NHS Pump Eligibility with a Low HbA1c

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badoop73535

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Type 1
Hi,

I was diagnosed with T1D just over a year ago and have been on MDI since. I'm interested in starting pump therapy but am yet to mention this to my diabetes team (I have a routine appointment in just under a month, I'll mention it then).

My A1c is 5.3% and so is not going to get any lower by starting pump therapy. It is on the low side and I have maybe 3-5 hypos per week so perhaps I could argue a pump could help me prevent hypos? It says on the NHS website about excessive hypos but no detail as to what constitutes "excessive".

Likewise, there's also a brief mention on the JDRF website about an excessive number of injections needed for good control being a factor. Would 8 injections / day be considered excessive?

Has anyone in a similar situation has qualified for pump therapy (or asked and been rejected)?
 
Hello and welcome to the forum.
Yes 8 injections are excessive and the fact you are going hypo as often as you do would also point to that 🙂

Do you Drive? If so watch what you are doing as your licence could be pulled if you are not careful.
Bottom line is if you don't ask you wont get. You will have to jump through many hoops, never take no for an answer though.
 
Insulin pumps are expensive which is one of the reasons why there are strict guidelines for them. I believe one reason why it is rare to recommend them in the first few years is that they can fail. They never fail at a good time and it is always stressful. During that stressful moment, you have to revert to MDI which is why injecting must be second nature.
Young children are often given pumps early because they need the ability to bolus very small doses.
The other thing to remember is that pumping is not the easy option. I found it more challenging that injecting. You still need to carb count … only much more accurately. You still need to basal test … and balance your basal for every 30 minutes not once or twice a day. You need to understand a lot lot more.

Thevreason I mention this is that you need a very good justification for pumping. Not just your HbA1C (pumping does not reduce HbA1C) or number of injections. Pumping doesn’t necessarily reduce hypos … especially if you don’t have the skills to use the pump. You need to be able to justify small doses and different basal rates at different times or day … and the cost.

So, why do you want a pump?
Not, what do I need to do to get a pump but what will you gain from the pump?
 
helli said:
Insulin pumps are expensive which is one of the reasons why there are strict guidelines for them. I believe one reason why it is rare to recommend them in the first few years is that they can fail. They never fail at a good time and it is always stressful. During that stressful moment, you have to revert to MDI which is why injecting must be second nature.
Young children are often given pumps early because they need the ability to bolus very small doses.
The other thing to remember is that pumping is not the easy option. I found it more challenging that injecting. You still need to carb count … only much more accurately. You still need to basal test … and balance your basal for every 30 minutes not once or twice a day. You need to understand a lot lot more.

Thevreason I mention this is that you need a very good justification for pumping. Not just your HbA1C (pumping does not reduce HbA1C) or number of injections. Pumping doesn’t necessarily reduce hypos … especially if you don’t have the skills to use the pump. You need to be able to justify small doses and different basal rates at different times or day … and the cost.

So, why do you want a pump?
Not, what do I need to do to get a pump but what will you gain from the pump?
Click to expand...
Sorry to derail the thread a bit here but @helli what is meant by accurate carb counting?
 
helli said:
Insulin pumps are expensive which is one of the reasons why there are strict guidelines for them. I believe one reason why it is rare to recommend them in the first few years is that they can fail. They never fail at a good time and it is always stressful. During that stressful moment, you have to revert to MDI which is why injecting must be second nature.
Young children are often given pumps early because they need the ability to bolus very small doses.
The other thing to remember is that pumping is not the easy option. I found it more challenging that injecting. You still need to carb count … only much more accurately. You still need to basal test … and balance your basal for every 30 minutes not once or twice a day. You need to understand a lot lot more.

Thevreason I mention this is that you need a very good justification for pumping. Not just your HbA1C (pumping does not reduce HbA1C) or number of injections. Pumping doesn’t necessarily reduce hypos … especially if you don’t have the skills to use the pump. You need to be able to justify small doses and different basal rates at different times or day … and the cost.

So, why do you want a pump?
Not, what do I need to do to get a pump but what will you gain from the pump?
Click to expand...

I can break down why I want a pump into a few reasons:

1. Flexibility with basal rates. After I come back from the gym for example, I am more insulin sensitive for a few hours and find I have to eat glucose tablets periodically for a few hours. It would be nice to be able to set a lower temporary basal for a few hours and not have to worry so much about that.

2. Being able to dose fractions of units. My carb ratio is currently 1 unit per 21 g carbs and it can make it difficult to stay in range if I want to eat a snack with say 30 g of carbs.

3. I also find with a lot of meals I have to split my dose into multiple injections. If I give everything up-front I go low, and if I don't give another couple units an hour or so later then I go high. With a pump I would be able to do an extended bolus.
 
Lily123 said:
Sorry to derail the thread a bit here but @helli what is meant by accurate carb counting?
Click to expand...
When carb counting on MDI we tend to round up or down to the nearest 10 units. If we are slightly under, that is little problem because we have ”spare” basal because it is assumed we need the same amount of basal for 24 or 12 hours. Using fast acting insulin for basal, means our basal level is much closer to what our body needs at that time of day so we have no “spare” basal.
Due to both of these reasons, we cannot round up or down the carbs. We have to be more accurate with carb counting.
 
badoop73535 said:
I can break down why I want a pump into a few reasons:

1. Flexibility with basal rates. After I come back from the gym for example, I am more insulin sensitive for a few hours and find I have to eat glucose tablets periodically for a few hours. It would be nice to be able to set a lower temporary basal for a few hours and not have to worry so much about that.

2. Being able to dose fractions of units. My carb ratio is currently 1 unit per 21 g carbs and it can make it difficult to stay in range if I want to eat a snack with say 30 g of carbs.

3. I also find with a lot of meals I have to split my dose into multiple injections. If I give everything up-front I go low, and if I don't give another couple units an hour or so later then I go high. With a pump I would be able to do an extended bolus.
Click to expand...
These are the reasons you need to explain to your DSN.
But be prepared to be knocked back.
There are alternatives to pumping for exercise and you can have half unit pens.
 
helli said:
When carb counting on MDI we tend to round up or down to the nearest 10 units. If we are slightly under, that is little problem because we have ”spare” basal because it is assumed we need the same amount of basal for 24 or 12 hours. Using fast acting insulin for basal, means our basal level is much closer to what our body needs at that time of day so we have no “spare” basal.
Due to both of these reasons, we cannot round up or down the carbs. We have to be more accurate with carb counting.
Click to expand...
So to the number like 52 instead of rounding it down to 50?
 
badoop73535 said:
I can break down why I want a pump into a few reasons:

1. Flexibility with basal rates. After I come back from the gym for example, I am more insulin sensitive for a few hours and find I have to eat glucose tablets periodically for a few hours. It would be nice to be able to set a lower temporary basal for a few hours and not have to worry so much about that.

2. Being able to dose fractions of units. My carb ratio is currently 1 unit per 21 g carbs and it can make it difficult to stay in range if I want to eat a snack with say 30 g of carbs.

3. I also find with a lot of meals I have to split my dose into multiple injections. If I give everything up-front I go low, and if I don't give another couple units an hour or so later then I go high. With a pump I would be able to do an extended bolus.
Click to expand...

You have to show what you’ve done to solve those problems and why it hasn’t worked and could only work with a pump. I don’t think having to snack after exercise would necessarily count. I have a pump and sometimes do that. What insulins are you taking? They often ask you to try a change of insulin.
 
badoop73535 said:
I can break down why I want a pump into a few reasons:

1. Flexibility with basal rates. After I come back from the gym for example, I am more insulin sensitive for a few hours and find I have to eat glucose tablets periodically for a few hours. It would be nice to be able to set a lower temporary basal for a few hours and not have to worry so much about that.

2. Being able to dose fractions of units. My carb ratio is currently 1 unit per 21 g carbs and it can make it difficult to stay in range if I want to eat a snack with say 30 g of carbs.

3. I also find with a lot of meals I have to split my dose into multiple injections. If I give everything up-front I go low, and if I don't give another couple units an hour or so later then I go high. With a pump I would be able to do an extended bolus.
Click to expand...
Could you not solve number 2 by getting a half unit pen and taking 1.5 units?
 
Inka said:
You have to show what you’ve done to solve those problems and why it hasn’t worked and could only work with a pump. I don’t think having to snack after exercise would necessarily count. I have a pump and sometimes do that. What insulins are you taking? They often ask you to try a change of insulin.
Click to expand...
Thanks for the advice.

I'm currently taking Levemir (morning and night) and Novorapid. I was on Lantus but changed to Levemir a few months ago due to the Lantus not lasting 24 hours and it sometimes causing bad lows right after I took it.
 
Levemir is probably a better voice than Lantus so that’s good. Do you reduce the Levemir on the days you exercise? And/or reduce your prior bolus?

The criteria isn’t just having a certain number of hypos, it’s “disabling hypoglycaemia” or “severe hypoglycaemia” or similar. I got my pump for that reason and it’s not a case of having a few hypos a week and so getting a pump. I had seizures due to hypoglycaemia and a number of ambulance call-outs. That was all despite trying various insulins and times/doses. My quality of life was severely impacted.
 
Inka said:
Levemir is probably a better voice than Lantus so that’s good. Do you reduce the Levemir on the days you exercise? And/or reduce your prior bolus?

The criteria isn’t just having a certain number of hypos, it’s “disabling hypoglycaemia” or “severe hypoglycaemia” or similar. I got my pump for that reason and it’s not a case of having a few hypos a week and so getting a pump. I had seizures due to hypoglycaemia and a number of ambulance call-outs. That was all despite trying various insulins and times/doses. My quality of life was severely impacted.
Click to expand...
Changing the Levemir on the days I exercise helps with the few hours post-exercise, but then it makes me high during the day before I exercise and in the evening after I've exercised.

I understand what is meant by "severe hypoglycaemia" but not "disabling hypoglycaemia". What hypo isn't disabling? Every other day I have to sit and not do anything for 30+ minutes while feeling awful.
 
Lily123 said:
So to the number like 52 instead of rounding it down to 50?
Click to expand...
Yes exactly, pumps can do boluses to the nearest 0.1 unit, in fact I think my daughter’s new one goes to the nearest 0.01, the mind boggles how small that is! (Or if it even makes a difference...)
Pumps also usually have bolus wizards in, so you just enter the carbs and it does all the sums for you and then gives you the exact amount of insulin. You have to make sure all your ratios are kept up to date though!
 
badoop73535 said:
Changing the Levemir on the days I exercise helps with the few hours post-exercise, but then it makes me high during the day before I exercise and in the evening after I've exercised.

I understand what is meant by "severe hypoglycaemia" but not "disabling hypoglycaemia". What hypo isn't disabling? Every other day I have to sit and not do anything for 30+ minutes while feeling awful.
Click to expand...

What about your bolus? Disabling means the affect on your life. Have you had seizures due to hypos? Paramedics? Or are you just talking about the normal hypos that are part of Type 1 and keeping good control? Having to sit down for a few minutes doesn’t count as disabling, no.
 
Inka said:
What about your bolus? Disabling means the affect on your life. Have you had seizures due to hypos? Paramedics? Or are you just talking about the normal hypos that are part of Type 1 and keeping good control? Having to sit down for a few minutes doesn’t count as disabling, no.
Click to expand...
Diabetes isn't a competition you know. Just because you go through something tough doesn't mean you have to minimise stuff other people go through.
 
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