy
Insulin pumps can change people’s lives. Insulin pump therapy or continuous subcutaneous insulin infusion (CSII) is one of the most significant advances in the treatment of diabetes, freeing people from the daily challenges of multiple daily injections, helping to reduce the risks of complications, raising quality of life and freeing up NHS time and resources. This is why access to pumps is such an important issue for Diabetes UK Scotland and, more importantly, for those living with or supporting others with diabetes.

The National Institute for Clinical Excellence (NICE) estimates that between 2 and 15 per cent of the Type 1 population could benefit from insulin pump therapy.  In Scotland this means that over 4,000 people with Type 1 diabetes could benefit. Currently only 2 per cent of people with Type 1 diabetes use a pump, compared to 3.9% in England and Wales, 10-20% in European nations and approximately 35% in the US . Provision across Scotland is patchy, ranging from 4.6 and 4.4 per cent in Tayside and Fife Health Boards respectively to a mere 0.4 per cent in Ayrshire and Arran and 0.9 per cent in Greater Glasgow and Clyde.

Table 1: Insulin Pump Usage by Health Board (Scottish Diabetes Survey 2010)

Health Board                   Type 1 Population 2010  Number of Pumps 2010  Percentage 2010
Ayrshire & Arran                                             2,238                                    18                       0.8%
Borders                                                              601                                    29                        4.8%
Dumfries & Galloway                                        888                                    20                        2.3%
Fife                                                                  1,911                                  113                        5.9%
Forth Valley                                                     1,568                                    40                         2.6%
Grampian                                                         3,045                                    63                         2.1%
Greater Glasgow & Clyde                               6,115                                    67                         1.1%
Highland                                                           1,706                                    18                         1.1%
Lanarkshire                                                       3,480                                   45                          1.3%
Lothian                                                              4,109                                 173                          4.2%
Orkney                                                                  116                                     3                          2.6%
Shetland                                                                119                                    2                          1.7%
Tayside                                                               1,837                                 104                         5.7%
Western Isles                                                        177                                     1                          0.6%
Scotland                                                          27,367                                  696                          2.5%

Diabetes Action Plan 2010

The Diabetes Action Plan 2010 makes it clear that insulin pumps are to be considered as a “mainstream therapy” and that NHS Boards are fully aware of their responsibility to invest in insulin pumps and the structured education required, with the expectation that; “Access to pump therapy should be boosted significantly across NHS Board areas over the lifetime of this Action Plan”.

At the end of 2009, Health Boards were asked by the Scottish Government to detail their planned investment in insulin pump services.  The Diabetes Action Plan included a commitment that by December 2010, the Scottish Diabetes Group would commission work on identifying guidance in order to deliver waiting times criteria based on the 18-week referral to treatment guarantee.  This has yet to be commissioned.

NICE Guidance
Not everyone is suitable for pump therapy and some people would not wish to be attached to a pump continuously. However, Diabetes UK Scotland believes that everyone who meets the criteria should have access to insulin pump therapy, in line with the criteria set out by NICE Guidance  TA151:
1.1 Continuous subcutaneous insulin infusion (CSII or ‘insulin pump’) therapy is recommended as a treatment option for adults and children 12 years and older with type 1 diabetes mellitus provided that:
• attempts to achieve target haemoglobin A1c (HbA1c) levels with multiple daily injections (MDIs) result in the person experiencing disabling hypoglycaemia. For the purpose of this guidance, disabling hypoglycaemia is defined as the repeated and unpredictable occurrence of hypoglycaemia that results in persistent anxiety about recurrence and is associated with a significant adverse effect on quality of life
• HbA1c levels have remained high (that is, at 8.5% or above) on MDI therapy (including, if appropriate, the use of long-acting insulin analogues) despite a high level of care.
1.2 CSII therapy is recommended as a treatment option for children younger than 12 years with type 1 diabetes mellitus provided that:
• MDI therapy is considered to be impractical or inappropriate, and
• children on insulin pumps would be expected to undergo a trial of MDI therapy between the ages of 12 and 18 years.
NHS Boards are expected to have made significant and sustained progress in increasing access to insulin pump therapy in line with the latest clinical guidance.
SIGN Guidelines
The Scottish Intercollegiate Guidelines Network (SIGN) also published a National Clinical Guideline on the management of diabetes in March 2010 (Guideline 116) supporting the use of pump therapy for those who meet NICE criteria, highlighting the benefits of CSII therapy for those for whom even small doses of insulin may result in hypoglycaemia (such as infants and young children). 

Advantages of Insulin Pump Therapy
The advantages of insulin pump therapy include:
• Improved glucose control
• Reduction in hypoglycaemic episodes
• Reduction in complications
• Multiple daily injections are replaced by one injection every 2-4 days
• More precise dosage delivers insulin more accurately, adjustments are immediate and are easier than with multiple daily injections (MDI)
• Improvement in the quality of life for those who live with constant fear of hypoglycaemic episodes
• More flexible lifestyle with freedom from restrictive eating and sleeping routines and restrictions on exercise
• More convenient and discreet than multiple daily injections

There are some disadvantages, but most pump users feel strongly that the benefits outweigh the drawbacks. Dr John A. McKnight, Consultant Physician at the Western General Hospital in Edinburgh has stated that; “there is no doubt that insulin pump therapy can make a big difference to some people with type 1 diabetes.”

Peter Hindmarsh, Professor of Paediatric Endocrinology at University College Hospital London believes that all under fives should be on a pump and concludes; “Those on insulin pumps do not want to go back to MDI, which is a testimony to what they think of them.”

There is an immense sense of injustice felt by some people who see insulin pump services available in other health board areas, or who have to endure long waiting times. We recognise the challenges involved but pumps can bring a real improvement in the quality of life of people for whom multiple daily injections are unsuitable.

i NICE Technology Appraisal 151, July 2008.
ii Pickup, J. Insulin Pump Therapy: Then and Now in Insulin Pump
iiiTherapy and Continuous Glucose Monitoring (ed) pp1-10, Oxford University Press, Oxford, 2009
iv  Diabetes Action Plan 2010: Quality Care for Diabetes in Scotland
v Written answer, S3W-30155, 22nd January 2010
vi Diabetes Action Plan 2010: Quality Care for Diabetes in Scotland
vii SIGN Guideline 116 on management of Diabetes, March  2010
vii Insulin Pumps: A New Lease for Life, Diabetes UK Scotland, 2011
viii Juvenile Diabetes Research Foundation website, www.jdrf.org.uk