NICE Guidelines
NICE Technology Appraisal Guidance No. 151 states
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.
or
- 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.
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.
It is recommended that CSII therapy be initiated only by a trained specialist team, which should normally comprise a physician with a specialist interest in insulin pump therapy, a diabetes specialist nurse and a dietitian. Specialist teams should provide structured education programs and advice on diet, lifestyle and exercise appropriate for people using CSI.
Following initiation in adults and children 12 years and older, CSII therapy should only be continued if it results in a sustained improvement in glycaemic control, evidenced by a fall in HbA1c levels, or a sustained decrease in the rate of hypoglycaemic episodes. Appropriate targets for such improvements should be set by the responsible physician, in discussion with the person receiving the treatment or their career.
CSII therapy is not recommended for the treatment of people with type 2 diabetes mellitus.
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The NICE Guidelines for managing Diabetes with CGM in Adults
1.6.22 Consider real-time continuous glucose monitoring for adults with type 1 diabetes who are willing to commit to using it at least 70% of the time and to calibrate it as needed, and who have any of the following despite optimised use of insulin therapy and conventional blood glucose monitoring:
More than 1 episode a year of severe hypoglycaemia with no obviously preventable precipitating cause.
Complete loss of awareness of hypoglycaemia.
Frequent (more than 2 episodes a week) asymptomatic hypoglycaemia that is causing problems with daily activities.
Extreme fear of hypoglycaemia.
Hyperglycaemia (HbA1c level of 75 mmol/mol [9%] or higher) that persists despite testing at least 10 times a day (see recommendations 1.6.11 and 1.6.12).
Continue real-time continuous glucose monitoring only if HbA1c can be sustained at or below 53 mmol/mol (7%) and/or there has been a fall in HbA1c of 27 mmol/mol (2.5%) or more. [New 2015]
1.6.23 For adults with type 1 diabetes who are having real-time continuous glucose monitoring, use the principles of flexible insulin therapy with either a multiple daily injection insulin regimen or continuous subcutaneous insulin infusion (CSII or insulin pump) therapy. [New 2015]
1.6.24 Real-time continuous glucose monitoring should be provided by a centre with expertise in its use, as part of strategies to optimise a person’s HbA1c levels and reduce the frequency of hypoglycaemic episodes. [New 2015]
And NICE guidelines for managing diabetes in children with CGM:
1.2.62 Offer ongoing real-time continuous glucose monitoring with alarms to children and young people with type 1 diabetes who have:
frequent severe hypoglycaemia or
impaired awareness of hypoglycaemia associated with adverse consequences (for example, seizures or anxiety) or
inability to recognise, or communicate about, symptoms of hypoglycaemia (for example, because of cognitive or neurological disabilities). [new 2015]
1.2.63 Consider ongoing real-time continuous glucose monitoring for:
neonates, infants and pre-school children
children and young people who undertake high levels of physical activity (for example, sport at a regional, national or international level)
children and young people who have comorbidities (for example anorexia nervosa) or who are receiving treatments (for example corticosteroids) that can make blood glucose control difficult. [new 2015]
1.2.64 Consider intermittent (real-time or retrospective) continuous glucose monitoring to help improve blood glucose control in children and young people who continue to have hyperglycaemia despite insulin adjustment and additional support. [new 2015]