Final guidance on insulin pump therapy published last week by the UK's National Institute for Health and Clinical Excellence (NICE) is less stringent on eligibility criteria, thereby giving access to a greater number of patients with Type 1 diabetes, yet the new guidelines for clinicians disappointed key patient advocacy groups.

NICE reviewed guidance published in February 2003 on the use of continuous subcutaneous insulin infusion and ruled insulin pump therapy is a viable treatment option for adults and children 12 years and older with Type 1 diabetes provided that attempts to reach target hemoglobin levels with multiple daily injections result in the person having "disabling hypoglycemia," or levels remain above 8.5% with multiple daily injections despite careful management of diabetes.

Insulin pump therapy should only be continued in adults and children 12 years and over if there has been a sustained improvement in the control of their blood glucose levels, according to the revised guidelines.

The publication Nursing In Practice, noting that the UK has the lowest number of children attaining good diabetes control in Europe, said it welcomed the changes as more patients can be treated with insulin pumps when doctors believe conventional insulin injections are impractical or inappropriate.

Yet Diabetes UK and Insulin Pump Therapy (INPUT, a UK patient support group), said the guidance "is not as progressive as we would have hoped, and specifically we are extremely disappointed that cost-effectiveness considerations have created eligibility criteria that could be seen as a perverse incentive against good blood glucose control."

The two associations said the NICE criteria do not "consider the quality of life benefits that an insulin pump may bring to some people with diabetes even if their control is at a level below 8.5."

Diabetes UK in July released new data estimating that up to 16,000 children age 16 or under in the UK are living with Type 1 diabetes and that the trend is increasing, particularly among children under five.

The association said in 2008 there have been more than 3,000 hospital admissions for children with Type 1 diabetes and that the UK has the fourth-highest incidence of Type 1 diabetes in children across Europe.

"Diabetes UK and INPUT believe that the devices should be available to people with diabetes based on individual clinical need, personal choice and suitability rather than based on cost considerations," the two groups stated in their formal response to NICE.

"It is clinicians and people with diabetes who must jointly agree that insulin pump therapy is a suitable treatment choice, and Primary Care Trusts must respect the decisions that clinicians make," the statement said.

NICE guidance in 2003 recommended use of insulin pumps only where multiple daily injections have failed and did not authorize reimbursement for patients where the use of daily injections poses a difficulty, significantly among children who struggle to keep up their treatment regime through self-injection.

A working group of Diabetes UK last year reported "an unacceptable variation in access to pumps across the UK."

In its published report, the group said uptake of insulin pump therapy in the UK remains very low at no more than 1% of Type 1 diabetes cases compared to 15% to 20% in other countries such as the U.S., Israel and Germany.

Varian, BrainLAB to upgrade Danish site

Rigshospitalet (Copenhagen, Denmark) has upgraded and expanded its radiotherapy capabilities with a contract awarded to Varian Medical Systems ((Palo Alto, California) and BrainLAB (Munich, Germany).

The reference medical facility for Denmark, the 1,120-bed Rigshospitalet will install three of Varian's RapidArc radiotherapy units for image-guided, intensity-modulated radiotherapy (IMRT) treatments.

The upgraded units will integrate the BrainLAB's ExacTrac imaging system as well as Varian's On-Board Imager for patient positioning.

Dr. Svend Aage Engelholm, chief radiation oncologist, said the new Novalis Tx platforms will be used for primarily for lung and prostate cancer therapies and that extra-cranial stereotactic treatments can now be delivered with an upgraded device.

Novalis Tx allows multiple beam energies of up to 18 million volts for treating deep-seated tumors with high dose delivery rates that lend themselves to higher patient throughput.

Novalis Tx radiosurgery covers a range of indications including malignant and benign lesions, brain metastases, arteriovascular malformations, and functional lesions with dynamic beam shaping and frameless precision patient positioning.

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