Professor John Pickup, Professor of Diabetes & Metabolism at Guy’s Hospital, London, writes:
“Many patients with type 2 diabetes eventually need insulin injections to achieve good blood glucose control. Whilst this switch from tablets to insulin produces improved long-term control in most people with type 2 diabetes, a proportion of those on insulin injections still struggle to obtain satisfactory HbA1c levels. It is logical, then, to ask if insulin pump therapy has a role in the treatment of type 2 diabetes, particularly in those with sub-optimal control on injections.
The latest NICE Guidelines on the use of insulin pumps, issued in 2008, state that ‘CSII therapy is not recommended for the treatment of people with type 2 diabetes mellitus’. The Appraisal Committee came to this view because the relatively few clinical trials that have been done to date of pumps in type 2 diabetes have shown no consistent difference in blood glucose control between insulin pump and intensive insulin injection treatment (multiple daily injections). Most countries have followed this view that the clinical benefit of insulin pumps is not established in type 2 diabetes, and consequently CSII is used in few patients with this type of diabetes. In the UK, NHS funding for CSII in people with type 2 diabetes will therefore be very difficult to obtain at present.
However, from a research and from the pump manufacturers’ point of view there has been a recent resurgence of interest in pumps in type 2 diabetes, which may change our (and maybe NICE’s) notion of pumps for type 2 diabetes. This is partly because special groups of people with type 2 diabetes have been identified who seem to do particularly well on CSII, namely those with a very high HbA1c on multiple injections, those with very high insulin requirements and those who also suffer from other conditions apart from diabetes which are contributing to the difficulty in controlling their diabetes. We are finding that pumps will probably work best when targeted at a (maybe relatively small) group of those with type 2 diabetes who have special control problems on injections.
The other factor that is changing our minds about pumps in type 2 diabetes is the range of smaller insulin pumps which are under development. Called ‘patch pumps’, these often have an integrated cannula built into the back of the pump, and promise to be more convenient to use. Some manufacturers are intending to trial these patch pumps first in type 2 diabetes. It is likely then that the next NICE review will have more information to consider in type 2 diabetes.”
The National Diabetes Information Service Insulin Pump Audit reported 35 patients with Type 2 diabetes using insulin pump therapy in England in 2009. It does not distinguish how many are funded by the NHS. The same audit noted 5,667 patients with Type 1 diabetes using insulin pumps.