# NHS Pump Eligibility with a Low HbA1c



## badoop73535 (Jan 30, 2022)

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)?


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## Pumper_Sue (Jan 30, 2022)

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.


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## Bruce Stephens (Jan 30, 2022)

badoop73535 said:


> It says on the NHS website about excessive hypos but no detail as to what constitutes "excessive".


You can read the NICE guidance here: https://www.nice.org.uk/guidance/ta151/chapter/1-Guidance


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## helli (Jan 30, 2022)

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?


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## Lily123 (Jan 30, 2022)

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.
> 
> ...


Sorry to derail the thread a bit here but @helli what is meant by accurate carb counting?


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## badoop73535 (Jan 30, 2022)

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.
> 
> ...



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.


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## helli (Jan 30, 2022)

Lily123 said:


> Sorry to derail the thread a bit here but @helli what is meant by accurate carb counting?


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.


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## helli (Jan 30, 2022)

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.
> 
> ...


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.


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## Lily123 (Jan 30, 2022)

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.


So to the number like 52 instead of rounding it down to 50?


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## Inka (Jan 30, 2022)

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.
> 
> ...



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.


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## Lucyr (Jan 30, 2022)

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.
> 
> ...


Could you not solve number 2 by getting a half unit pen and taking 1.5 units?


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## badoop73535 (Jan 30, 2022)

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.


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.


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## badoop73535 (Jan 30, 2022)

Lucyr said:


> Could you not solve number 2 by getting a half unit pen and taking 1.5 units?


A half unit pen would help for sure.


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## Inka (Jan 30, 2022)

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.


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## Lucyr (Jan 30, 2022)

badoop73535 said:


> A half unit pen would help for sure.


Why don’t you switch to one? Makes sense given your ratio.


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## badoop73535 (Jan 30, 2022)

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.


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.


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## badoop73535 (Jan 30, 2022)

Lucyr said:


> Why don’t you switch to one? Makes sense given your ratio.


I didn't know they were a thing until recently.


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## Sally71 (Jan 30, 2022)

Lily123 said:


> So to the number like 52 instead of rounding it down to 50?


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!


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## Inka (Jan 30, 2022)

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.



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.


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## badoop73535 (Jan 30, 2022)

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.


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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## Lily123 (Jan 30, 2022)

Sally71 said:


> 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!


Ah that’s understandable for the insulin doses. I use an accu chek aviva expert so it tells me the exact amount down to the nearest 0.1 but then rounds it up or down as I use a half unit pen


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## rayray119 (Jan 30, 2022)

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.


i always enter the exact number of carbs into my calacater but round down or up to the nearest half unit.


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## Inka (Jan 30, 2022)

badoop73535 said:


> I didn't know they were a thing until recently.



Right, so get one (or two), adjust your bolus and/or exercise snacks and see how you go. You have to prove you’ve made a proper effort to sort things and show that the tools available to you haven’t been able to do that.


badoop73535 said:


> 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.



No need to be rude, thanks. People here are trying to help you, including me. You won’t get a pump because you have a few hypos, and you won’t get a pump unless you can evidence efforts to solve your problems and why those efforts haven’t succeeded. Having these things pointed out to you now will help you formulate a plan in advance of asking for a pump, and then you’ll be ahead - ie you can demonstrate you’ve tried a number of things to solve your issues.


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## everydayupsanddowns (Jan 30, 2022)

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.
> 
> ...



Those were very much the reasons I was interested in pursuing pump therapy. 

But I was also able to explain the difficulties I had with hypos and how they were affecting my quality of life. The lack of pattern and unpredictability meant that I worried about them happening at pretty much any time. The vast majority were mild, but I was having severe hypos overnight too (where my wife would have to help me out, rather than ambulance call outs).

Depending on how pump-supportive your team are, and how convinced they are that a pump would improve things for you, you may find your experience with hypos is enough. Though they may want you to try a few other options first (eg DAFNE or equivalent).

The wording of the guidance is worth paying attention to 

_1.1 Continuous subcutaneous insulin infusion (CSII or 'insulin pump') therapy is recommended as a treatment option for adults and children 12 years and older with type 1 diabetes mellitus provided that: 
_

_attempts to achieve target haemoglobin A1c (HbA1c) levels with multiple daily injections (MDIs) result in the person experiencing disabling hypoglycaemia. For the purpose of this guidance, disabling hypoglycaemia is defined as the repeated and unpredictable occurrence of hypoglycaemia that results in persistent anxiety about recurrence and is associated with a significant adverse effect on quality of life

or_
_HbA1c levels have remained high (that is, at 8.5% [69 mmol/mol] or above) on MDI therapy (including, if appropriate, the use of long-acting insulin analogues) despite a high level of care._


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## Pumper_Sue (Jan 30, 2022)

@badoop73535 no one is trying to be negative towards you, what we are trying to do is prepare you for the battle ahead regarding getting a pump.

What's been pointed out is very good sound advice for you to try if they work fine if not then a pump may be on the cards. We are actually doing your homework for you so you are well armed in advance


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## badoop73535 (Jan 30, 2022)

Inka said:


> Right, so get one (or two), adjust your bolus and/or exercise snacks and see how you go. You have to prove you’ve made a proper effort to sort things and show that the tools available to you haven’t been able to do that.
> 
> 
> No need to be rude, thanks. People here are trying to help you, including me. You won’t get a pump because you have a few hypos, and you won’t get a pump unless you can evidence efforts to solve your problems and why those efforts haven’t succeeded. Having these things pointed out to you now will help you formulate a plan in advance of asking for a pump, and then you’ll be ahead.



I'm not being rude. I just simply find it frustrating to have hypos minimised as just "having to sit down for a few minutes" when the impact goes far beyond that. You can explain what counts and doesn't count as "disabling hypoglycaemia" without minimising other people's experiences in that way.


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## Inka (Jan 30, 2022)

badoop73535 said:


> I'm not being rude. I just simply find it frustrating to have hypos minimised as just "having to sit down for a few minutes" when the impact goes far beyond that. You can explain what counts and doesn't count as "disabling hypoglycaemia" without minimising other people's experiences in that way.



Then you’re being overly sensitive. I have hypos where I have to sit down for a few minutes too. They’re not nice and they’re annoying, but they don’t qualify as “disabling hypoglycaemia” under the pump criteria, which is what you’re asking about.


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## rayray119 (Jan 31, 2022)

Sally71 said:


> 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!


I think sometimes that 0.01 would make at least make a very small amount of difference in me.


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## rayray119 (Jan 31, 2022)

i use a half-unit pen for novorapid. and will be stating for livermir. but may point was I seem to be sensitive to a tiny bit of extra insulin or carb. my radio I'm doing at the moment is 1 to 15


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## rayray119 (Jan 31, 2022)

Benny G said:


> I understand. When I used to do a lot of long distance cycling I used various ratios, the most extreme was approximately 1 to 80 or a half unit to 40. I don't do so much exercise these days and my base ratio is closer to 1 to 5 due to a low carb way of eating.
> 
> My point is you are not only sensitive to extra insulin or carbs, your ratio is also sensitive.
> 
> For you I would count a half unit to 7.5 (1/15) as your base line, when you are busy that can easily change to a half unit to 15 (1/30) Slumped on a sofa for a lazy weekend your ratio could drop to a half unit to 5 (1/10)


hmm yes hard to work out on days I'm working.  those days I'm very active and learning what works 1 time I'm working doesn't nersally work the next time.


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## rayray119 (Jan 31, 2022)

so my 4 units of livermir are giving 0.16 per hour


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## rayray119 (Jan 31, 2022)

Benny G said:


> I understand. When I used to do a lot of long distance cycling I used various ratios, the most extreme was approximately 1 to 80 or a half unit to 40. I don't do so much exercise these days and my base ratio is closer to 1 to 5 due to a low carb way of eating.
> 
> My point is you are not only sensitive to extra insulin or carbs, your ratio is also sensitive.
> 
> For you I would count a half unit to 7.5 (1/15) as your base line, when you are busy that can easily change to a half unit to 15 (1/30) Slumped on a sofa for a lazy weekend your ratio could drop to a half unit to 5 (1/10)


i would love to be able to get things more exact


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## helli (Jan 31, 2022)

rayray119 said:


> i would love to be able to get things more exact


Type 1 diabetes is not a great for a perfectionist or for someone who wants to see things exact.
There are too many things which can affect our blood sugars and, whilst we are going through the honeymoon period, we have another spark to throw in the fire as our pancreas can suddenly decide to pump out some insulin. 
An extra 0.01 units of insulin will never help smooth out the impact of stress or a waking beta cell or having to run for the bus or ...
It is important we learn how to manage these things without controlling them - if we aim to control diabetes, diabetes will control us. 

Be nice to yourself and accept inexactitudes.


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## rayray119 (Jan 31, 2022)

Benny G said:


> That's right. The rest of your basal is being covered by your honeymoon supply.
> 
> The honeymoon is also one of the reasons your active schedule causes such confusion.


I'm learning tough trial and error only a minor blip yesterday(well perhaps too) and that was me not stacking when I walked home I'll remember next time.  not going to let it put me off doing the shifts because if I do I'll never learn how best to handle them.


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## rayray119 (Jan 31, 2022)

helli said:


> Type 1 diabetes is not a great for a perfectionist or for someone who wants to see things exact.
> There are too many things which can affect our blood sugars and, whilst we are going through the honeymoon period, we have another spark to throw in the fire as our pancreas can suddenly decide to pump out some insulin.
> An extra 0.01 units of insulin will never help smooth out the impact of stress or a waking beta cell or having to run for the bus or ...
> It is important we learn how to manage these things without controlling them - if we aim to control diabetes, diabetes will control us.
> ...


i more might talk about the first place that if I had that extra insulin if romd up it would make a small difference not that I wanted the extra 0.01 insullin


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## rayray119 (Jan 31, 2022)

helli said:


> Type 1 diabetes is not a great for a perfectionist or for someone who wants to see things exact.
> There are too many things which can affect our blood sugars and, whilst we are going through the honeymoon period, we have another spark to throw in the fire as our pancreas can suddenly decide to pump out some insulin.
> An extra 0.01 units of insulin will never help smooth out the impact of stress or a waking beta cell or having to run for the bus or ...
> It is important we learn how to manage these things without controlling them - if we aim to control diabetes, diabetes will control us.
> ...


I'm learning and trying to keep things positive. however, you say a pumps not being  great thing being one but I've found someone who went on it just after 2 weeks and is abousoullty fine. I'm not saying I'm going to get one but its best not to shud them for everyone as a no go  as for some people, it did seem that was the best option steight off. I also know off some people tried them for a bit found they weren't for them and then went back to pens I don't see a problem with this. not criticizing just something to think about 


but yes I do understand things aren't always going to go right that's not quite what I meant.


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