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Diabet. Med. 29, 971 (2012)

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[ Cover image: Insulin injection. Computer artwork of a syringe, with other syringes and pancreases in the background. Credit: David Mack/Science Photo Library. ]

Insulin therapy using an insulin injection was introduced in 1922. Progress towards a more physiological approach to insulin replacement has been painfully slow. One advance has been the use of continuous subcutaneous insulin infusion (CSII or insulin pumps) with or without glucose sensor augmentation. However, this therapeutic option is expensive and requires a trained multidisciplinary team to deliver an insulin pump service. It is therefore important to consider who would most benefit from such therapy and its cost-effectiveness. The availability of insulin pumps as a therapeutic option for the treatment of diabetes varies both between and within countries depending on the health system and its affordability for that country.

In this month’s issue, Carlsson and colleagues (page 1055) examine the availability of insulin pump therapy in people with Type 1 diabetes attending 10 hospital outpatient clinics in Sweden. The use of insulin pumps varied between clinics and women were 1.5-fold more likely to use such therapy. Other features associated with pump use were a higher HbA1c at baseline, lower creatinine, high and low insulin doses, and younger age. People with Type 1 diabetes aged 20–30 years were two times more likely to begin to use insulin pumps than those aged 40–50 years.

In the UK there are national guidelines (the National Institute for Health and Clinical Excellence; NICE) that recommend consideration of pump therapy in people with Type 1 diabetes on multiple daily injections with HbA1c > 69 mmol/mol (8.5%) despite the person trying to improve their diabetes control or in those in whom target HbA1c cannot be reached because of hypoglycaemia. The recommendations are even more relaxed in children. NICE also states that insulin pump therapy should only be started by a trained team that includes a doctor who specializes in insulin pump therapy, a diabetes nurse and a dietician. It is then recommended that the therapy should only be continued if there is a sustained improvement in HbA1c and/or less hypoglycaemia; quality of life should also be added to this list. An audit of pump services is currently being undertaken in the UK but it is likely to find that access is variable between sites, with some regions still not having access to a pump service as the commissioners of health care will not fund the service that requires not only the cost of the pump and its consumables but all members of the pump team, including the funding of educational packages. The availability of an insulin pump for a person with Type 1 diabetes then becomes a post-code lottery. This is an unacceptable state of affairs.

Some patients with Type 1 diabetes do not want to use an insulin pump, but would consider the use of a continuous glucose monitoring system (CGMS). Unfortunately, there is no formal guidance on this issue in many countries, which makes it even more difficult for this to be considered an option, despite the wishes of those living with diabetes and health professionals advising on best practice.