I did not push the issue all the way to the top. The refusal came from a hospital locum registrar on the diabetes team. His view was that T1 use of metformin was not standard. A pretty weak argument but I didn't want to push it. The same guy told me that pramlintide was only approved by NICE for T2 (true, but irritating and nonsensical), and that naltrexone use for diabetics was an off-label use, also true. At this point I kind of gave up trying to get the team to support the solutions I had identified myself, and decided to accept their solution, which was a pump. I'm embracing the pump and I will return to seeking metformin, pramlintide and low dose naltrexone if and when the pump has done the best it can do. In the mean time, I really need to start doing strength exercise to improve my insulin sensitivity. I don't need an off-label prescription for that!