Insulin pump therapy

also known as continuous subcutaneous insulin infusion (CSII)

Insulin pump therapy should be offered as a treatment for diabetes to children, young persons and adults with Type 1 diabetes as part of a cohesive and comprehensive diabetes service. Appropriateness should be determined by clinical need, personal choice and suitability - not on the basis of where a person lives or ability to pay. National Institute for Health and Clinical Excellence (NICE) guidance1,2 should be locally implemented in a uniform manner putting an end to the existing UK postcode lottery.

Continuous subcutaneous insulin infusion (CSII) is an increasingly popular treatment option. It offers significant benefit over Multiple Daily Injections (MDI) for some in terms of diabetes management and quality of life3. The forthcoming review of NICE insulin pump therapy guidance should take on board emerging evidence showing benefits to those prone to frequent hypoglycaemia and significant variability in day-to-day blood glucose levels4. Greater emphasis should also be placed on the quality of life benefits reported by people with diabetes. Implementation criteria should be incorporated to ensure access to the therapy and services.

• Pump therapy is an alternative insulin delivery option and awareness should be raised amongst healthcare professionals and people with Type 1 diabetes alike.
• Transparent, consistent and equitable protocols should be in place in all localities covering:
  - assessment, referral, follow-up, ongoing support, education, support during initiation, supply of consumables, discontinuation, staff training and competencies.
• Funding for pumps and consumables should be accessible when criteria are met.
• The development of local pump centres, with appropriate infrastructure, staff, education and training, should be encouraged. Local arrangements need to be put in place to support this.
• Teams delivering pump therapy services should establish databases to support quality assurance and adverse events reporting and national audit.
  

Background

It is estimated that around five to six thousand (2 per cent) of people with Type 1 diabetes currently use pumps in the UK. This compares to between an estimated 10-20 per cent in other European member states and around 15-20 per cent in the United States5. Thus indicating that CSII is under-utilised in the UK. Pump therapy is not a new treatment, with it first being introduced in the late 1970’s. As with any new treatment, there were initial problems, which led to safety concerns. However, the new generation of pumps have been improved with additional safety features and are widely used in Europe, suggesting that safety fears have been addressed.

Suitability

Pump therapy may not suitable for everyone. It is however being successfully used by children, teenagers6-8 and adults - including women during pregnancy9. Cases are also increasing of pump therapy being used with infants and babies10, including those that are premature11. The key to successful use of pump therapy is motivation. Those most suited must have received structured education, have a good knowledge and understanding of diabetes and of how insulin, exercise and food intake affect blood glucose levels. They must be willing to take significant responsibility for their day-to-day diabetes management or have reliable adult supervision12,13. This requires the commitment to regular testing of blood glucose levels and confidence in acting on results.

Cost benefits and quality of life

The main costs of CSII are associated with the capital purchase of the pump and consumables e.g. infusion sets and reservoirs.14 Estimated average yearly costs are £1650 per person.14 Benefits associated with using CSII include a reduction in HbA1c; total daily insulin; reduced incidence of and less severe hypoglycaemia; improved day-to-day and longer-term glycaemic control; reduced hospital admissions, consultant consultations and episodes of hyperglycaemia 3,15-21. Use of pump therapy appears to derive cost benefits to local health services through a reduction in primary care contacts, reduction in hospital admissions and hospital outpatient contacts. Evidence has shown that an estimated saving of £23,532 over 2 years can be derived which offset the costs of pump therapy22. Treatment with insulin pumps has been shown to be associated with improved glycaemic control and reduced incidence of complications. This produces an incremental cost effectiveness ratio (ICER) of £25,648 per QALY, representing good value for money 23.
A recent systematic review of published literature relating to quality of life associated with insulin pump use in Type 1 diabetes reports that “existing research is flawed making a judgement about the quality of life benefits of insulin pump use difficult”24. There is however, no strong evidence that there is no benefit. Those using CSII report that it can be a much more convenient method of delivering insulin. It can reduce diabetes related worry; bring about more flexible eating habits; increase lifestyle flexibility; improve carer quality of life7 and sleep patterns3,8,16,21. The Five Nations Trial reported improvement in all diabetes quality of life scores and perception of mental health, compared to MDI therapy3. Further research is needed to assess quality of life benefits. Limited evidence is currently available concerning benefit of pump therapy for people with Type 2 diabetes using intensive insulin therapy25. Respondents to a survey of children and young persons views about their diabetes services rated the need to improve access to insulin pumps as one of their top priorities to improve care26.