Updated NICE T1 guidelines published

smc4761

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Plesae excuse my ignorance here. I have been diabetic for over 30 years but the following mean nothing to me could someone please explain, Thanks.

CGM

MDI

LCHF
 
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tim2000s

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CGM = continuous glucose monitoring

MDI = multiple Daily Injection (basal bolus treatment)

LCHF = Low Carb Higher Fat ( a lifestyle choice to reduce carbs in the diet aiming for nutritional ketosis and mostly adopted by T2s).
 
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smc4761

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CGM = continuous glucose monitoring

MDI = multiple Daily Injection (basal bolus treatment)

LCHF = Low Carb Higher Fat ( a lifestyle choice to reduce carbs in the diet aiming for nutritional ketosis and mostly adopted by T2s).

Thanks for the prompt reply
 

ConradJ

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@smc4761

If you go to the home page of the website ( www.diabetes.co.uk ) there's a really excellent search box in the top right of the menu.

Search on the above from there and you will get excellent, human friendly explanations.

Best wishes,
Conrad
 
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Scardoc

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If many type 1s take this NICE guidance to heart, then unless they can test bg levels about 6-8 times per day (many UK GPs are now trying to reduce the amounts of teststrips prescribed to be no more than 150 per month) or follow a lower carb way of eating food to reduce the swings, then I can see that trying to achieve an hba1c of 6.5% or under, is going to put an increased demand on call outs for paramedics to deal with hypoglycaemia and admittance to A&E because tight control usually impairsc awareness to recogonise the hypo feeling at a safe bg level or for the need for 3rd party assistance. Hopefully the wise will look at the buccal lining route and using Glucogel in a bottle and give 3rd party help silently. Sadly, the funding of cgm is still a very costly business and unless the prices reduce, then a CCG wont be able to fund cgm and pumps. CCGs would need to approach government officials and ask where the money is going to come from, if not from taxes?

At the end of the day, the guidance on bg levels is down to a dsn or hospital consultant to advise on and not NICE unless it will be to someones benefit to obtain a pump or to prevent nerve damage complications from getting worse.

I don't follow this logic. The vast majority of T1's do not meet the previous targets so I wouldn't expect any sudden increase in hypo's, lack of hypo awareness or the resulting strain on paramedics. If anything, a reduced target may result in an even poorer set of results (and no doubt Barbara Young will jump straight on them) in the immediate future but could, potentially, in the longer term lead to people achieving lower results. Who knows. There's nothing to set the heather alight in these guidelines or to indicate that anyone is closer to understanding why so many T1's cannot achieve the target HbA1C.

As for the CGM - we'd all love one but given the expense involved the guidelines are clearly saying "these are for people who desperately need the help". And why not? Testing between 4 & 10 times a day should be more than sufficient to build the picture and gain confidence with what is going on with your BG levels. Naturally, this can change and you'll need to get obsessive now and then to allow for changes.
 
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Spiker

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Personally I'd still trade a pump for a CGM though if it was a straight swap. Which on cost grounds it looks like it ought to be.
 
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tim2000s

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As for the CGM - we'd all love one but given the expense involved the guidelines are clearly saying "these are for people who desperately need the help". And why not? Testing between 4 & 10 times a day should be more than sufficient to build the picture and gain confidence with what is going on with your BG levels. Naturally, this can change and you'll need to get obsessive now and then to allow for changes.

The thing is, if you are testing at 10 times per day and you are adhering to the guidelines to replace lancets every time, then you are spending £1800 of the NHS's money annually if you are using AccuCheck Aviva test strips and the fastclix lancets (at NHS prices).

A Libre costs (at retail, not NHS, prices) £1,290 per annum, and a Dexcom using xDrip without purchasing a receiver (or maybe the G5 with smartphone app) costs around £1,600 per year.

If you are driving a lot then perhaps there needs to be some work with the NHS and DVLA to understand how the CGM model works, but the costs are not as prohibitive in relation to finger prick testing as everyone seems to think.

By the way, I fall into the high volume of testing line to keep my bg levels on track.
 
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Spiker

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The thing is, if you are testing at 10 times per day and you are adhering to the guidelines to replace lancets every time, then you are spending £1800 of the NHS's money annually if you are using AccuCheck Aviva test strips and the fastclix lancets (at NHS prices).

A Libre costs (at retail, not NHS, prices) £1,290 per annum, and a Dexcom using xDrip without purchasing a receiver (or maybe the G5 with smartphone app) costs around £1,600 per year.

If you are driving a lot then perhaps there needs to be some work with the NHS and DVLA to understand how the CGM model works, but the costs are not as prohibitive in relation to finger prick testing as everyone seems to think.

By the way, I fall into the high volume of testing line to keep my bg levels on track.
But are you factoring in the cost of continuing to test at least 5x per day with Dexcom to meet manufacturers recommendations on calibration tests and pre-dosing tests?

That's £900 of your £1800 that can't be mitigated by CGM other than by ignoring manufacturer safety instructions. And neither NICE nor the NHS can make policy on that basis. Not without developing steel gonads.

Also they probably have to base their official cost benefit analysis on official manufacturer consumables policy, so no "sensor stretching" (reuse) for Dexcom.

I realise Abbot say no calibration needed for the Libre but I believe that has not held up in practical use?
 
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tim2000s

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But are you factoring in the cost of continuing to test at least 5x per day with Dexcom to meet manufacturers recommendations on calibration tests and pre-dosing tests?
No, because I was basing it on being twice a day, which is I believe the recommendation. Or when you are more than 20% out, which you won't know if you aren't testing your BG anyway :s

I realise Abbot say no calibration needed for the Libre but I believe that has not held up in practical use?
Hum... Interesting question. Once I'm happy with the sensor, then I test very infrequently (days go between blood tests). With the Libre, at £1,290 for year one, you still have more than enough "budget" for 3-4 finger pricks per day.
 
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Spiker

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No, because I was basing it on being twice a day, which is I believe the recommendation. Or when you are more than 20% out, which you won't know if you aren't testing your BG anyway :s


Hum... Interesting question. Once I'm happy with the sensor, then I test very infrequently (days go between blood tests). With the Libre, at £1,290 for year one, you still have more than enough "budget" for 3-4 finger pricks per day.
Tbh I never followed Dexcom's recommendation which is to finger prick test before every bolus. I guess you could double two of those up with calibration tests so that's 3-4 per day rather than 5-6.

However I did find the Dexcom G4 performed a lot better when I over calibrated, calibrating about 4 times a day at the normal finger prick times. It tracked a lot closer to the finger prick result and started picking up events (eg hypos) it had been missing. Particularly after long reuse of the sensor.

What if any sensor reuse did you assume for your £1800/year number?
 

tim2000s

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What if any sensor reuse did you assume for your £1800/year number?
Three weeks use on the Dex sensors - that seems to be the consensus of stretching with xDrip and others. That makes up the £1600. If you go for two weeks, it becomes more expensive.
 

Spiker

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Three weeks use on the Dex sensors - that seems to be the consensus of stretching with xDrip and others. That makes up the £1600. If you go for two weeks, it becomes more expensive.
So the problem is that NICE couldn't make recommendations based on practices that violate the manufacturer usage instructions. Which rules out Dexcom as no reuse jacks the annual cost up into the region of £4-5K even assuming a free receiver. I think there is still a strong argument there for the Libre though.

Or if NICE grew huge balls it could say to Dexcom, we will approve your product for NHS supported use in the UK provided that you officially recognise and support sensor reuse for (say) 3 weeks per sensor. Not even guarantee it, just support it and don't prohibit it.
 
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tim2000s

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Or if NICE grew huge balls it could say to Dexcom, we will approve your product for NHS supported use in the UK provided that you officially recognise and support sensor reuse for (say) 3 weeks per sensor. Not even guarantee it, just support it and don't prohibit it.
You know where the life comes from though... Not the amount of time it will stay attached but the amount of time the sensor reagent is certified for accuracy...
 

donnellysdogs

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The trouble is that NICE have to go by the "official" route of costings... And if thats a sensor lasting say a week.. Thats it. If they haven't been approved for a longer period it invalidates any arguments that anybody can put forward.

Ie just as a small different example. Degludec that CCGs have double red for prescribing. Even though I can prove that it would be cheaper its only based upon assimptions that I would be using xx less units, 1 needle officially per day instead of 2. This had to go before the prescribing manager of the CCG even though it is officially sort of available through NICE.

NICE have to bear in mind facts and not "what if's" and then the Prescribing Managers of CCGs would also base their availability on facts too. Extending sensors just won't come in to the equation.
 
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Spiker

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You know where the life comes from though... Not the amount of time it will stay attached but the amount of time the sensor reagent is certified for accuracy...
Yes, that's where they are coming from on sensor life, but I also know it can remain accurate for approaching 6 weeks in some cases. NICE and Dexcom could study reuse jointly to put some parameters on it.
 

Spiker

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You know where the life comes from though... Not the amount of time it will stay attached but the amount of time the sensor reagent is certified for accuracy...
NICE and Dexcom could come up with a guideline saying discard sensor and don't reuse after X instances of Y discrepancy in calibration.
 

donnellysdogs

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NICE are meant to be independent. That would also involve getting different approval by the EU and manufacturer guarantees...
Its not all down to NICE.
 
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Spiker

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NICE are meant to be independent. That would also involve getting different approval by the EU and manufacturer guarantees...
Its not all down to NICE.
Don't worry, I know it ain't gonna happen. :-/

With the Libre, maybe.
 

ConradJ

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So the problem is that NICE couldn't make recommendations based on practices that violate the manufacturer usage instructions. Which rules out Dexcom as no reuse jacks the annual cost up into the region of £4-5K even assuming a free receiver. I think there is still a strong argument there for the Libre though.

Or if NICE grew huge balls it could say to Dexcom, we will approve your product for NHS supported use in the UK provided that you officially recognise and support sensor reuse for (say) 3 weeks per sensor. Not even guarantee it, just support it and don't prohibit it.

Alternatively, they could grow "huge gonads" (lol ...thanks Spiker) and tell Dexcom etc that they will approve 200,000 IDDS per annum (2/3'ds of the IDDS population) for a 5-10 year contract if the price = ...

Dexcom etc would be foolish not to accept as the guaranteed demand will enable them to increase productivity and efficiency.
 
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